CRA76 RECURRENT SECONDARY SPONTANEOUS PNEUMOTHORAX IN A COPD PATIENT WITH GIANT BULLA: A MANAGEMENT PREDICAMENT

Muhamad Thaqif Sidek¹, Nor Safiqah Sharil², Boon Hau Ng¹, Nik Nuratiqah Nik Abeed¹, Andrea Ban Yu Lin¹

¹Respiratory Unit, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
²Faculty of Medicine and Science, Universiti Sains Islam Malaysia, Negeri Sembilan, Malaysia

Background
Chronic obstructive pulmonary disease (COPD) patients with severe emphysema and bullae are predisposed to secondary spontaneous pneumothorax (SSP). A multidisciplinary approach is crucial when this complication arises, particularly in the presence of persistent air leak and subcutaneous emphysema. Herein, we report a case of recurrent SSP in a COPD patient with giant bulla, highlighting the complexities of management.

Case Presentation
A 67-year-old male with a 50-pack-year smoking history and known COPD (GOLD 3, Group E) was diagnosed with emphysema with multiple bullae. The largest bulla measured 8.6 cm in the right upper lobe. He developed an acute right-sided SSP while being assessed for endobronchial valve placement (Zephyr valve). Upon admission, a chest tube was inserted and non-invasive ventilation was initiated as a stabilizing measure. However, this led to a persistent air leak and subsequent subcutaneous emphysema. Surgical intervention was considered but deferred due to significant cardiovascular risk. A structured approach incorporating pulmonary rehabilitation, physiotherapy, and gradual weaning from ventilation resulted in successful resolution of the pneumothorax and subcutaneous emphysema. Pleurodesis was then performed, ultimately allowing for home discharge.

Discussion
This case accentuates the management predicament of recurrent SSP with persistent air leak in COPD patients with giant bulla. Thorough assessment is essential, taking into account emphysema distribution, collateral ventilation, and individual risk factors prior to surgical (bullectomy, lung volume reduction) or bronchoscopic (endobronchial valves, coils, or sealants) intervention. The interplay between invasive and conservative strategies underscores the importance of individualized, multidisciplinary decision-making to optimize patient outcomes.