Bullectomy used to treat a patient with pulmonary vesicles related to COVID-19: A case report

INTRODUCTION

因电子发票与纸质发票具有同等法律效力，如果公立医疗机构接受以电子发票替代纸质发票的方式，将大大减少空白纸质发票的使用。同时，电子发票的运用也可解决异地设仓企业票货难以同行的问题。

Corona virus disease 2019 (COVID-19) presents with a severe phenotype in as many as 26% of patients. Medical therapy is lacking, and many of these patients require intubation and even extracorporeal life support[4]. COVID-19 mainly attacks the lungs and other organs that express angiotensin-converting enzyme 2 receptors[5]. Patients with pneumonia who are infected with COVID-19 have been reported to develop pulmonary vesicles and tension pneumothorax with the use of ventilators. Pulmonary vesicles are defined as peripheral predominant consolidation patterns with internal round cystic changes[6]. Because of the high risk of health care worker transmission and the difficulty in performing an operation with full personal protective equipment,operations for patients infected with COVID-19 are quite difficult; thus, these operations are extremely rare. Recently, we performed a bullectomy under special circumstances as the last option to treat a patient.

CASE PRESENTATION

Chief complaints

Intermittent fever for 1 wk.

思维导图是由英国学者Tony Buzan于20世纪60年代提出的，它通过色彩、图形等图文并茂的形式表达一种发散性思维的有效图形，可以达到增强记忆效果的目的，这种图文并重的形式可以将复杂的主题关系用层层的图形表现出来[3]。将思维导图用于“过程控制”教学活动中，可以使学生提高发散思维能力，理清思维脉络。这种教学改革与探索将有利于学生的课程学习和知识体系建立。

History of present illness

The patient suffered from chest tightness and chest pain due to infection with COVID-19 5 d ago. He urgently went to the local hospital to see a doctor. The perfect chest Xray showed a right pneumothorax, and the patient’s dyspnea was progressively worsening. The local hospital gave an emergency tracheal intubation, connected to a ventilator to assist breathing, and transferred him to our intensive care unit for treatment.

Sun等[58]研究发现，在恶唑酮和二硝基氟苯引起的过敏性耳肿胀小鼠中，喂药枇杷核提取物可以显著抑制小鼠体内组胺和肿瘤坏死因子-α含量的增加，对小鼠的过敏性皮炎有拮抗作用。在过敏性鼻炎模型中，枇杷核提取物同样可以抑制大鼠肥大细胞释放组胺，降低打喷嚏的频率[59]。Kim等[60]研究了枇杷叶提取物对小鼠过敏的作用，发现枇杷叶提取物可以降低免疫球蛋白I个E介导的皮肤过敏反应并降低肥大细胞的组胺释放的含量，此外还可以降低因佛波醇12-肉豆蔻酸酯-13-乙酸盐和钙离子载体A23187刺激产生的肿瘤坏死因子的产生。

美国政府高度重视科技创新，率先组织实施各类科技创新计划，如曼哈顿计划、人类基因组计划以及信息高速公路计划等[3]。2007年，美国的次贷危机对美国甚至全球经济产生了巨大冲击，为了激活美国经济，联邦政府于2009年[4]、2011年[5]、2015年[6]相继发布了结合时代背景的《美国创新战略》，对实现美国经济增长和持续创新具有重大的推动作用。以下将对3版美国创新战略进行比较分析。

History of past illness

Denies the history of diabetes, heart disease,. Denies the history of infectious diseases such as tuberculosis and hepatitis. Denies the history of food and drug allergy. Denies the history of trauma surgery.

Personal and family history

Denies the family history of genetic disease.

Physical examination

T 38.3 ℃, P 85 bmp, HR 20 bmp, diastolic blood pressure: 69 mmHg, systolic blood pressure: 116 mmHg, mentally clear, good spirits, no yellowing of skin and mucous membranes throughout the body, and superficial lymph nodes less than swollen.Pharyngeal is not congested, breath sounds in both lungs are clear, heart rhythm is uniform, no pathological murmurs are heard in each valve area. HR 85 bpm, the heart rhythm is uniform, no pathological murmur is heard in each valve area. Abdomen is soft, no tenderness and rebound pain, liver, spleen and ribs are not in reach, Murphy sign is negative, there is no percussion pain in the kidneys, no redness and swelling of the limbs and joints, and no edema of the lower limbs.

This patient with vesicles underwent bullectomy and had a poor prognosis. He showed diffuse alveolar damage and extensive necrosis in bullectomy specimen.

Laboratory examinations

Imaging examinations

The X-ray before bullectomy: Infection of both lungs, massive pneumothorax on the right side; The chest CT scan before bullectomy; Severe infection of both lungs,extensive bullae; The X-ray after bullectomy; The X-ray before bullectomy: Both lung infections, the right pneumothorax improved significantly.

FINAL DIAGNOSIS

Spontaneous pneumothorax, Respiratory failure, lung infection with COVID-19, Septic shock, ARDS.

TREATMENT

Received ECMO support, underwent a bullectomy.

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OUTCOME AND FOLLOW-UP

试验动物选用48周龄、体况一致、体重相近的360只蛋鸡。随机分为4组，每组3个重复，每个重复30只。每个组分别饲喂一种日粮。预试期1周，正式期6周。

DISCUSSION

The etiology of pulmonary bulla is complex and includes chronic obstructive pulmonary disease, emphysema, ventilator-related lung injury, and COVID-19[1].Patients who have pulmonary vesicles shown on chest CT scans, and peripheral predominant consolidation patterns with internal round cystic changes[6], are more prone to pulmonary bullous formation. However, the influence of COVID-19 on pulmonary vesicles has not yet been reported.

正如文中张无忌所说的，只因立场不同，就能下手如此决绝，想杀便杀，对旁人的评价丝毫不放在心上，灭绝师太和韦一笑的行事作风从本质上其实并无区别，同样“自由”。但是他们在江湖中得到的评价一个是一代宗师，一个是邪魔外道，只因二者的心性不同。

Our study found that as alveolar structure destruction occurred quickly, the wall of the air cavity was significantly thicker than that of common pulmonary bulla(Figure 1G and H). In this process, the inflammatory storm is also an important factor[4]. Thus, we believe that the destruction of alveolar structure due to COVID-19 easily induces emphysema and then causes the formation of pulmonary vesicles.

调节矿浆pH值至9.5左右，粗选磨矿细度为-0.074mm%占65%，起泡剂BK204用量为21g/t，对AP系列捕收剂与常规铜捕收剂Z-200分别进行了试验。试验流程见图5，试验结果见图6。从图中试验结果可以看出，AP、AP-II、AP0、AP-K等AP系列捕收剂对铜均具有较好的选择性。本次研究选用AP-K作为粗选I的捕收剂进行后续试验。

Although pulmonary vesicles are not exactly bulla, they can easily develop into them. The most effective approach to treat symptomatic pulmonary bulla is surgical resection[7], which is widely accepted by thoracic surgeons worldwide. Nevertheless,it was a difficult choice for treating COVID-19 patients with pulmonary vesicles. It is clear that when patients have tension pneumothorax, chest drainage tubes must be placed as soon as possible. In this study, one patient underwent bullectomy, with pulmonary vesicles induced by COVID-19 and tension pneumothorax. To our knowledge, this operation was the first bullectomy performed on a COVID-19 patient with both gross and histologic findings. Regrettably, the outcome of this patient was poor after undergoing bullectomy (Figure 1F).

This is also the first report on pathological findings of COVID-19 complicated by emphysematous bulla formation in the lung. Interactions of multiple factors, including diffuse alveolar damage overlapping with extensive necrosis, abundant neutrophils in lung tissue that can produce matrix metalloproteinase, and elevated levels of cytokines such as interleukins in the peripheral blood, may have led to bulla formation in this case.

CONCLUSION

In conclusion, COVID-19 may induce the formation of pulmonary vesicles, which have a thicker air cavity wall than common bulla. Considering ventilator-related lung injury, it is recommended to choose the ventilator mode and PEEP carefully. Based on the extensive destruction of lung tissue by COVID-19, the use of bullectomy is limited,only as a last resort and trial treatment if the patient accepts. More research is needed to explore the specific mechanisms of pulmonary vesicle formation to improve the efficacy of COVID-19 pneumonia treatment, especially in patients with severe COVID-19 with vesicles.

记录两组患者的住院时长、卧床时长、医疗费用、健康知识评分、并发症的发生率以及护理满意度等。其中,护理满意度通过自制的护理满意度调查表进行统计:满意、一般以及不满意。

We thank all our colleagues who helped us during the current study. We greatly appreciate the kind assistance of Professor Bicheng Wang and Doctor Lijun Cai (Both are in the Department of Pathology, Zhongnan Hospital of Wuhan University, Wuhan,China) in staining the sections, as well as Doctor Xianguo Wang and Doctor Zetian Yang (Both are in the Department of Thoracic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China) for his assistance in discussing the key issues of this study.We are also grateful to the many front line medical staff for their dedication in the face of the COVID-19 outbreak, despite the potential threat to their own lives and the lives of their families.