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

INTRODUCTION

因電子發票與紙質發票具有同等法律效力，如果公立醫療機構接受以電子發票替代紙質發票的方式，將大大減少空白紙質發票的使用。同時，電子發票的運用也可解決異地設倉企業票貨難以同行的問題。

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.

思維導圖是由英國學者Tony Buzan于20世紀60年代提出的，它通過色彩、圖形等圖文并茂的形式表達一種發散性思維的有效圖形，可以達到增強記憶效果的目的，這種圖文并重的形式可以將復雜的主題關系用層層的圖形表現出來[3]。將思維導圖用于“過程控制”教學活動中，可以使學生提高發散思維能力，理清思維脈絡。這種教學改革與探索將有利于學生的課程學習和知識體系建立。

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]研究發現，在惡唑酮和二硝基氟苯引起的過敏性耳腫脹小鼠中，喂藥枇杷核提取物可以顯著抑制小鼠體內組胺和腫瘤壞死因子-α含量的增加，對小鼠的過敏性皮炎有拮抗作用。在過敏性鼻炎模型中，枇杷核提取物同樣可以抑制大鼠肥大細胞釋放組胺，降低打噴嚏的頻率[59]。Kim等[60]研究了枇杷葉提取物對小鼠過敏的作用，發現枇杷葉提取物可以降低免疫球蛋白I個E介導的皮膚過敏反應并降低肥大細胞的組胺釋放的含量，此外還可以降低因佛波醇12-肉豆蔻酸酯-13-乙酸鹽和鈣離子載體A23187刺激產生的腫瘤壞死因子的產生。

美國政府高度重視科技創新，率先組織實施各類科技創新計劃，如曼哈頓計劃、人類基因組計劃以及信息高速公路計劃等[3]。2007年，美國的次貸危機對美國甚至全球經濟產生了巨大沖擊，為了激活美國經濟，聯邦政府于2009年[4]、2011年[5]、2015年[6]相繼發布了結合時代背景的《美國創新戰略》，對實現美國經濟增長和持續創新具有重大的推動作用。以下將對3版美國創新戰略進行比較分析。

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.

通過采取科學有效的識記方式，學生在記憶單詞時的難度明顯降低，對于詞匯學習的興趣也會提升，自然能更好地融入英語課堂。

OUTCOME AND FOLLOW-UP

試驗動物選用48周齡、體況一致、體重相近的360只蛋雞。隨機分為4組，每組3個重復，每個重復30只。每個組分別飼喂一種日糧。預試期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.

正如文中張無忌所說的，只因立場不同，就能下手如此決絕，想殺便殺，對旁人的評價絲毫不放在心上，滅絕師太和韋一笑的行事作風從本質上其實并無區別，同樣“自由”。但是他們在江湖中得到的評價一個是一代宗師，一個是邪魔外道，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.

調節礦漿pH值至9.5左右，粗選磨礦細度為-0.074mm%占65%，起泡劑BK204用量為21g/t，對AP系列捕收劑與常規銅捕收劑Z-200分別進行了試驗。試驗流程見圖5，試驗結果見圖6。從圖中試驗結果可以看出，AP、AP-II、AP0、AP-K等AP系列捕收劑對銅均具有較好的選擇性。本次研究選用AP-K作為粗選I的捕收劑進行后續試驗。

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.

記錄兩組患者的住院時長、臥床時長、醫療費用、健康知識評分、并發癥的發生率以及護理滿意度等。其中,護理滿意度通過自制的護理滿意度調查表進行統計:滿意、一般以及不滿意。

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.