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The curve after the development of giant bulla is shifted to the right with decreased flow rates. Progressive narrowing and/or distortion of airways surrounding the expanding bulla may explain this.

The surgical removal of a giant bulla in generalized emphysema is an accepted procedure. The success depends on the size of the bulla and evidence of retraction of adjacent lung tissue. Long-term follow-up after a giant bullectomy reveals little recurrence and decline in pulmonary function comparable to the general population., In our case, we cannot be sure whether bulla formation represented natural disease progression or a consequence of LVRS. However, the temporal relation to the LVRS, as well as above considerations, suggest that bulla formation was a consequence of the surgery read only.

In conclusion, we speculate that heterogeneous improvement of elastic lung recoil after LVRS contributed to the bulla formation. The retraction of lung surrounding the bulla may have distorted or narrowed the bronchi, thus leading to decreased flow rates at comparable recoil pressures over the long term. This patient fared poorly after the bullectomy, and it is not clear if this procedure can be recommended for treatment of this possible complication of LVRS.
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