Pulmonary “bulla” are pathologically dilated air spaces distal to the terminal bronchiole and are more than 2 cm in diameter in distended state. Anaesthetic management of a paediatric patient with bullae for thoracic surgery deserves special consideration in view of the possible complications associated with the bullae.

An 11 year old boy with large bullae in left hemithorax was undergoing open thoracotomy for left upper lobectomy. After attaching standard ASA monitors, 18G epidural catheter inserted at T7 level after sedating the patient with Fentanyl and Midazolam. Superior and translaryngeal nerve block given using inj. Lignocaine 2%. Anaesthesia induced with Sevoflurane in oxygen and air and trachea intubated with a 28 F left sided Double Lumen tube with the patient breathing spontaneously. Right radial and PICC line inserted following intubation. Anaesthesia maintained with oxygen-air (Fio2-50%), Isoflurane (MAC- 0.8-1) and epidural boluses of 0.25% Bupivacaine and Fentanyl. Spontaneous ventilation was preserved till chest wall was opened. One lung ventilation was used while dissecting the bullae.

Surgery went on uneventfully and trachea was extubated successfully at the end.

The specific anaesthetic implications in our case were, the presence of the giant bullae in a paediatric patient which can enlarge further under anaesthesia or rupture with IPPV leading to tension pneumothorax. If the bulla is highly compliant, tidal volume may be wasted in the form of dead space ventilation. We avoided nitrous oxide and maintained spontaneous ventilation till the lung was isolated.