A 41 year old patient presents with symptoms of increasing shortness of breath and the CT scan is done. The treatment of choice for the lesion illustrated in the figure is

A. bronchodilators, chest physiotherapy and steroids for periodic exacerbations.
B. bronchoscopic drainage.
C. course of pulmonary rehabilitation.
D. excision of the lesion.
E. tube thoracostomy.

Answer D

The recruitment of poorly ventilated, compressed lung parenchyma is the primary aim in the treatment of giant bullous disease. It is unlikely that bronchodilators or chest physiotherapy provide much relief, but both of these modalities are useful in the perioperative period. Chest physiotherapy may be especially useful in a patient who is a chronic sputum producer. Steroids may also be of use in the perioperative period when there is reversible airways disease, but these drugs may contribute to a prolonged air leak following operation. 

Bronchoscopic drainage is extremely useful for a lung abscess where drainage is probably more important than antibiotic therapy. It has no place in the management of giant bullous disease. 

Pulmonary rehabilitation, a prescribed course of treadmill walking, bicycling, and upper body conditioning while transcutaneous oximetry is measured, may be extremely helpful in getting debilitated patients through the perioperative period. Patients often improve their exercise capability during the rehabilitation period to a remarkable degree, much to their (and their doctor's) surprise.