Pulmonary blisters are air bubbles located under the dirty pleura or in the lung parenchyma and are generally significant when they are 0.8 cm or more. It is more common in young or elderly people and has both congenital and secondary causes. It is equivalent to a time bomb in the human body, with about 50% chance of spontaneous rupture and 100% chance of spontaneous expansion and enlargement. Therefore, clinically significant pulmonary blisters should be treated clinically to exclude the bombs in the body. In the past, the traumatic open-heart surgery forced people to balance the gain and loss between the trauma of the incision and the surgical cure, while the endoscopic technique eliminated the gain and loss and cured almost 100% of this disorder. As with the diagnosis of pneumothorax, only CT examination can confirm the number and localization of pulmonary blisters, while general chest radiographs and chest x-rays do not provide a comprehensive and clear overview of pulmonary blisters. Therefore, the diagnostic value of CT for pulmonary blisters is again emphasized. Pulmonary blisters are usually secondary to inflammatory lesions of the fine bronchi. For example, pneumonia, emphysema and tuberculosis, most often coexist clinically with emphysema. Pulmonary blisters secondary to pneumonia or lung abscess are most often seen in infants and young children, either singly or in multiple cases. Due to inflammatory lesions, the small bronchial mucosa is edematous, resulting in partial obstruction of the lumen, producing a live door effect, and air can enter the alveoli and not be easily discharged. Chest x-ray interpretation is the main method to recognize and diagnose pulmonary blisters. The manifestation is characterized by increased lung translucency and thin-walled cavities of varying sizes and numbers. The cavities are sparsely textured or have only striated shadows and are surrounded by compressed dense lung tissue. Large pulmonary blisters can look similar to a pneumothorax and are difficult to identify. CT is an effective differential diagnostic method that reduces the overlapping shadows of pulmonary bullae in stereoscopic position, can show the extent of the bullae, and also helps to differentiate them from pneumothorax. When diagnosing pneumothorax and massive pulmonary blister, thoracentesis should be done with caution. In the beginning, if the pulmonary herpes is mistaken for pneumothorax and thoracentesis is performed, it may lead to pneumothorax of medical origin and even become a tension pneumothorax. If no distinction can be made between pulmonary herpes or tension pneumothorax and the patient is in high respiratory distress, temporary puncture or drainage and decompression may be recommended in emergency situations to save life, but at the same time, preparations for further thoracotomy should be made. Spontaneous pneumothorax is the most common complication of pulmonary maculoplasty, followed by infection and spontaneous hemopneumothorax. 1. Spontaneous pneumothorax pulmonary blister can be asymptomatic. When the pressure suddenly increases during sudden exertion, such as violent cough, heavy lifting or sports, the pulmonary blister ruptures and gas enters the pleural cavity from the lung, forming spontaneous pneumothorax, there may be difficulty in breathing, shortness of breath, panic, rapid pulse, etc. The pneumothorax makes the negative pressure in the pleural cavity disappear, and the gas compresses the lung tissue to make it atrophy toward the hilum, the degree of atrophy depends on the amount of gas entering the pleural cavity and the original The degree of atrophy depends on the amount of gas entering the chest cavity and the pathology of the original lesions of the lung and pleura. If the patient has emphysema, pulmonary fibrosis, long-term chronic infection of lung tissue, etc. in addition to pulmonary herpes, when the pulmonary herpes ruptures, although some of the gas enters the chest cavity, and the degree of lung tissue atrophy can be less, but because the patient’s original lung function has been reduced, the symptoms are also more serious. After the rupture of the pulmonary blister, a small part of the fissure is small, and the fissure closes by itself after the lung tissue atrophy, the air leakage stops, the pneumothorax is gradually absorbed, the negative chest pressure is restored, and the lung reopening is healed. 2. Tension pneumothorax if the lung blister ruptures and forms a live valve, the negative pressure in the chest cavity increases when inhaling, the gas enters the chest cavity, and the live valve closes when exhaling, the gas cannot be discharged, especially when coughing, the airway pressure increases when the vocal valve closes, the gas enters the chest cavity, the vocal valve opens, the airway pressure decreases, the fissure closes again, and the amount of gas in the chest cavity increases with each breath and cough, forming tension pneumothorax. In tension pneumothorax, the lung tissue on the affected side is completely atrophied and the mediastinum is pushed to the healthy side, while the lung tissue on the healthy side is also compressed and the large blood vessels of the heart are displaced and the large veins are distorted and deformed, which affects the blood return and causes serious obstruction to the respiratory circulation. The affected side of the thorax is elevated, mostly accompanied by subcutaneous emphysema on the affected side, and the trachea is obviously displaced to the healthy side, which is critical and often requires emergency treatment. 3. Spontaneous hemothorax caused by pulmonary blister, most of the spontaneous hemothorax caused by the apical pulmonary blister or pulmonary tissue around the blister and the apex of the chest adhesions and adhesion tears active bleeding. The small arteries in the adhesion zone can be up to 0.2 cm in diameter, and the vessels originate from the body circulation with high pressure, while the thoracic cavity is under negative pressure, which increases the tendency of bleeding. In addition, the bleeding is difficult to stop automatically because the blood in the thoracic cavity does not coagulate due to the defibrotic effect of lung, heart and diaphragm movements. Clinical symptoms may vary depending on the speed of bleeding. When bleeding is slow, patients may present with gradually increasing chest tightness, dyspnea, blunted diaphragm angle visible on X-ray, or parabolic images of pleural effusion. When bleeding is rapid, shock can be manifested in a short period of time. 4. spontaneous hemopneumothorax When the adhesions between the pulmonary blister and surrounding lung tissues and chest wall are torn, if there are blood vessels ruptured in the adhesion zone and the lung tissues are also damaged, spontaneous hemopneumothorax is formed. In recent years, some scholars pointed out that the amplitude of diaphragm activity may play a decisive role in the occurrence of spontaneous hemopneumothorax, and that the amplitude of diaphragm activity increases during vigorous activities such as rejection of air and force, which produces a sudden direct or indirect pull on the adhesive band at the top of the chest. If the tear is on the wall side or central part of the cord, only a hemothorax will occur. The diaphragm is more active in long and lean young people, and because the pectoral muscles are more underdeveloped, they rely more on abdominal breathing. Women are predominantly thoracic breathers and have a lower incidence. The right lung is triple-lobed and its lobe space plays a buffering role against the violent downward pull, and there is still a liver under the right lung, which may be the reason why the right side has less morbidity. Therefore, patients with spontaneous hemopneumothorax are characterized by young age, more males than females, more left side than right side, and more long and lean body type. Bilateral spontaneous pneumothorax also occurs from time to time, mostly with the left side first and the right side second, and in individual cases, it occurs bilaterally at the same time, and the condition is critical and even life-threatening. 5. Secondary infection of pulmonary blisters In most cases, pulmonary blisters occur at the distal end of the bronchus above the eighth level, and most of them are not infected, but if the draining bronchus is blocked and the bronchus of pulmonary blisters is filled with inflammatory secretions, patients may have fever, cough, cough and other symptoms of infection. Small sized pulmonary blisters, especially patients aged >60 years, with chronic obstructive pulmonary disease and low respiratory function are not suitable for surgery. Treatment is mostly non-surgical, such as abstinence from smoking, exercise of lung function, and control of respiratory tract infections. In addition to the above, surgical treatment should be considered for bulky pulmonary blisters, especially for recurrent complications such as spontaneous pneumothorax or secondary infections. The most advanced surgical treatment is thoracoscopic radical resection of pulmonary herpes, which has been carried out in many cases in the Department of Thoracic Surgery of Shanghai Yuanda Cardiothoracic Hospital, and patients come to us by name. 1. The key point of pulmonary herpes resection surgery is to cut open the pulmonary herpes and then carefully suture the air leakage area. The excess wall of the herpes is partially excised and the edges are sutured. Smaller pulmonary blisters can be sutured or ligated. For bilateral pulmonary herpes, the surgery can be done bilaterally with a split excision or bilateral open heart in one go, depending on the patient’s condition. Some people make wall pleurodesis or apply other methods to promote adhesions between lung and chest wall to prevent recurrence of spontaneous pneumothorax after removal of pulmonary blisters. Pneumonectomy can be performed via televised thoracoscopy if available. If there is no normal lung tissue after resection of pulmonary blister, lobectomy can be considered according to the patient’s respiratory function. External drainage of the pulmonary herpes is used as a temporary or long-term treatment for patients with pulmonary herpes who are at great risk for open chest. A 2.5 cm section of rib is removed from the herpes closest to the chest wall, and sutures are placed through both the wall pleura and the wall of the herpes as purse-string sutures with the wall pleura intact. A flexible rubber tube with a balloon is inserted. After filling the balloon and pulling the drainage tube to tighten the wall of the herpes against the chest wall, the drainage tube was fixed properly. And intensify antibiotic therapy. The need for drainage is much longer than after pulmonary herpetotomy. Infection usually occurs more or less seriously, and infection sometimes helps the herpes to close.