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Reexpansion pulmonary edema
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01.20.06 (2 years ago)
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Unilateral reexpansion pulmonary edema is a rare life threatening complication of the treatment of lung atelectasis, pleural effusion or pneumothorax. However the pathogenesis is not completely understood5. It is characterized by the development of unilateral pulmonary edema in a lung that has been rapidly re-inflated following a variable period of collapse secondary to a pleural effusion or pneumothorax6. Miller et al2 showed that in the experimental animal, REPE occurs only if the lung has been collapsed for more than 3 days and if negative pressure is applied to the pleural space. However reexpansion pulmonary edema in humans have occurred when no negative pressure was applied to the pleural effusion4,7.
The etiology of REPE remains incompletely defined and is multi factorial in nature. It appears to be due to increased permeability of the pulmonary vasculature. High protein content has been found in edema fluid8 indicating that it is leakiness of the capillaries rather than an increased hydrostatic pressure difference that leads to the edema. It has also been suggested that the lung injury could be due to reperfusion and oxygen free radical formation in the collapsed lung9. This hypothesis is supported by the observation that inhalation of oxygen (FiO2 0.4) prevents pulmonary edema when lungs are reexpanded10.
The clinical picture varies considerably from asymptomatic radiological findings to dramatic respiratory failure with circulatory shock. The commonest presentation is pernicious cough or chest tightness during or immediately following thoracentesis or chest tube placement. The cough can be productive with copious amounts of frothy pink sputum. Other symptoms include dyspnea, tachypnea, tachycardia, fever, hypotension, nausea, vomiting, and cyanosis. The symptoms progress for 24 to 48 hours, and the chest radiograph reveals pulmonary edema in the ipsilateral lung. Rarely pulmonary edema can be bilateral or in contra lateral lung. If the patient does not die within the first 48 hours, recovery is usually complete11. In a review of 53 reported cases by Volpicelli et al, there were 11 deaths (20%)5.
There is a trend for the duration of collapse to be a risk for reexpansion pulmonary edema in patients with effusions or pneumothoraces who are undergoing tube thoracostomy or thoracentesis12. In such cases underwater-seal drainage should be preferred rather than to a negative pressure apparatus. The amount of pleural fluid withdrawn during thoracentesis should be limited to 1000 ml unless pleural pressures are monitored (11). Matsura et al revealed young age and extent of lung collapse as independent risk factors for reexpansion pulmonary edema12.
The management of reexpansion pulmonary edema differs distinctly from that of cardiogenic pulmonary edema13. The best treatment of reexpansion pulmonary edema remains supportive with intravenous fluids, oxygen, and morphine. Diuresis is detrimental due to hypovolemic status and should be avoided11. In severe conditions mechanical ventilation is required; however there are a few literature case reports of the treatment of reexpansion pulmonary edema with non-invasive continuous positive airway pressure5.
References
1. Murat A, Arslan A, Balci AE. Acta Radiol. 2004 ;45(4):431-3.
2. Miller WC, Toon R, Palat H, et al. Experimental pulmonary edema following re-expansion of pneumothorax. Am Rev Respir Dis 1973;8:664-6.
3. Trachiotis GD, Vricella LA, Aaron BL, Hix WR. Reexpansion pulmonary edema. Updated in 1997. Ann Thorac Surg 1997;63:1207.
4. Mahfood S, Hix WR, Aaron BI, et al. Re-expansion pulmonary edema. Ann Thorac Surg 1988;45:340-345.
5. Volpicelli G, Fogliati C, Radeschi G, Frascisco M. A case of unilateral re-expansion pulmonary oedema successfully treated with non-invasive continuous positive airway pressure. Eur J Emerg Med. 2004;11(5):291-4.
6. Tarver RD, Broderick LS, Conces DJ Jr. Reexpansion pulmonary edema. J Thorac Imaging 1996;11:198-202.
7. Olcott EW. Fatal Reexpansion pulmonary edema following pleural catheter placement. J Vasc Interv Radiol 1994;5:176-178.
8. Waqaruddin M, Bernstein A. Re-expansion pulmpnary edema. Thorax 1975;30:54-60.
9. Pavlin DJ. Lung re-expansion: for better or worse. Chest 1986;89:2-3
10. Pavlin DJ, Nessly ML, Cheney FW. Hemodynamic effects of rapidly evacuating prolonged pneumothorax in rabbits. J Appl Physiol 1987;62:477-484
11. Light RW. Pleural Disease. 4th ed. Baltimore:Williams & Wilkins, 2003; 370.
12. MatsuraY, Nomimura T, Murakami H, Matsushima T, Kakehashi M, Kajihara H. Clinical analysis of reexpansion pulmonary edema. Chest 1991; 100:1562-1566.
13. Beng ST, Mahadevan M. An uncommon life-threatening complication after chest tube drainage of pneumothorax in the ED. Am J Emerg Med. 2004;22(7):615-619.
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