Reexpansion Pulmonary Edema

Yosawadee Visoottiviseth, M.D.

Outline
Introduction Incidence Predisposing factors Mechanisms Clinical features Radiographic findings

Reexpansion Pulmonary Edema (RPE)

Uncommon complication of treatment of

Pneumothorax Large pleural effusion

Develop within 2-4 hrs Progress for 1-2 days Resolve within 5-7 days

Hansell DM et al. Imaging of diseases of the chest. 2010.

Incidence
Unknown Generally considered to be very low Can occur after

Treatment of pneumothorax with ICD Large-volume thoracocentesis Intraoperative

Neustein SM. RPE. J Cardiothorac Vasc Anesth 2007; 21(6): 887-891.

Predisposing Factors

Complete pneumothoraces

With gross lung collapse

Most > 3 days Or drainage > 1L

Chronicity of pneumothorax/effusion

High negative aspiration pressure

Hansell DM et al. Imaging of diseases of the chest. 2010.

Mechanisms
Surfactant depletion Hypoxic capillary damage

Increase capillary permeability Immediately prior to the development of pulmonary edema

Marked increase in cardiac output

Hansell DM et al. Imaging of diseases of the chest. 2010.

Lung collapse Decrease lung perfusion Hypoxemic lung reperfusion

Decrease surfactant production

Less compliance Need higher negative aspiration pressure

Hydrostatic mechanisms

Free radical release Capillary endothelial injury Increase capillary permeability

Pulmonary edema
Webb WR et al. Thoracic imaging: pulmonary and cardiovascular radiology. 2011.

Clinical Features

Rapid onset of dyspnea and tachypnea

Within 1-2 hrs after reexpansion of a collapsed lung

Cough Hypotension (from hypovolemia)

Neustein SM. RPE. J Cardiothorac Vasc Anesth 2007; 21(6): 887-891.

Radiographic Findings

Ipsilateral airspace opacity

Consolidation Ground glass opacity

Case reports

Contralateral pulmonary edema after RPE in a collapsed lung

Hansell DM et al. Imaging of diseases of the chest. 2010. Webb WR et al. Thoracic imaging: pulmonary and cardiovascular radiology. 2011.

A 50-year-old smoker presented with acute-onset breathlessness and right-sided chest pain of four days' duration. There was no history of chest trauma. A posteroanterior chest radiograph (Panel A) demonstrated a right-sided pneumothorax. His symptoms improved immediately on placement of a chest tube. Two hours later, he again became breathless, and examination revealed extensive right-sided chest crackles. Chest radiography was repeated and showed a fully expanded right lung (Panel B), albeit with features of pulmonary edema. The arrowheads in Panel B show the position of the chest tube. The patient's condition improved after continuous positive airway pressure was delivered through a face mask overnight. The chest tube was removed after three days. At follow-up six weeks later, the patient was asymptomatic and well. The results of further investigations were consistent with the presence of mild chronic obstructive pulmonary disease.

Tariq SM et al. Reexpansion pulmonary edema after pneumothorax. NEJM 2006; 354: 19.

(A) The x-ray film on the left reveals a moderate-large right effusion. (B) After complete drainage, the x-ray film on the right reveals a hazy ground-glass infiltrate in the right lower-lobe. A follow-up roentgenogram 1 day later revealed complete clearing radiographic resolution of this opacity. (C) The chest CT scan on the left reveals a large left pleural effusion with contralateral shift of the mediastinum and total left lung atelectasis. (D) The CT scan on the right reveals ground-glass airspace opacities in the left upper and lower lobes. These had completely resolved on a follow-up chest CT scan 2 weeks later.

Feller-Kopman D et al. Ann Thorac Surg 2007;84:1656-1661.

Treatment
Supportive PEEP Diuresis Vasopressor Prostaglandin analogs

Misoprostol, ibuprofen, indocin

Neustein SM. RPE. J Cardiothorac Vasc Anesth 2007; 21(6): 887-891.

Prevention

Dont apply suction too early after insertion of a chest tube

After 48 hrs, in case of persistent pneumothorax

Use suction pressure -10 to -20 cmH2O

Neustein SM. RPE. J Cardiothorac Vasc Anesth 2007; 21(6): 887-891.

Conclusion
RPE is a rare complication Occur after reexpansion of a collapsed lung Develop within 2-4 hrs Progress for 1-2 days Resolve within 5-7 days

References

Hansell DM et al. Imaging of diseases of the chest. 2010. Webb WR et al. Thoracic imaging: pulmonary and cardiovascular radiology. 2011. Neustein SM. Reexpansion pulmonary edema. J Cardiothorac Vasc Anesth 2007; 21(6): 887-891. Tariq SM et al. Reexpansion pulmonary edema after pneumothorax. NEJM 2006; 354: 19. Feller-Kopman D et al. Large-Volume Thoracentesis and the risk of reexpansion pulmonary edema. Ann Thorac Surg 2007;84:1656-1661.