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Reexpansion Reexpansion Pulmonary EdemaPulmonary Edema
Yosawadee Visoottiviseth, M.D.Yosawadee Visoottiviseth, M.D.
Outline Outline
IntroductionIntroduction IncidenceIncidencePredisposing factorsPredisposing factorsMechanismsMechanismsClinical featuresClinical featuresRadiographic findingsRadiographic findings
Reexpansion Pulmonary Edema (RPE)Reexpansion Pulmonary Edema (RPE)
Uncommon complication of treatment ofUncommon complication of treatment ofPneumothoraxPneumothoraxLarge pleural effusionLarge pleural effusion
Develop within 2-4 hrs Develop within 2-4 hrs Progress for 1-2 daysProgress for 1-2 daysResolve within 5-7 daysResolve within 5-7 days
Hansell DM et al. Imaging of diseases of the chest. 2010.
Incidence Incidence
UnknownUnknownGenerally considered to be very lowCan occur after
Treatment of pneumothorax with ICDLarge-volume thoracocentesisIntraoperative
Neustein SM. RPE. J Cardiothorac Vasc Anesth 2007; 21(6): 887-891.
Predisposing FactorsPredisposing Factors
Complete pneumothoraces Complete pneumothoraces With gross lung collapseWith gross lung collapse
Chronicity of pneumothorax/effusionChronicity of pneumothorax/effusionMost > 3 daysMost > 3 days
High negative aspiration pressureHigh negative aspiration pressureOr drainage > 1LOr drainage > 1L
Hansell DM et al. Imaging of diseases of the chest. 2010.
Mechanisms Mechanisms
Surfactant depletionSurfactant depletionHypoxic capillary damage Hypoxic capillary damage
Increase capillary permeabilityIncrease capillary permeabilityMarked increase in cardiac outputMarked increase in cardiac output
Immediately prior to the development of Immediately prior to the development of pulmonary edemapulmonary edema
Hansell DM et al. Imaging of diseases of the chest. 2010.
Webb WR et al. Thoracic imaging: pulmonary and cardiovascular radiology. 2011.
Lung collapse
Decrease lung perfusion
Hypoxemic lung
Free radical release
Capillary endothelial injury
Increase capillary permeabilityHydrostatic mechanisms
Less compliance
Need higher negative aspiration pressure
Decrease surfactant production
Pulmonary edema
reperfusion
Clinical FeaturesClinical Features
Rapid onset of dyspnea and tachypneaWithin 1-2 hrs after reexpansion of a
collapsed lungCoughHypotension (from hypovolemia)
Neustein SM. RPE. J Cardiothorac Vasc Anesth 2007; 21(6): 887-891.
Radiographic FindingsRadiographic Findings
Ipsilateral airspace opacityIpsilateral airspace opacityConsolidationConsolidationGround glass opacityGround glass opacity
Case reportsCase reportsContralateral pulmonary edema after RPE in a Contralateral pulmonary edema after RPE in a
collapsed lungcollapsed 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-yearA 50-year--old smoker presented with acuteold smoker presented with acute--onset breathlessness and rightonset breathlessness and right--sided chest pain of sided chest pain of four days' durationfour days' duration. . There was no history of chest traumaThere was no history of chest trauma. . A posteroanterior chest radiograph A posteroanterior chest radiograph ((Panel APanel A) ) demonstrated a rightdemonstrated a right--sided pneumothoraxsided pneumothorax. . His symptoms improved immediately on His symptoms improved immediately on placement of a chest tubeplacement of a chest tube. . Two hours later, he again became breathless, and examination Two hours later, he again became breathless, and examination revealed extensive rightrevealed extensive right--sided chest cracklessided chest crackles. . Chest radiography was repeated and showed a Chest radiography was repeated and showed a fully expanded right lung fully expanded right lung ((Panel BPanel B)), albeit with features of pulmonary edema, albeit with features of pulmonary edema. . The arrowheads in The arrowheads in Panel B show the position of the chest tubePanel B show the position of the chest tube. . The patient's condition improved after continuous The patient's condition improved after continuous positive airway pressure was delivered through a face mask overnightpositive airway pressure was delivered through a face mask overnight . . The chest tube was The chest tube was removed after three daysremoved after three days. . At followAt follow--up six weeks later, the patient was asymptomatic and wellup six weeks later, the patient was asymptomatic and well . . The results of further investigations were consistent with the presence of mild chronic obstructive The results of further investigations were consistent with the presence of mild chronic obstructive pulmonary diseasepulmonary 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 Treatment
SupportiveSupportivePEEPPEEPDiuresisDiuresisVasopressor Vasopressor Prostaglandin analogsProstaglandin analogs
Misoprostol, ibuprofen, indocinMisoprostol, ibuprofen, indocin
Neustein SM. RPE. J Cardiothorac Vasc Anesth 2007; 21(6): 887-891.
Prevention Prevention
Don’t apply suction too early after insertion Don’t apply suction too early after insertion of a chest tubeof a chest tubeAfter 48 hrs, in case of persistent After 48 hrs, in case of persistent
pneumothoraxpneumothorax
Use suction pressure -10 to -20 cmHUse suction pressure -10 to -20 cmH22OO
Neustein SM. RPE. J Cardiothorac Vasc Anesth 2007; 21(6): 887-891.
Conclusion Conclusion
RPE is a rare complicationRPE is a rare complicationOccur after reexpansion of a collapsed Occur after reexpansion of a collapsed
lunglungDevelop within 2-4 hrs Develop within 2-4 hrs Progress for 1-2 daysProgress for 1-2 daysResolve within 5-7 daysResolve within 5-7 days
References 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.