Re-expansion pulmonary edema

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


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


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)


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


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


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


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.

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Re-expansion pulmonary edema