Acute respiratory distress syndrome of the contralateral lung after reexpansion pulmonary edema of a collapsed lung

Acute contralateral reexpansion pulmonary edema within a few hours of pleural drainage

We report a case of an 83-year-old male patient with massive tuberculous pleural effusion. Percutaneous drainage was performed following a diagnosis of tuberculous pleurisy. Fifteen minutes into the procedure, the patient's condition deteriorated suddenly, necessitating mechanical ventilatory support. A chest radiograph performed after intubation showed partial collapse of the affected lung with pneumothorax. Despite sufficient air drainage and lung expansion, the patient's oxygen demand remained high. A repeat chest radiograph performed 30 minutes after chest tube insertion revealed partial expansion of the affected lung and severe infiltrative patterns in the unaffected lung, suggesting contralateral reexpansion pulmonary edema.

Severe localized re-expansion pulmonary oedema: An unusual instance

A lobar re-expansion pulmonary oedema (REPO) after pleural drainage procedure is rare and usually asymptomatic. We report a 56-year-old man with severe left lower lobar REPO after tube thoracostomy drainage of a loculated hydro-pneumothorax of 2 days' duration with underlying chronic obstructive pulmonary disease. The clinical manifestations were immediate and disproportionate to the radiological extent of REPO. The severity of lobar REPO was probably related to the pre-existing emphysematous changes and airway obstruction. Supplemental oxygen and intermittent pleural drainage led to clinical recovery within 24 hours, followed by radiological clearance of alveolar opacities within 3 days.

Contralateral reexpansion pulmonary edema with ipsilateral collapsed lung after pleural effusion drainage: a case report

Reexpansion pulmonary edema is a rare but potentially life-threatening condition that occurs when a collapsed lung reexpands, usually in the same side of collapsed lung. We present a rare case in which a 57-year-old Korean man had a large amount of malignant pleural effusion. After undergoing tube thoracostomy drainage for the pleural effusion, a contralateral reexpansion pulmonary edema developed while the ipsilateral lung was half collapsed. The patient was dyspneic with an oxygen saturation that dropped to 66 %. After conservative treatment with oxygen therapy, steroid administration, and negative suction application (suction pressure of -20 cm H₂O) in the right pleural cavity for five days, the right lung could be fully expanded without development of reexpansion pulmonary edema, and the reexpansion pulmonary edema in the left lung resolved. Although it is a very rare condition, it is important to know that contralateral occurrence of reexpansion pulmonary edema can occur, especially when the ipsilateral lung is collapsed. Being aware of this potential condition can allow for early and proper management.

Predictive value of systemic and local inflammation parameters in talc pleurodesis assessment

BACKGROUND

One option for the palliative treatment of recurrent malignant pleural effusion is powdered talc using thoracoscopy. This paper presents the results of selected systemic and local manifestations of the talc-induced inflammatory reaction using a videothoracoscope.

METHOD

A total of 114 patients with repeated malignant pleural effusion were treated at the Cardiac Surgery Clinic in Hradec Kralove from January 2010 to December 2012. Those with a life expectancy more than ≥ 3 months were eligible for talcage surgery. The group was retrospectively divided according to treatment results into Group A (N1 = 98 - successful) and Group B (N2 = 16 - relapsing). The pleural effusion was quantified using ultrasound over 1 year at 3-month intervals. Systemic changes due to the inflammatory reaction (body temperature, serum leukocyte and CRP levels) were evaluated. Local indicators of inflammation included changes in the leukocyte cell population in the effusion and changes in the pleural CRP levels. The dynamics of local expression of membrane receptors TLR-2 and CD-64 on granulocyte and monocyte cell populations in the pleural effusion were also evaluated.

RESULTS

The reaction after talcage, included a significant increase in axillary temperature and leukocyte count, 12 h after the procedure. The dynamics were different in the two groups. The dynamics of local inflammatory changes were an early increase in the pleural CRP levels in both groups. The time interval of local inflammatory development and duration was related to the treatment efficacy and showed a significant rise 2 h after talcage in Group A. In Group B the local inflammatory reaction was slower and the rise was only observed 24 h after talc application. A decrease in lymphocyte count and an increase in granulocyte count 2 h after talcage were found. After an initial drop in monocyte level, a rise occurred within 24 h after talcage. Changes in the expression of TLR-2 and CD-64 receptors in relation to their cell carriers were observed depending on time after talcage.

CONCLUSION

The differences in the serum and pleural effusion CRP levels suggest that the surgical stress manifests itself locally in the pleural space with a lower intensity and time delay. The TLR-2 and CD-64 receptors exhibit different behaviour depending on the type of cell membrane where they are found. The inverse relation between the granulocyte increase and TLR-2 receptor decrease in the membrane immediately after talcage is a new finding. The dynamics of TLR-2 expression on the monocytes demonstrates a direct proportion between the increasing expression of the TLR-2 receptor and increasing percent fraction of the cell carrier.

Propofol attenuates pulmonary injury induced by collapse and reventilation of lung in rabbits

Propofol is an anesthetic drug with antioxidant and anti-inflammatory properties. We previously found that propofol attenuated lipopolysaccharide-induced acute lung injury in rabbits. This study was performed to evaluate the effects of propofol on lung injury caused by collapse and reventilation in rabbits. The wet/dry weight ratio of the lung, lung injury scores, percentage of polymorphonuclear leukocytes, albumin concentration, malondialdehyde, and interleukin-8 levels in bronchoalveolar lavage fluid were significantly increased in both lungs of the reventilation group. The degree of increase in these parameters was more significant in the right (reventilated) than in the left (non-reventilated) lung. Propofol attenuated these changes. These findings suggest that reventilation of a collapsed lung can cause injury in the contralateral non-reventilated lung as well as the reventilated lung. Propofol may provide a beneficial effect on lung injury induced by collapse and reventilation of the lung.

Hyperoxia during one lung ventilation: inflammatory and oxidative responses

BACKGROUND

It is common practice during one lung ventilation (OLV) to use 100% oxygen, although this may cause hyperoxia- and oxidative stress-related lung injury. We hypothesized that lower oxygen (FiO(2) ) during OLV will result in less inflammatory and oxidative lung injury and improved lung function.

METHODS

Twenty pigs (8.88 ± 0.84 kg; 38 ± 4.6 days) were assigned to either the hyperoxia group (n = 10; FiO(2)  = 100%) or the normoxia group (n = 10; FiO(2)  < 50%). Both groups were subjected to 3 hr of OLV. Blood samples were tested for pro-inflammatory cytokines and lung tissue was tested for these cytokines and oxidative biomarkers.

RESULTS

There were no differences between groups for partial pressure of CO(2) , tidal volume, end-tidal CO(2) , plasma cytokines, or respiratory compliance. Total respiratory resistance was greater in the hyperoxia group (P = 0.02). There were higher levels of TNF-α, IL-1β, and IL-6 in the lung homogenates of the hyperoxia group than in the normoxia group (P ≤ 0.01, 0.001, and 0.001, respectively). Myeloperoxidase and protein carbonyls (PC) were higher (P = 0.03 and P = 0.01, respectively) and superoxide dismutase (SOD) was lower in the lung homogenates of the hyperoxia group (P ≤ 0.001).

CONCLUSION

Higher myeloperoxidase, PC, and cytokine levels, and lower SOD availability indicate a greater degree of injury in the lungs of the hyperoxia animals, possibly from using 100% oxygen. In this translational study using a pig model, FiO(2)  ≤ 50% during OLV reduced hyperoxic injury and improved function in the lungs.

Surfactant administration prior to one lung ventilation: physiological and inflammatory correlates in a piglet model

OBJECTIVES

To test the hypothesis that surfactant, when given prophylactically during one lung ventilation (OLV), improves physiological stability and reduces inflammation.

METHODS

Prospective controlled animal study. After 30 min of mechanical ventilation, surfactant was administered to the left lung of the treatment group. Right lung mechanical ventilation continued for 3 hr, after which the left lung was unblocked. Bilateral mechanical ventilation was continued for 30 min thereafter. Physiological parameters and biomarkers of inflammation in plasma, lung tissue homogenates, and bronchoalveolar lavage (BAL) were measured.

MEASUREMENTS AND MAIN RESULTS

Oxygenation improved in the surfactant group, reaching statistical significance at 3 hr of OLV and again after 30 min of bilateral mechanical ventilation following the OLV. Plasma levels of interleukin (IL)-1 β, IL-6, and tumor necrosis factor (TNF)-α showed a trend for reduction. The lung homogenates from the ventilated lungs had significantly lower levels of IL-1 β (P < 0.01) and IL-6 (P < 0.01). The BAL specimen showed an overall reduction in the cytokine levels; IL-1 β was significantly lower in the ventilated lungs (P < 0.01).

CONCLUSIONS

Surfactant administration improves oxygenation and decreases inflammation, as evidenced by a decrease in several inflammatory cytokines both in the plasma and lungs of a piglet model of OLV.

Reexpansion pulmonary edema following a posttraumatic pneumothorax: a case report and review of the literature

The reexpansion pulmonary edema is a rare, but life threatening complication of a pneumothorax. Early recognition and a fast symptom orientated therapy are necessary for a good outcome. Several cases after non traumatic pneumothoraces are reported. We describe a patient who presented with a post-traumatic right pneumothorax. After the insertion of a chest tube he developed a reexpansion pulmonary edema, which had to be treated by an intubation.

Additionally, a review of the literature regarding case reports of reexpansion pulmonary edema is presented.

Human models of acute lung injury

Acute lung injury (ALI) is a syndrome that is characterised by acute inflammation and tissue injury that affects normal gas exchange in the lungs. Hallmarks of ALI include dysfunction of the alveolar-capillary membrane resulting in increased vascular permeability, an influx of inflammatory cells into the lung and a local pro-coagulant state. Patients with ALI present with severe hypoxaemia and radiological evidence of bilateral pulmonary oedema. The syndrome has a mortality rate of approximately 35% and usually requires invasive mechanical ventilation. ALI can follow direct pulmonary insults, such as pneumonia, or occur indirectly as a result of blood-borne insults, commonly severe bacterial sepsis. Although animal models of ALI have been developed, none of them fully recapitulate the human disease. The differences between the human syndrome and the phenotype observed in animal models might, in part, explain why interventions that are successful in models have failed to translate into novel therapies. Improved animal models and the development of human in vivo and ex vivo models are therefore required. In this article, we consider the clinical features of ALI, discuss the limitations of current animal models and highlight how emerging human models of ALI might help to answer outstanding questions about this syndrome.

Protective ventilation to reduce inflammatory injury from one lung ventilation in a piglet model

OBJECTIVES

To test the hypothesis that protective ventilation strategy (PVS) as defined by the use of low stretch ventilation (tidal volume of 5 ml x kg(-1) and employing 5 cm of positive end expiratory pressure (PEEP) during one lung ventilation (OLV) in piglets would result in reduced injury compared to a control group of piglets who received the conventional ventilation (tidal volume of 10 ml x kg(-1) and no PEEP).

BACKGROUND

PVS has been found to be beneficial in adults to minimize injury from OLV. We designed the current study to test the beneficial effects of PVS in a piglet model of OLV.

METHODS

Ten piglets each were assigned to either 'Control' group (tidal volume of 10 ml x kg(-1) and no PEEP) or 'PVS' group (tidal volume of 5 ml x kg(-1) during the OLV phase and PEEP of 5 cm of H2O throughout the study). Experiment consisted of 30 min of baseline ventilation, 3 h of OLV, and again 30 min of bilateral ventilation. Respiratory parameters and proinflammatory markers were measured as outcome.

RESULTS

There was no difference in PaO2 between groups. PaCO2 (P < 0.01) and ventilatory rate (P < 0.01) were higher at 1.5 h OLV and at the end point in the PVS group. Peak inflating pressure (PIP) and pulmonary resistance were higher (P < 0.05) in the control group at 1.5 h OLV. tumor necrosis factor-alpha (P < 0.04) and IL-8 were less (P < 0.001) in the plasma from the PVS group, while IL-6 and IL-8 were less (P < 0.04) in the lung tissue from ventilated lungs in the PVS group.

CONCLUSIONS

Based on this model, PVS decreases inflammatory injury both systemically and in the lung tissue with no adverse effect on oxygenation, ventilation, or lung function.

Proanthocyanidin to prevent formation of the reexpansion pulmonary edema

Background

We aimed to investigate the preventive effect of Proanthocyanidine (PC) in the prevention of RPE formation.

Methods

Subjects were divided into four groups each containing 10 rats. In the Control Group (CG): RPE wasn't performed. Then subjects were followed up for three days and they were sacrificed after the follow up period. Samplings were made from tissues for measurement of biochemical and histopathologic parameters. In the Second Group (PCG): The same protocol as CG was applied, except the administration of PC to the subjects. In the third RPE Group (RPEG): Again the same protocol as CG was applied, but as a difference, RPE was performed. In the Treatment Group (TG): The same protocol as RPEG was applied except the administration of PC to the subjects.

Results

In RPEG group, the most important histopathological finding was severe pulmonary edema with alveolar damage and acute inflammatory cells. These findings were less in the TG group. RPE caused increased MDA levels, and decreased GPx, SOD and CAT activity significantly in lung tissue.

Conclusion

PC decreased MDA levels. Oxidative stress plays an important role in pathophysiology of RPE and PC treatment was shown to be useful to prevent formation of RPE.

Delayed onset of contralateral pulmonary edema following reexpansion pulmonary edema of a collapsed lung after video-assisted thoracoscopic surgery

This case report describes a 61-year-old man who developed reexpansion pulmonary edema (RPE) of the collapsed left lung after video-assisted thoracoscopic surgery because of left thoracic empyema, complicated with secondary contralateral pulmonary edema later. The left lung was gently reexpanded after surgery under one-lung ventilation anesthesia for 2.5 hours. The patient developed RPE of the left lung immediately after surgery, and required mechanical ventilation with positive end-expiratory pressure support. RPE was resolved within 24 hours. Nevertheless, delayed onset of contralateral pulmonary edema manifested on chest radiography 4 days later without clinical symptoms such as tachypnea or dyspnea. There was no evidence of pulmonary infection, fluid overload, postoperative renal insufficiency or cardiogenic onslaught. Late manifestation of contralateral pulmonary edema in the wake of previous left-sided RPE was suspected from exclusion of possible culprits. Response to steroid therapy made inflammation-related pulmonary edema a likely diagnosis. This case demonstrates that delayed contralateral pulmonary edema with only radiographic evidence can emerge 4 days after resolution of RPE of a collapsed lung. Methods to prevent RPE and management of one-lung ventilation are described.

Acute lung injury and outcomes after thoracic surgery

PURPOSE OF REVIEW

The present review evaluates the evidence available in the literature tracking perioperative mortality and morbidity as well as the pathogenesis and management of acute lung injury (ALI) in patients undergoing thoracotomy.

RECENT FINDINGS

Over the last decade, despite increasing age and comorbid conditions, the operative mortality has remained unchanged for patients undergoing lung resection, whereas procedure-related complications have declined. Better clinical outcomes are achieved in high-volume hospitals and when procedures are performed by a thoracic surgeon. Postthoracotomy ALI has become the leading cause of operative death, its incidence has remained stable (2-5%) and earlier diagnosis can be made by assessing the extravascular lung water volume with the single-indicator dilution technique. The pathogenesis of ALI implicates a multiple-hit sequence of various triggering factors (e.g. oxidative stress and surgical-induced inflammation) in addition to injurious ventilatory settings and genetic predisposition.

SUMMARY

Knowledge of the perioperative risk factors of major complications and understanding of the mechanisms of postthoracotomy ALI enable anesthesiologists to implement 'protective' lung strategies including the use of low tidal volume (VT) with recruitment maneuvers, a goal-directed fluid approach and prophylactic treatment with inhaled beta2-adrenergic agonists.

Fulminant unilateral pulmonary edema after insertion of a chest tube: a complication after a primary spontaneous pneumothorax

INTRODUCTION

The insertion of a chest tube in cases of large pleural effusion or spontaneous pneumothorax is a common surgical procedure often performed by a physician in training under the supervision of a senior physician.

CASE PRESENTATION

The authors report the case of a 35-year-old man with a persistent, complete spontaneous pneumothorax of approximately 30 hours' duration. Within 90 minutes after insertion of a chest tube, he developed severe unilateral pulmonary edema and required mechanical ventilation. FINDINGS AND CLINICAL COURSE: Computerized tomography revealed severe, unilateral pulmonary edema referred to as re-expansion pulmonary edema. After emergency endotracheal intubation and mechanical ventilation with continuous positive airway pressure, the pulmonary edema resolved completely and the patient recovered.

CONCLUSION

Re-expansion edema is a rare, potentially life-threatening complication of the drainage of a spontaneous pneumothorax. With early recognition and timely treatment, complete resolution can be achieved. Risk factors include rapid re-expansion of the lung, young patient age, and a large pneumothorax persisting longer than 24 hours. If these risk factors are present, the chest tube should be inserted without primary suction. Doing so allows the lung to re-expand more slowly and may prevent this severe complication.

Low dose methylprednisolone prophylaxis to reduce inflammation during one-lung ventilation

BACKGROUND

The specific aim of this study was to examine the efficacy of a low dose of methylprednisolone in minimizing inflammatory response in juvenile piglets when given 45-60 min prior to onset of one-lung ventilation.

METHODS

Twenty piglets aged 3 weeks were assigned to either the control group (n = 10) or methylprednisolone group (n = 10). The animals were anesthetized and after 30 min of ventilation, they had their left lung blocked. Ventilation was continued via right lung for 3 h. The left lung was then unblocked. Following another 30 min of bilateral ventilation, the animals were euthanized and both lungs were harvested. The methylprednisolone group had a single dose (2 mg x kg(-1)) of methylprednisolone given i.v. 45-60 min prior to onset of one-lung ventilation. Physiological parameters (PaO2, resistance, and compliance) and markers of inflammation (tumor necrosis factor [TNF]-alpha, interleukin [IL]-1beta, IL-6, and IL-8) were measured at baseline and every 30 min thereafter. Lung tissue homogenates from both collapsed and ventilated lungs were analyzed for TNF-alpha, IL-1beta, IL-6, and IL-8.

RESULTS

The methylprednisolone group had higher partial pressure of oxygen (P = 0.01), lower plasma levels of TNF-alpha (P = 0.03) and IL-6 (P = 0.001) when compared with control group. Lung tissue homogenate in the methylprednisolone group had lower levels of TNF-alpha (P < 0.05), IL-1beta (P < 0.05), and IL-8 (P < 0.05) in both the collapsed and the ventilated lungs.

CONCLUSIONS

In a piglet model of one-lung ventilation, use of prophylactic methylprednisolone prior to collapse of the lung improves lung function and decreases systemic pro-inflammatory response. In addition, in the piglets who received methylprednisolone, there were reduced levels of inflammatory mediators in both the collapsed and ventilated lungs.

One-lung ventilation: For how long?

OBJECTIVE

Lung injury induced by one-lung ventilation is rare, but it is a condition that may result in high mortality. This study evaluates the effects of one-lung ventilation and occlusion time on collapsed and contralateral lungs.

METHODS

Sprague-Dawley rats were allocated randomly into 7 groups consisting of 6 animals each: sham; O1, 1 hour of occlusion/2 hours of re-expansion; C1, 3 hours of mechanical ventilation control; O2, 2 hours of occlusion/2 hours of re-expansion; C2, 4 hours of mechanical ventilation control; O3, 3 hours of occlusion/2 hours of re-expansion; and C3, 5 hours of mechanical ventilation control groups. In the occlusion groups, the left lung was collapsed by bronchial occlusion. Malondialdehyde activity was determined in the blood, and myeloperoxidase and malondialdehyde activity was determined in the collapsed and contralateral lungs. Lung tissues were also examined histopathologically.

RESULTS

Malondialdehyde and myeloperoxidase levels rose as occlusion duration increased. This increase was greater in the occlusion groups than that in their own control groups. Increases were significant in the O2 compared with the O1 groups (P < .005). Histologically, tissue damage increased as occlusion time rose injury in collapsed and contralateral lungs. Injury was greater in the occlusion groups than injury in their own control groups (P < .005).

CONCLUSIONS

Our findings show that biochemical and histopathologic injury occur in collapsed and contralateral lungs in one-lung ventilation, and this injury increases as occlusion time rises. We believe that occlusion and occlusion time-related injury should be borne in mind in the clinic under conditions requiring the application of one-lung ventilation.

Re-expansion unilateral pulmonary oedema after surgical drainage of a giant hepatic cyst: a case report

Re-expansion pulmonary oedema is an uncommon and potentially life-threatening complication after rapid expansion of a collapsed lung. Symptom onset (cough, chest pain, dyspnoea) is often sudden and the clinical picture may be dramatic. Pathogenesis is complex and partially unclear. A well-timed intensive therapy allows a better prognosis. To date, only one case of re-expansion pulmonary oedema following fenestration of a giant hepatic cyst has been reported in the literature. We here report a new case after surgical fenestration of a giant hepatic cyst.

Improved outcomes in islet isolation and transplantation by the use of a novel hemoglobin-based O2 carrier

During isolation, islets are exposed to warm ischemia. In this study, intraductal administration of oxygenated polymerized, stroma-free hemoglobin-pyridoxalated (Poly SFH-P) was performed to improve O2 delivery. Rat pancreata subjected to 30-min warm ischemia were perfused intraductally with collagenase in oxygenated Poly SFH-P/RPMI or RPMI (control). PO2 was increased by Poly SFH-P (381.7 +/- 35.3 mmHg vs. 202.3 +/- 28.2, p = 0.01) and pH maintained within physiological range (7.4-7.2 vs. 7.1-6.6, p = 0.009). Islet viability (77% +/- 4.6 vs. 63% +/- 4.7, p = 0.04) was improved and apoptosis lower with Poly SFH-P (caspase-3: 34,714 +/- 2167 vs. 45,985 +/- 1382, respectively, p = 0.01). Poly SFH-P improved islet responsiveness to glucose as determined by increased intracellular Ca2+ levels and improved insulin secretion (SI 5.4 +/- 0.1 vs. 3.1 +/- 0.2, p = 0.03). Mitochondrial integrity was improved in Poly SFH-P-treated islets, which showed higher percentage change in membrane potential after glucose stimulation (14.7% +/- 1.8 vs. 9.8 +/- 1.4, respectively, p < 0.05). O2 delivery by Poly SFH-P did not increase oxidative stress (GSH 7.1 +/- 2.9 nm/mg protein for Poly SFH-P vs. 6.8 +/- 2.4 control, p = 0.9) or oxidative injury (MDA 1.8 +/- 0.9 nmol/mg protein vs. 6.2 +/- 2.4, p = 0.19). Time to reach normoglycemia in transplanted diabetic nude mice was shorter (1.8 +/- 0.4 vs. 7 +/- 2.5 days, p = 0.02), and glucose tolerance improved in the Poly SFH-P group (AUC 8106 +/- 590 vs. 10,863 +/- 946, p = 0.03). Oxygenated Poly SFH-P improves islet isolation and transplantation outcomes by preserving mitochondrial integrity.