Recurrent re-expansion pulmonary edema

Management of spontaneous pneumothorax

Management of patients with a spontaneous pneumothorax continues to challenge clinicians. Recent guidelines help provide care pathways for these patients and highlight the many areas in need of additional study. Management options for spontaneous pneumothoraces should be selected based primarily upon a patient's clinical status. Observation or pleural air drainage, in selected patients, plays a significant role in patients with primary spontaneous pneumothorax. By contrast, pleural air drainage plays the central role in patients with a secondary spontaneous pneumothorax. Surgically directed recurrence prevention and air leak management are preferred for both primary and secondary spontaneous pneumothorax patients.

Thoracoscopy talc poudrage : a 15-year experience

OBJECTIVES

To review our experience with thoracoscopy and talc poudrage during the previous 15 years with regards to efficacy, side effects, morbidity, and mortality.

METHODS

Six hundred fourteen consecutive patients (58.6% female; mean age, 54.5 years) underwent thoracoscopy with talc poudrage from August 1983 to May 1999. Of these, 457 patients had malignant pleural effusions, 108 patients had benign pleural effusions, and 49 patients had spontaneous pneumothorax.

RESULTS

Sixty-four patients were excluded from evaluation for efficacy: 30 patients (4.9%) because the lung did not expand at the time of the procedure and 34 patients (5.5%) because they died within 30 days of the thoracoscopy. All exclusions were in the malignant group. The overall success rate of the 393 patients with malignant pleural effusions was 93.4%, while the overall success for the 108 patients with benign effusions was 97%, although 7 patients (7%) with benign effusions required a second thoracoscopy. The success rate with pneumothorax was 100%. Major morbidity included empyema in 4%, reexpansion pulmonary edema in 2.2%, and respiratory failure 1.3%.

CONCLUSION

Thoracoscopy with talc poudrage is effective in producing a pleurodesis in malignant and benign pleural effusion and in spontaneous pneumothorax. However, it should be noted that the insufflation of talc has a systemic distribution associated with a low rate of morbidity and perhaps does induce ARDS, which is sometimes fatal in a small percentage of patients. Because of these side effects, the search for a better agent should be continued.

[Re-expansion pulmonary edema after excision of an intrathoracic tumor]

We report an acute respiratory insufficiency following the removal of a large intrathoracic fibroma (3.1 kg) in a 6 year-old child, caused by a re-expansion pulmonary oedema (unilateral oedema occurring within one hour after expansion). This oedema improved rapidly and was followed by a well-tolerated pleural effusion. This complication is due to discrepancy between a small lung and a large thoracic cavity, due to the prolonged time course of the tumor growth. These oedemas are caused by rapid lung re-expansion, the volume of the removed tumor and the depth of postoperative pleural suction. The value of positive-end expiratory pressure is discussed.

[Postoperative re-expansion causing unilateral pulmonary edema]

A case of re-expansion pulmonary oedema is reported. A 7-year-old girl, after having been operated on for a lung tumour, had a postoperative haemothorax combined with atelectasis of the left upper lobe. After she had recovered from the first dose of chemotherapy, the thoracotomy wound was reopened to remove the partially organised and lysed haemothorax, as well as the very thickened pleura. The patient developed clinical signs of pulmonary oedema very shortly after the end of the anaesthetic (tachypnoea, cyanosis, a decrease in oxygen saturation when FIO2 < 1, pink frothy secretions in the endotracheal tube). End-inspiratory crepitations became audible in the left lung field only. The chest film showed left-sided diffuse nodular alveolar opacities. The girl was again ventilated, with + 5 cmH2O positive end-expiratory pressure. She was extubated 36 h later, and discharged a few days later without any sequela. This case was the first to be described in a child after pleural surgery. The death rate, estimated from a literature survey, is about 20%.

Acute localised pulmonary oedema. Re-expansion pulmonary oedema following the surgical repair of a ruptured hemidiaphragm

Re-expansion pulmonary oedema is a rare complication to follow the treatment of pneumothorax or pleural effusion. A unique case is described here which occurred in a young man immediately after the surgical repair of a ruptured diaphragm. The possible causative mechanisms are discussed.

Reexpansion pulmonary edema

Unilateral reexpansion pulmonary edema (RPE) is a rare complication of the treatment of lung collapse secondary to pneumothorax, pleural effusion, or atelectasis. Although RPE generally is believed to occur only when a chronically collapsed lung is rapidly reexpanded by evacuation of large amounts of air or fluid, in this review 15 of 47 cases of RPE available for assessment occurred when the pulmonary collapse was of short duration or when the lung was reexpanded without suction. The pathogenesis of RPE is unknown and is probably multifactorial. Implicated in the etiological process of RPE are chronicity of collapse, technique of reexpansion, increased pulmonary vascular permeability, airway obstruction, loss of surfactant, and pulmonary artery pressure changes. Since the outcome of RPE was fatal in 11 of 53 cases reviewed (20%), physicians treating lung collapse must be aware of the possible causes and endeavor to prevent the occurrence of this complication.

Reexpansion hypotension. A complication of rapid evacuation of prolonged pneumothorax

Three cases of hypotension are described that followed rapid evacuation of persistent unilateral pneumothorax. Common features included the presence of a pneumothorax for approximately one week before treatment commenced and profuse unilateral reexpansion edema, a rising hematocrit reading, hypotension, and anuria after evacuation of the pneumothorax in spite of a relatively normal pulmonary capillary wedge pressure. In one case, cardiac output was measured and found to be low (1.54 and 1.65 L/min/sq m), with a pulmonary capillary wedge pressure of 10 to 14 mm Hg. Death due to cardiovascular collapse occurred in one patient; ischemic colitis, acute renal failure, disseminated intravascular coagulation, and ischemic necrosis of both humeral heads occurred in another. The cases presented and the literature reviewed suggest that cardiovascular compromise was the end result of the combined effects of intravascular volume depletion and myocardial depression.