Reexpansion pulmonary edema: review of pediatric cases

Reexpansion Pulmonary Edema following Tube Thoracostomy in a Pediatric Patient with Anterior Mediastinal Mass

Reexpansion pulmonary edema (RPE) is an exceedingly rare and potentially fatal complication of a rapidly reexpanded lung following evacuation of air or fluid from the pleural space secondary to conditions such as a mediastinal mass, pleural effusion, or pneumothorax. Clinical presentations can range from mild radiographic changes to acute respiratory failure and hemodynamic instability. The rapidly progressive nature of the disease makes it important for clinicians to appropriately diagnose and manage patients who develop RPE. We present a case of a child with a large malignant pleural effusion who developed severe RPE after tube thoracostomy and ultimately required venoarterial extracorporeal membrane oxygenation (VA-ECMO). The patient was 7-year-old Caucasian male with newly diagnosed ambiguous T cell myeloid leukemia. A chest computerized tomography (CT) demonstrated a large pleural effusion causing tracheal shift and left bronchus compression as well as an anterior mediastinal mass causing compression of the right atria and right ventricle. Tube thoracostomy was performed in the operating room (OR) with deep sedation. The procedure was complicated with hypoxemia, bradycardia, and pulseless cardiac arrest. After return of spontaneous circulation, the child continued to have refractory hypoxemia, profound hypotension, and frothy secretions. Endotracheal intubation was performed with a size 5.0 cuffed endotracheal tube. Chest radiograph demonstrated opacification of the left hemithorax with chest infiltrates. Patient required VA-ECMO for circulatory support. Supportive therapy of RPE was continued and decannulation was done on day three. Tracheal extubation was performed on day five.

Re-Expansion Pulmonary Edema in Children - A Rare Complication After Pneumothorax Drainage: A Case Report

Background

Re-expansion Pulmonary Edema (RPE) is a non-cardiogenic form of pulmonary edema which occurs following rapid lung expansion after drainage of significant pneumothorax or pleural effusion, and rarely following resection of obstructive mediastinal mass. RPE is a rare but potentially fatal phenomenon with only few case reports in the pediatric literature.

Methods

We are reporting a case of RPE in a 5-year-old girl following drainage of pneumothorax who succumbed to worsening hypoxemia despite therapy with mechanical ventilation and other supportive care.

Conclusion

RPE should be anticipated, and early preventive, diagnostic and therapeutic measures should be instituted in high-risk patients who require significant pleural fluid or air drainage.

An evidence-based review of primary spontaneous pneumothorax in the adolescent population

Primary spontaneous pneumothorax (PSP) is a relatively common problem in emergency medicine. The incidence of PSP peaks in adolescence and is most common in tall, thin males. Recent advances in the care of patients with PSP have called into question traditional approaches to management. This clinical review highlights the changing management strategies for PSP and concludes with a proposed evidence-based pathway to guide the care of adolescents with PSP.

Is severe re-expansion pulmonary edema still a lethal complication of closed thoracostomy or thoracic surgery?

Background

Re-expansion pulmonary edema (REPE) is a lethal complication that can occur after inserting a chest tube. However, no clinical research reports have analyzed the progress and treatment of REPE, except for a single case report review. We retrospectively analyzed the common clinical characteristics, clinical progress, and treatment outcome of REPE with respiratory failure.

Methods

We retrospectively reviewed the clinical features, treatment, and outcomes of eight patients with REPE who required ventilator care from March 2004 to March 2018.

Results

The mean PaO₂/FiO₂ ratio of the patients immediately after intubation was 106.5±20.2 (range, 75-128), which indicated severe hypoxia in all cases. On the first day of treatment, most of the patients showed improvement in hypoxia symptoms, and most improved to the extubation level on day 3. The mean duration of ventilator use was 2.5±0.8 days (range, 1-4 days), and the mean duration of inotropic drug use was 1.1±0.7 days (range, 0-2 days). The mean intensive care unit (ICU) stay was 4.4±1.5 days (range, 3-8 days). No deaths were recorded during the study period, and no cases of permanent complications due to REPE were observed.

Conclusions

REPE requiring ventilator care is a lethal disease. However, continued development of ICU care has dramatically decreased mortality. Low positive end-expiratory pressure (PEEP), low tidal and high O₂ ventilator care represents the most appropriate treatment for REPE.

Re-expansion pulmonary edema after resection of cerebellar lesion in a patient with bronchial occupying lesion: A case report

RATIONALE

Re-expansion pulmonary edema (RPE) is a non-cardiogenic pulmonary edema, and is secondary to pulmonary collapse caused due to various reasons. However, RPE is rarely encountered during non-thoracic surgeries and is associated with much higher risk than that occurring in thoracic surgeries.

PATIENT CONCERNS

Herein we have reported a case report of a 55-years-old male patient. Preoperative examination indicated occupying lesions in the bronchus and cerebellar hemisphere. Under general anesthesia, the patient received resection of cerebellar lesion and developed acute atelectasis, and RPE occurred when cannulation was withdrawn after re-expansion. Supportive and symptomatic treatment was given to the patient for recovery well.

DIAGNOSIS

RPE.

INTERVENTIONS

The trachea was cannulated and connected to a ventilator for assisted ventilation. The patient was also given symptomatic treatment including nebulization, diuresis, and anti-inflammation.

OUTCOMES

The patient recovered well and was discharged on day 8 after surgery.

LESSONS

Patients with occupying lesions of the airway should undergo bronchoscopy to determine the location, size, and distance of the lesion from the incisors. The anesthesiologists should determine appropriate anesthetic regimens according to the examination results to avoid acute atelectasis and postoperative pulmonary edema.

Reexpansion Pulmonary Edema in Pediatrics

Reexpansion pulmonary edema is a rare complication that may occur after drainage of pneumothorax or pleural effusion. A number of factors have been identified that increase the risk of developing reexpansion pulmonary edema, and pathophysiologic mechanisms have been postulated. Patients may present with radiographic findings alone or may have signs or symptoms that prompt evaluation and diagnosis. Clinical presentations range from mild cough to respiratory failure and hemodynamic compromise. Treatment strategies are supportive, and should be tailored to match the severity of the condition.