• Registration
  • Login
JETem
  • Home
  • About
    • Aim and Scope
    • Our Team
    • Editorial Board
    • FAQ
  • Issues
    • Current Issue
    • Ahead of Print
    • Past Issues
  • Visual EM
    • Latest Visual EM
    • Search Visual EM
    • Thumbnail Library
  • For Authors
    • Instructions for Authors
    • Submit to JETem
    • Photo Consent
    • Policies
      • Peer Review Policy
      • Copyright Policy
      • Editorial Policy, Ethics and Responsibilities
      • Conflicts of Interest & Informed Consent
      • Open Access Policy
  • For Reviewers
    • Instructions for JETem Reviewers
    • Interested in Being a JETem Reviewer?
  • Topic
    • Abdominal / Gastroenterology
    • Administration
    • Board Review
    • Cardiology / Vascular
    • Clinical Informatics, Telehealth and Technology
    • Dermatology
    • EMS
    • Endocrine
    • ENT
    • Faculty Development
    • Genitourinary
    • Geriatrics
    • Hematology / Oncology
    • Infectious Disease
    • Miscellaneous
    • Neurology
    • Ob / Gyn
    • Ophthalmology
    • Orthopedics
    • Pediatrics
    • Procedures
    • Psychiatry
    • Renal / Electrolytes
    • Respiratory
    • Toxicology
    • Trauma
    • Ultrasound
    • Wellness
    • Wilderness
  • Modality
    • Curricula
    • Innovations
    • Lectures
    • Oral Boards
    • Podcasts
    • Simulation
    • Small Group Learning
    • Team Based Learning
    • Visual EM
  • Contact Us

Re-expansion Pulmonary Edema

Kathryn Bennett, BS, BA* and Benjamin Feldman, MD*

*University of California, Irvine, Department of Emergency Medicine, Orange, CA

Correspondence should be addressed to Kathryn Bennett, BS, BA at khbennet@uci.edu

DOI: https://doi.org/10.21980/J8WS6V Issue 2:3
RespiratoryVisual EM
No ratings yet.

History of present illness:

A 95-year-old male with history of atrial fibrillation presented to the emergency department for shortness of breath for one week. A chest X-ray showed a large right-sided pleural effusion. Given the unknown etiology of the effusion, and the patient’s dyspnea, a thoracentesis was performed. Under ultrasound guidance, 2.9 liters of cloudy yellow fluid was removed. The patient tolerated the procedure well and a post procedural chest X-ray was performed, which is noted below. A few hours later, the patient became tachypneic and oxygenation saturation dropped from 100% to 91%-92% on room air, and was found to have decreased breath sounds on the right. An additional chest X-ray was performed which showed pulmonary re-expansion edema and patient was subsequently admitted for observation.

Significant findings:

Initial chest X-ray (chest X-ray 1) showed a right-sided pleural effusion with compressive atelectasis of the mid to lower right lung. Repeat chest X-ray immediately after evacuation (chest X-ray 2) shows improvement of the pleural effusion and a new trace apical right pneumothorax measuring 6.7 mm. When the patient became tachypneic, a third X-ray (chest X-ray 3) showed persistent trace apical right pneumothorax measuring 6.7 mm.

Discussion:

Re-expansion pulmonary edema (RPE) is a rare complication that can occur following thoracentesis of a pleural effusion or chest tube drainage of pneumothorax, and is a potentially fatal complication due to the resulting abrupt reduction in pleural pressure.1,2 RPE pathophysiology is not fully understood; however, risk factors include presence of pleural effusion in conjunction with pneumothorax, young patients (<40), large pneumothoraces, and when pneumothorax has been present for longer than one week.3 Large volume thoracenteses are characterized by removal of more than 1000 mL of pleural fluid during a therapeutic thoracentesis.4

It is important to note that RPE is usually self-limiting and treatment is generally supportive, typically ranging from oxygen support and diuretics to intubation, mechanical ventilation, hemodynamics, and steroids in more severe cases.1,5 Preventive strategies include limiting drainage of pleural fluid if the patient reports chest pressure or discomfort during thoracentesis and using low negative pressure (less than −20 cm H2O) for suction.6 A more precise treatment approach may establish a “safe” volume of fluid to remove by combining symptom monitoring with serial measures of pleural pressure. Using this methodology, the amount of fluid aspirated often exceeds the traditionally observed limits of 1000 to 1500 mL, and many patients fare well with removal above 1500 mL.4 As with traditional methods of therapeutic thoracentesis, precautions are followed and fluid removal is stopped if the patient feels chest pressure or becomes hypotensive, if pleural pressure falls less than -20 cm H2O, or if no more fluid can be aspirated.4 Close patient monitoring and early recognition of symptoms, especially in the presence of known risk factors, is paramount because delayed treatment may lead to a fatal outcome.

Topics:

Re-expansion pulmonary edema, pleural effusion, thoracentesis, pneumothorax, drainage, chest tube, ventilation.

References:

  1. Meeker J, Jaeger A, Tillis W. An uncommon complication of a common clinical scenario: exploring reexpansion pulmonary edema with a case report and literature review. J Community Hosp Intern Med Perspect. 2016;6(3):10.3402/jchimp.v6.32257. doi: 10.3402/jchimp.v6.32257
  2. Dias OM, Teixeria LR, Vargas FS. Reexpansion pulmonary edema after therapeutic thoracentesis. Clinics. 2010;65(12):1387-1389. doi: 10.1590/S1807-59322010001200026
  3. Echevarria C, Twomey D, Dunning J, Chanda B. Does re‐expansion pulmonary oedema exist? Interact Cardivoasc Thorac Surg. 2008;7:485-489. doi: 10.1510/icvts.2008.178087
  4. Light RW, Jenkinson SG, Minh VD, George RB. Observations on pleural fluid pressures as fluid is withdrawn during thoracentesis. Am Rev Respir Dis. 1980;121:799-804. doi: 10.1164/arrd.1980.121.5.799
  5. Verhagen M, Van Buijtenen J, Geeraedts L. Reexpansion pulmonary edema after chest drainage for pneumothorax: a case report and literature overview. Respir Med Case Rep. 2015;14:10-12. doi: 10.1016/j.rmcr.2014.10.002
  6. Kasmani R, Irani F, Okoli K, Mahajan V. Re-Expansion pulmonary edema following thoracentesis. CMAJ. 2010;182(18): 2000-2002. doi: 10.1503/cmaj.090672
Icon

Re-expansion Pulmonary Edema - Case Report

1 file(s) 1.4 MB
Download
Icon

Re-expansion Pulmonary Edema - Images

1 file(s) 1.65 MB
Download
Issue 2:3X-Ray

Reviews:

No ratings yet.

Please rate this





Asymptomatic Wolff-Parkinson-White Syndrome:...

04 Jul, 17

Pneumonia Diagnosed by Point-of-Care Ultrasound

04 Jul, 17
JETem is an online, open access, peer-reviewed journal-repository for EM educators

Most Viewed

  • Telemedicine Consult for Shortness of Breath Due to Sympathetic Crashing Acute Pulmonary Edema
  • Anticholinergic Toxicity in the Emergency Department
  • The Suicidal Patient in the Emergency Department Team-Based Learning Activity
  • Child Maltreatment Education: Utilizing an Escape Room Activity to Engage Learners on a Sensitive Topic
  • Acute Chest Syndrome

Visit Our Collaborators

About

Education

Learners should benefit from active learning. JETem accepts submissions of team-based learning, small group learning, simulation, podcasts, lectures, innovations, curricula, question sets, and visualEM.

Scholarship

We believe educators should advance through the scholarship of their educational work. JETem gives educators the opportunity to publish scholarly academic work so that it may be widely distributed, thereby increasing the significance of their results.

Links

  • Home
  • Aim and Scope
  • Current Issue
  • For Reviewers
  • Instructions for Authors
  • Contact Us

Newsletter

Sign up to receive updates from JETem regarding newly published issues and findings.

Copyright © 2016 JETem. All rights reserved.