Severe re-expansion pulmonary edema after chest tube insertion for the treatment of spontaneous pneumothorax

Abstract

Rationale: Re-expansion pulmonary edema (REPE) is a rare complication after chest tube insertion for the treatment of spontaneous pneumothorax. However, this complication can be life threatening when it occurs. Therefore, it is necessary to recognize REPE early and treat it appropriately. In the present study, we report a severe REPE case occurring after chest tube insertion in a patient with spontaneous pneumothorax. Patient concerns: A 27-year-old male patient visited out hospital with chest pain on the left, which had started a week ago. After diagnosed with pneumothorax and having chest tube insertion, the patient complained of sudden shortness of breath, persistent cough, foamy sputum, and vomiting. Diagnosis: Based on the symptoms and imaging findings, the patient was diagnosed as REPE. Interventions: After the condition of the patient deteriorated rapidly, he was transferred to intensive care unit and then mechanical ventilation and conservative treatment were performed after endotracheal intubation. Outcomes: After mechanical ventilation and conservative treatment in the intensive care unit, the symptoms and radiological findings improved, and then mechanical ventilation was weaned and the chest tube was removed from the patient. However, due to recurrent pneumothorax after removal of the chest tube, video assisted thoracoscopic surgery (VATS) wedge resection was performed. At 6 months post-operative follow up, he was well with normal radiological findings. Lessons: REPE occurs rarely, but once it does, it causes a serious condition that can be life-threatening. Therefore, patients with the risk factors related to it should receive a closed observation after chest tube insertion. Moreover, if REPE occurs, appropriate treatments should be carried out by recognizing it early.

Severe re-expansion pulmonary oedema requiring veno-venous extracorporeal membrane oxygenation treatment

“…The recommended clinical management is supportive care consisting of non-invasive positive-pressure ventilation, as well as mechanical ventilation, if necessary. Coughing may be the initial symptom 2. Stopping drainage immediately may have been an option for suppressing the progression of oedema in the present patient.…”

“…Its incidence ranges from 0.9% to 14.4% in patients with spontaneous pneumothorax undergoing drainage. The risk factors of REPE include longer duration and greater extent of lung collapse, young age and rapid lung expansion 1 2. One recent study reported an incidence of 21.6% in patients with a lung collapse duration longer than 4 days and severe lung collapse.…”

Risk factors for re-expansion pulmonary edema following chest tube drainage in patients with spontaneous pneumothorax: A systematic review and meta-analysis

“…Patients with unilateral pulmonary edema may benefit from lying on the unaffected side to improve intrapulmonary shunt. 27 , 28 There are no specific medication guidelines for RPE. Some evidence suggests that the use of diuretics, steroids, and inotropes may be considered based on clinical indications.…”

Edema pulmonar por reexpansión. Reporte de Caso

“…Se ha descrito una incidencia entre 0,9 y 20 % por todas las causas de edema pulmonar y menor al 1 % tras una toracostomía cerrada 4 , con una relación de hombres a mujeres de 38:9 y una mayor prevalencia en la segunda y tercera décadas de la vida, pues las personas de mayor edad presentan cambios en la mecánica pulmonar y características de la barrera alveolo-capilar secundarios al envejecimiento que funcionan como un factor protector para el EPR [4][5][6] .…”

“…Adicionalmente, los vasos sanguíneos se adaptan al colapso pulmonar crónico y la hipoxia prolongada y, debido a sus cambios histológicos, son vulnerables a la tracción. La reexpansión y la reperfusión del pulmón isquémico aumenta los radicales libres de oxígeno, que conduce a daño endotelial vascular directo [4][5][6][7] . Si bien, por lo general, el EPR ocurre en el mismo pulmón inicialmente colapsado, se han descrito casos en los que ocurre bilateral o incluso contralateral [7][8][9] , por lo que en la patogénesis del EPR también se ha descrito el rol de sustancias vasoactivas como histamina, prostaglandina o factores neurogénicos 6,7 .…”