Re-expansion pulmonary oedema after spontaneous pneumothorax treatment with chest tube placement

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RodriguesD, etal. BMJ Case Rep 2021;14:e241734. doi:10.1136/bcr-2021-241734
Re- expansion pulmonary oedema after spontaneous
pneumothorax treatment with chest tubeplacement
Denny Rodrigues , Margarida Valério, Teresa Costa
Images in…
To cite: RodriguesD,
ValérioM, CostaT. BMJ Case
Rep 2021;14:e241734.
doi:10.1136/bcr-2021-
241734
Pulmonology, Centro Hospitalar
e Universitario de Coimbra EPE,
Coimbra, Portugal
Correspondence to
Dr Denny Rodrigues;
dennymarques@ gmail. com
Accepted 13 March 2021
© BMJ Publishing Group
Limited 2021. No commercial
re- use. See rights and
permissions. Published by BMJ.
DESCRIPTION
Re- expansion Pulmonary oedema (RPE) is a rare
but potentially fatal complication, which can arise
after a rapid decompressive treatment of pulmo-
nary collapse secondary to pleural effusion, pneu-
mothorax or atelectasis. The pathophysiological
mechanism is still poorly understood, admitting
a multifactorial aetiology underlying the process
of increasing the permeability of the pulmonary
microvascular structure secondary to the abrupt
re- expansion process.1 2
A 21- year- old male patient, active smoker (three
pack- years), without drug abuse, recent trauma or
pathological history. He was admitted to the emer-
gency department after 6 days of sudden onset of
dyspnoea, left pleuritic chest pain, palpitations and
dry cough, with progressive worsening.
The patient had no evident morphological abnor-
malities, blood pressure was 112/68 mm Hg, heart
rate 100 bpm, respiratory rate 22 bpm, periph-
eral oxygen saturation of 99% (room air) and was
apyretic. He presented a hyper- resonant left haemi-
thorax with decreased lung sounds on auscultation.
Chest X- ray confirmed left tension pneumothorax
(figure 1). Blood samples showed normal haemo-
gram, coagulation and inflammatory parameters.
The patient was then treated with oxygen therapy
and placement of a chest tube on the fifth left inter-
costal space, with subaquatic seal (without suction),
leading to improved symptoms.
One hour after the procedure he developed
tachycardia, productive cough, dyspnoea and respi-
ratory distress, unresponsive to oxygen therapy. A
repeat chest X- ray confirmed the correctly posi-
tioned chest tube, complete left lung expansion,
but showed alveolar opacities (figure 2). RPE was
assumed and treatment with diuretics, corticoste-
roids and continuous positive airway pressure was
initiated. As a result, the symptoms improved, and
clinical stability was achieved.
The patient was transferred to intermediate care
unit and positive pressure was stopped. One hour
after, he underwent in to acute respiratory failure,
requiring orotracheal intubation, invasive mechan-
ical ventilation and admission into intensive care
unit. He stayed on mechanical invasive ventilation
for 6 days. At the 7th day of intensive care unit
stay, there was a complete resolution of RPE, but
a persistent air leak was noted, so the patient was
submitted to surgical pleurodesis (pleural abrasion)
via video- assisted- thoracoscopy. He was discharged
10 days later, asymptomatic and with a normal
chest X- ray.
The diagnosis of RPE is made by a combina-
tion of clinic and imaging findings. Most common
symptoms include productive cough, tachycardia,
hypotension, cyanosis, fever and chest pain. The
severity of the symptoms is variable, from mild
(documented only by imaging), to acute respiratory
Figure 1 Chest X- ray showing complete left lung
collapse, tracheal and mediastinal deviation to the right
side.
Figure 2 Chest X- ray showing alveolar opacities on the
left lung, chest drainage tube with extremity positioned
on the left lung apex.
on March 5, 2022 by guest. Protected by copyright.http://casereports.bmj.com/BMJ Case Rep: first published as 10.1136/bcr-2021-241734 on 24 March 2021. Downloaded from

2RodriguesD, etal. BMJ Case Rep 2021;14:e241734. doi:10.1136/bcr-2021-241734
Images in…
distress syndrome. The most common finding in chest X- rays
is an alveolar filling pattern, usually ipsilateral but it can reach
any anatomical portion of the lung parenchyma. These findings
usually arise between 2 and 4 hours after the thoracic cavity
drainage, which can worsen in the first 48 hours and persist for
four to 5 days, after which the oedema is expected to resolve,
typically without sequelae.3–5
Stablished RPE risk factors include longer pneumothorax
evolution, usually greater than 3 days and pneumothorax size,
being the risk directly proportional to its size. It is usually a self-
limiting complication that only requires supportive treatment,
with oxygen therapy, diuretics and positive pressure therapy.
In greater severity situations, systemic corticosteroid therapy is
advised and invasive mechanical ventilation may be necessary.3 5 6
Contributors Substantial contributions to the conception or design of the work,
or the acquisition, analysis or interpretation of data: DR, MV and TC. Drafting the
work or revising it critically for important intellectual content: DR, MV and TC. Final
approval of the version published: DR, MV and TC. Agreement to be accountable for
all aspects of the work in ensuring that questions related to the accuracy or integrity
of any part of the work are appropriately investigated and resolved: DR, MV and TC.
Funding This study was funded by Centro Hospitalar e Universitário de Coimbra
(945074).
Competing interests None declared.
Patient consent for publication Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
ORCID iD
DennyRodrigues http:// orcid. org/ 0000- 0003- 0722- 4843
REFERENCES
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6 Morioka H, Takada K, Matsumoto S, etal. Re- expansion pulmonary edema: evaluation
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Learning points
►Re- expansion pulmonary oedema can arise after a rapid
decompressive treatment of the pneumothorax.
►The risk of occurrence increases with the pneumothorax
duration and its size (increased risk for larger pneumothorax).
►Treatment is supportive care, but steroids, haemodynamic and
ventilatory support may be needed.
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on March 5, 2022 by guest. Protected by copyright.http://casereports.bmj.com/BMJ Case Rep: first published as 10.1136/bcr-2021-241734 on 24 March 2021. Downloaded from