Reexpansion Pulmonary Edema Research Articles

Complications after Thoracocentesis and Chest Drain Insertion: A Single Centre Study from the North East of England

Introduction: There are no prospective studies looking at complications of pleural procedures. Previous British Thoracic Society Pleural audits and retrospective case series inform current practice. Incidence of any complication is between 1–15%. We sought to add to the existing literature and inform local practice with regards to intercostal drains and thoracocenteses. Methods: Local Caldicott approval was sought for a review of all inpatient adult pleural procedures coded as ‘T122 drainage of pleural cavity’ and ‘T124 insertion of tube drain into pleural cavity’. Those undergoing thoracocentesis (all with a Rocket 6 Fg catheter) and intercostal drain insertion (ICD, all with Rocket 12 Fg drain) were identified. Continuous variables are presented as mean (±range) and categorical variables as percentages where appropriate. Results: 1159 procedures were identified. A total of 199 and 960 were done for pneumothorax and effusions respectively. Mean age was 68.1 years (18–97). There were 280 thoracocenteses and 879 ICDs. Bleeding occurred in 6 (0.5%), all ICDs (clotting and platelets were within normal range; one patient was on aspirin and one on aspirin and clopidogrel). All settled except for one who had intercostal artery rupture needing cardiothoracic intervention (no anti-coagulation). Nine pneumothoraces occurred (0.78%) in seven ICDs and two aspirations). There were three definite pleural space infections (0.3%) with three ICDs. Fall out rates for ICDs were 35 (3%). Nine were not sutured, and out of those, seven inserted in the Accident and Emergency department, out of hours. All others ‘came out’ due to patient factors (previous quoted rates up to 14%). Surgical emphysema occurred in 43 (41 ICDs), 3.7%. Eight were due to fall outs and three required surgical intervention. There was no re-expansion pulmonary oedema nor direct deaths. Conclusions: Complication rates of ICD and thoracocenteses are low. Checklists might help to remind operators of the need for suturing. Limitations of this study are its retrospective nature and reliance on correct hospital coding. We are currently contributing to a prospective observational study on pleural complications.

Complications of thoracoscopic talc insufflation for the treatment of malignant pleural effusions: a meta-analysis

BackgroundTalc pleurodesis is an effective treatment for malignant pleural effusions (MPEs). This study was designed to estimate complication rates of thoracoscopic talc insufflation.MethodsLiterature search was conducted in electronic databases and studies were selected if they reported complication rates of thoracoscopic talc insufflation in cancer patients with MPEs. Meta-analyses of proportions were performed to obtain incidence rates of complications.ResultsTwenty-six studies (4482 patients; age 62.9 years [95% confidence interval (CI): 61.5, 64.4]; 50% [95% CI: 43, 58] females) were included. Intraoperative, perioperative, 30-day, and 90-day mortality rates were 0% [95% CI: 0, 1], 2% [95% CI: 0, 4], 7% [95% CI: 3, 13] and 21% [95% CI: 5, 43] respectively. Incidence rates [95% CI] of various complications were: pain (20% [1, 2]), fever (14% [3, 4]), dyspnea (13% [5, 6]), pneumothorax (6% [7, 8]) pneumonia (4% [0, 12]), emphysema (3% [3, 7]), prolonged air leakage (3% [0, 7]), prolonged drainage (3% [9, 10]), thromboembolism (3% [9, 11]), lung injury (2% [7, 12]), respiratory insufficiency (2% [0, 5]), re-expansion pulmonary edema (1% [0, 3]), empyema (1% [0, 2]), respiratory failure (0% [0, 1]), and acute respiratory distress syndrome (ARDS; 0% [0, 1].ConclusionsWhereas pain and fever were the most frequent complications of thoracoscopic talc insufflation, the incidence of ARDS was low. Pneumothorax, pneumonia, emphysema, prolonged air leakage, pulmonary embolism, arrythmia, re-expansion pulmonary edema, and empyema are important complications of thoracoscopic talc insufflation.

Re-expansion pulmonary oedema with Takotsubo cardiomyopathy: a rare complication of giant hepatic cyst drainage.

Re-expansion pulmonary oedema with Takotsubo cardiomyopathy: a rare complication of giant hepatic cyst drainage.

Re-expansion pulmonary edema after large left pleural effusion

Background: Reexpansion pulmonary edema (REPE) is a complication that arises from a precipitous or rapid expansion of a collapsed lung. This rare complication is thought to arise after using an intercostal drainage tube in patients with a tension pneumothorax, those with large pleural effusions, and occasionally when used therapeutically in thoracentesis. There are a multitude of risk factors, and it usually self-limiting, with the mainstay of treatment being supportive with oxygen. It is believed that 20% of cases are fatal. Case report: A 60-year-old male was treated with a 28 French tube for a large left pleural effusion. He developed REPE shortly after and developed severe shortness of breath, for which he required high flow oxygen. He was managed in the Intermediate Care Unit (IMCU) and shortly after was discharged home.

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

Re-expansion Pulmonary oedema (RPE) is a rare but potentially fatal complication, which can arise after a rapid decompressive treatment of pulmonary collapse secondary to pleural effusion, pneumothorax or atelectasis. The...

Re-expansion Pulmonary Edema after Chest Drainage for Pneumothorax; Evaluation of Risk Factors in 630 Episodes

Re-expansion Pulmonary Edema after Chest Drainage for Pneumothorax; Evaluation of Risk Factors in 630 Episodes

A survey of medical thoracoscopy practices in India.

Background:Medical thoracoscopy (MT) is a useful diagnostic and therapeutic procedure for a variety of pleural conditions. There is a lack of literature on prevalent practices of MT in India.Aims and Objectives:The objective of the study was to study the prevalent practices of MT in India.Materials and Methods:A structured online survey on various aspects of thoracoscopy was designed on the “Google Forms” web software.Results:One hundred and eight responses were received, of which 100 respondents performed MT. The majority were pulmonologists, and most had started performing thoracoscopy within the last 5 years. Rigid thoracoscope was the most commonly used instrument. The common indications of procedure included undiagnosed pleural effusion, talc pleurodesis, and adhesiolysis. Local anesthesia with conscious sedation was the preferred anesthetic modality. Midazolam, along with fentanyl, was the most widely used sedation combination. 2% lignocaine was the most commonly used concentration for local infiltrative anesthesia. Nearly two-thirds of the respondents reported having encountered any complication of thoracoscopy. Significant reported complications included empyema, incision/port-site infection, re-expansion pulmonary edema, and procedure-related mortality.Conclusion:MT is a rapidly evolving interventional pulmonology procedure in India. There is, however, a significant variation in practice and variable adherence to available international guidelines on thoracoscopy. Formal training programs within India and national guidelines for pleuroscopy considering the local resources are required to improve the safety and yield of this useful modality.

Re-expansion pulmonary edema after thoracentesis for iatrogenic pneumothorax and severe subcutaneous emphysema.

Subclavian central venous catheterization can cause severe complications, including tension pneumothorax, subcutaneous emphysema, and pneumomediastinum. Re‐expansion pulmonary edema after thoracentesis is a life‐threatening complication.

Response to the Time

Response to the Time

Complications following symptom-limited thoracentesis using suction.

Thoracentesis using suction is perceived to have increased risk of complications, including pneumothorax and re-expansion pulmonary oedema (REPO). Current guidelines recommend limiting drainage to 1.5 L to avoid REPO. Our purpose was to examine the incidence of complications with symptom-limited drainage of pleural fluid using suction and identify risk factors for REPO. A retrospective cohort study of all adult patients who underwent symptom-limited thoracentesis using suction at our institution between January 1, 2004 and August 31, 2018 was performed, and a total of 10 344 thoracenteses were included. Pleural fluid ≥1.5 L was removed in 19% of the procedures. Thoracentesis was stopped due to chest discomfort (39%), complete drainage of fluid (37%) and persistent cough (13%). Pneumothorax based on chest radiography was detected in 3.98%, but only 0.28% required intervention. The incidence of REPO was 0.08%. The incidence of REPO increased with Eastern Cooperative Oncology Group performance status (ECOG PS) ≥3 compounded with ≥1.5 L (0.04-0.54%; 95% CI 0.13-2.06 L). Thoracentesis in those with ipsilateral mediastinal shift did not increase complications, but less fluid was removed (p<0.01). Symptom-limited thoracentesis using suction is safe even with large volumes. Pneumothorax requiring intervention and REPO are both rare. There were no increased procedural complications in those with ipsilateral mediastinal shift. REPO increased with poor ECOG PS and drainage ≥1.5 L. Symptom-limited drainage using suction without pleural manometry is safe.

Robotic‐assisted cardiac surgery without lung isolation utilizing single‐lumen endotracheal tube intubation

This study assessed the feasibility and outcomes of performing robotic cardiac surgery without lung isolation using single-lumen (SL) endotracheal tube intubation. Between 2013 and 2017, 132 patients underwent robotically-assisted atrial septal defect closure. A retrospective analysis was performed of 23 patients (11 males, mean age 30.9 ± 5 years) who underwent robotic surgery with double-lumen (DL) endotracheal tube intubation (group 1) compared with 109 patients (57 males, mean age 32.4 ± 7.5 years) undergoing the same procedure with SL endotracheal intubation (group 2). The patient groups were compared in terms of demographic characteristics, operative data, and complications. The technical feasibility of the robotic procedure without lung isolation was evaluated. There were no mortality, intraoperative complication, and conversion. Mean total anesthesia time was significantly decreased in the SL intubation group (238.3 ± 22.4 vs 227.2 ± 21.2 minutes; P = .025). First-pass intubation success was significantly higher in the SL intubation group (17 [73.9%] vs 98 [89.9%] patients; P = .032). Mean ventilation time (10.9 ± 5.3 hours), intensive care unit stay (16.8 ± 10.1 hours), and the length of hospital stay (3.8 ± 1.2 days) was significantly decreased in patients with SL tube (P < .05). Unilateral reexpansion pulmonary edema was observed in five (21.7%) patients with DL tube, whereas no patient with SL tube had this complication. SL endotracheal tube intubation without lung isolation is a feasible and safe airway alternative in robotic cardiac procedures. This approach resulted in shorter anesthesia time, ventilation time and the length of hospital stay. Port placement and robotic set-up can be uneventfully performed without lung isolation.

Bilateral Re-expansion Pulmonary Edema after Cardiac Surgery Successfully Treated with Venovenous Extracorporeal Membrane Oxygenation

Bilateral Re-expansion Pulmonary Edema after Cardiac Surgery Successfully Treated with Venovenous Extracorporeal Membrane Oxygenation

A rare case of re-expansion pulmonary oedema after medical thoracoscopy

Re-expansion pulmonary oedema of the lung occurs after rapid removal of air or liquid from the pleural space by either chest drainage or thoracocentesis. Re-expansion pulmonary oedema is a rare but serious complication. A 29-year-old male patient presented to us with left-sided massive pleural effusion. We performed medical thoracoscopy; however, an hour after procedure, he started having cough and increased breathlessness. Chest radiograph showed left-sided homogeneous opacity in the left mid and lower zone consistent with unilateral pulmonary oedema. He was managed conservatively along with bi-level positive airway pressure non-invasive ventilator support. His condition improved gradually and was discharged successfully after 5 days.

148 Pericardial Decompression Syndrome - a Case Report of Transient Ventricular Failure Post-pericardiocentesis

Pericardial decompression syndrome (PDS) is a rare syndrome characterised by cardiac dysfunction following pericardiocentesis for large pericardial effusions with suspected tamponade [[1]Vandyke Jr., W.H. Cure J. Chakko C.S. Gheorghiade M. Pulmonary edema after pericardiocentesis for cardiac tamponade.The New England Journal of Medicine. 1983; 309: 595-596Crossref PubMed Scopus (55) Google Scholar]. It is a significant cause of morbidity in patients with metastatic malignancies [[2]Pradhan R. Okabe T. Yoshida K. Angouras D.C. DeCaro M.V. Marhefka G.D. Patient characteristics and predictors of mortality associated with pericardial decompression syndrome: a comprehensive analysis of published cases. [Review].European Heart Journal Acute Cardiovascular Care. 2015; 4: 113-120Crossref PubMed Scopus (18) Google Scholar]. A 36-year-old male with metastatic lung adenocarcinoma presented with dyspnoea, tachycardia, hypotension, and right heart failure. Electrocardiogram showed electrical alternans and chest x-ray revealed cardiac enlargement. A transthoracic echocardiogram (TTE) demonstrated a large global pericardial effusion with features of tamponade. Pericardiocentesis immediately removed 1.2L of haemoserous fluid. Eleven hours later, the patient developed pulmonary oedema requiring diuretics and non-invasive ventilation. TTE revealed biventricular dilatation with severe global systolic dysfunction, and raised pulmonary pressures. A small residual pericardial effusion remained. CT coronary angiogram revealed calcium score of zero. He was discharged on bisoprolol, ramipril, and ivabradine. Progress TTE 6 weeks post-pericardiocentesis revealed resolution of systolic function. Three possible mechanisms include pre/afterload mismatch [[1]Vandyke Jr., W.H. Cure J. Chakko C.S. Gheorghiade M. Pulmonary edema after pericardiocentesis for cardiac tamponade.The New England Journal of Medicine. 1983; 309: 595-596Crossref PubMed Scopus (55) Google Scholar], unmasking of pre-existing LV dysfunction [[3]Wolfe M.W. Edelman E.R. Transient systolic dysfunction after relief of cardiac tamponade.Annals of Internal Medicine. 1993; 119: 42-44Crossref PubMed Scopus (42) Google Scholar], and myocardial stunning from compression of epicardial vessels [[4]Braverman A.C. Sundaresan S. Cardiac tamponade and severe ventricular dysfunction.Annals of Internal Medicine. 1994; 120: 442Crossref PubMed Scopus (20) Google Scholar]. Literature reviews [2Pradhan R. Okabe T. Yoshida K. Angouras D.C. DeCaro M.V. Marhefka G.D. Patient characteristics and predictors of mortality associated with pericardial decompression syndrome: a comprehensive analysis of published cases. [Review].European Heart Journal Acute Cardiovascular Care. 2015; 4: 113-120Crossref PubMed Scopus (18) Google Scholar, 5Ayoub C. Chang M. Kritharides L. A case report of ventricular dysfunction post pericardiocentesis: stress cardiomyopathy or pericardial decompression syndrome?.Cardiovascular Ultrasound. 2015; 13: 1-12PubMed Google Scholar] note that PDS occurred after drainage of 450-2100ml, onset within seconds to weeks, a third of cases were fatal, and two thirds of systolic dysfunction normalised. Intercostal catheters are routinely clamped to prevent re-expansion pulmonary oedema, however no such guidelines exist for pericardiocentesis. Here we suggest limiting immediate drainage to 200ml in order to reduce the likelihood of PDS. Further research on limiting the rate and volume of drainage may clarify how to prevent PDS.

Preventive Strategy for Reexpansion Pulmonary Edema After Minimally Invasive Cardiac Surgery

Reexpansion pulmonary edema is a serious complication of minimally invasive cardiac surgery through the right minithoracotomy. As reexpansion mechanical injury and ischemia reperfusion injury to the collapsed lung are possible mechanisms, we introduced a preventive protocol that consists of intermittent ventilation of the right lung, restoration of bilateral ventilation, administration of mannitol before unclamping the aorta, and institution of mild hypothermia. Among 469 patients who underwent minimally invasive cardiac surgery, we used this protocol in 379 patients. Reexpansion pulmonary edema incidence decreased significantly from 7.8% to 2.1% (P= .006). Although further evaluation is required, our protocol may be effective in preventing reexpansion pulmonary edema.

The Intralobular Gradient as Seen in Re-Expansion Pulmonary Edema.

The Intralobular Gradient as Seen in Re-Expansion Pulmonary Edema.

The Impact of Gravity vs Suction-driven Therapeutic Thoracentesis on Pressure-related Complications: The GRAVITAS Multicenter Randomized Controlled Trial

Thoracentesis can be accomplished by active aspiration or drainage with gravity. This trial investigated whether gravity drainage could protect against negative pressure-related complications such as chest discomfort, re-expansion pulmonary edema, or pneumothorax compared with active aspiration. This prospective, multicenter, single-blind, randomized controlled trial allocated patients with large free-flowing effusions estimated≥ 500mL 1:1 to undergo active aspiration or gravity drainage. Patients rated chest discomfort on 100-mm visual analog scales prior to, during, and following drainage. Thoracentesis was halted at complete evacuation or for persistent chest discomfort, intractable cough, or other complication. The primary outcome was overall procedural chest discomfort scored 5min following the procedure. Secondary outcomes included measures of discomfort and breathlessness through 48h postprocedure. A total of 142 patients were randomized to undergo treatment, with 140 in the final analysis. Groups did not differ for the primary outcome (mean visual analog scale score difference, 5.3mm; 95%CI, -2.4 to 13.0; P= .17). Secondary outcomes of discomfort and dyspnea did not differ between groups. Comparable volumes were drained in both groups, but the procedure duration was significantly longer in the gravity arm (mean difference, 7.4 min; 95%CI, 10.2 to 4.6; P< .001). There were no serious complications. Thoracentesis via active aspiration and gravity drainage are both safe and result in comparable levels of procedural comfort and dyspnea improvement. Active aspiration requires less total procedural time. ClinicalTrials.gov; No.: NCT03591952; URL: www.clinicaltrials.gov.

A case of re-expansion pulmonary edema after minimally invasive cardiac surgery managed through the use of differential lung ventilation and the affected lung up lateral position

A case of re-expansion pulmonary edema after minimally invasive cardiac surgery managed through the use of differential lung ventilation and the affected lung up lateral position

The successful use of extra-corporeal membrane oxygenation as rescue therapy for unilateral pulmonary edema following minimally invasive mitral valve surgery.

Unilateral right pulmonary edema has been reported as a potential life-threatening complication after minimally invasive mitral valve surgery. Nearly 2% of these cases in the immediate postoperative period have been reported to require extra-corporeal membrane oxygenation support as a rescue therapy for severe hypoxia. The exact pathophysiology of this condition remains unclear, but has been assumed to be related to ischemia-reperfusion injury and re-expansion pulmonary edema. We present in this report the successful use of extra-corporeal membrane oxygenation to manage two cases of severe hypoxia and multiorgan dysfunction secondary to unilateral right pulmonary edema.

Medical image of the month: reexpansion pulmonary edema

Medical image of the month: reexpansion pulmonary edema