Reexpansion Pulmonary Edema Research Articles

Imaging of Combat-Related Thoracic Trauma - Review of Penetrating Trauma.

Combat-related thoracic trauma is a significant contributor to morbidity and mortality of the casualties from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Penetrating, blunt, and blast injuries were the most common mechanisms of trauma. Imaging plays a key role in the management of combat-related thoracic trauma casualties. This review discusses the imaging manifestations of thoracic injuries from penetrating trauma, emphasizing epidemiology and diagnostic clues seen during OEF and OIF. The assessment of radiologic findings in patients who suffer from combat-related thoracic trauma is the basis of this review article. The imaging modalities for this study include multi-detector computed tomography and chest radiography. High-velocity penetrating projectile injuries appear as hemorrhage and re-expansion pulmonary edema from the temporary cavity and a linear, blood-filled track from the permanent cavity. In cases where the projectile passes totally through the body, entrance wounds at the skin surface and tracks through the subcutaneous tissues may be the only indications of penetrating trauma. When assessing vascular injury, special attention should be paid to the right hilum in contrast-enhanced multi-detector computed tomography, as contrast is concentrated in the superior vena cava and superior cavoatrial junction may obscure small fragments. Additionally, CT angiography may show vessel disruption or extravasation of contrast distal to normal vessel location in addition to intraluminal filling defects and pseudo-aneurysms. Tension pneumopericardium may rarely complicate penetrating or blunt chest trauma. On imaging, distension of the pericardial sack by pneumopericardium and compression of the heart support the diagnosis of tension. On multi-detector computed tomography in the acute trauma setting, fluid in the pleural space should be considered hemothorax, particularly when Hounsfield units are above 35. Acutely, extravasated blood will have similar attenuation to the thoracic vasculature, whereas clotted blood will have higher values of 50-90 Hounsfield units. Combat-related thoracic trauma continues to be a significant contributor to the morbidity and mortality of those injured during OEF and OIF. This review of the imaging manifestations of penetrating thoracic injury during OEF and OIF focuses on key diagnostic findings for clinicians caring for combat casualties. The distinct injury pattern and atypical imaging manifestations of penetrating trauma are important to recognize early due to the acuity of this patient population and the influence of accurate diagnosis on clinical management.

Prevention of Pulmonary Edema after Minimally Invasive Cardiac Surgery with Mini-Thoracotomy Using Neutrophil Elastase Inhibitor.

Unilateral re-expansion pulmonary edema (RPE) is a rare but one of the most critical complications that may occur after re-expansion of a collapsed lung after minimally invasive cardiac surgery (MICS) with mini-thoracotomy. We performed a total of 40 consecutive patients with MICS by right mini-thoracotomy with single-lung ventilation between January 2013 and June 2016. We divided the patients into control group (n = 13) and neutrophil elastase inhibitor group (n = 27). Neutrophil elastase inhibitor group received continuous intravenous infusion of neutrophil elastase inhibitor at 0.2-0.25 mg/kg per hour from the start of anesthesia until extubation during the perioperative period. There were no relations with operative time, cardiopulmonary bypass (CPB) time, aortic clamp time, and intraoperative water valances for postoperative mechanical ventilation support time. Compared with the neutrophil elastase inhibitor group, the control group had significantly higher initial alveolar-arterial oxygen gradient and significantly lower initial ratio of partial pressure of arterial oxygen to fraction of inspired oxygen at the intensive care unit (ICU). The control group had significantly longer postoperative mechanical ventilation support time and hospital stay compared with the neutrophil elastase inhibitor group. Neutrophil elastase inhibitor may have beneficial effects against RPE after MICS with mini-thoracotomy.

Effect of Noninvasive Positive Pressure Ventilation During Large Volume Thoracentesis on Pleural Manometry

SESSION TITLE: Pleural Disease SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: It has been observed that the symptoms of chest pain during large volume thoracentesis and the possibility of re-expansion pulmonary edema occur due to a large drop in the intrapleural pressure during large volume thoracentesis. Due to these factors thoracenteses are frequently terminated prior to the removal of maximal volumes. Consequently, patients may have incomplete drainage or need for multiple procedures. This is an initial pilot study to determine whether the application of non-invasive positive pressure ventilation at a relatively low pressure (CPAP 5mm H2O) during large volume thoracentesis could prevent excessive drop in pleural pressure (pPl). METHODS: A prospective, randomized controlled, non-blinded study of 49 consecutive adults who underwent thoracentesis was performed. We compared the changes in opening and closing pPl using a pleural manometry in patients assigned to continuous positive airway pressure of 5 mmH2O (treatment group) and patients without CPAP (control group). The Mann Whitney U test was used to analyze the results. An independent t test was used to compare the average volume drained between the two groups. RESULTS: Patients treated with CPAP 5 mmH2O had a significantly smaller drop in pleural pressures as compared to patients without CPAP (median of -11cmH2O vs -17.5 cmH2O respectively, p = 0.006). The average volume drained was not statistically significant in the CPAP group (1380 ml) vs the non-CPAP group (1371ml) with a p value 0.953. CONCLUSIONS: Our study demonstrates that the application of CPAP at 5 mmH2O is an effective measure to minimize drops in intrapleural pressures during large volume thoracentesis. We did not collect data on patients’ adverse events post procedure. Further studies at potentially higher CPAP pressure, side effects recording and follow-up imaging are needed to evaluate if preventing the drop in Ppl with CPAP will directly correlate with symptoms and adverse effects. CLINICAL IMPLICATIONS: The application of CPAP during large volume thoracentesis is an effective measure to minimize drops in intrapleural pressures, potentially decreasing adverse effects during this procedure. DISCLOSURE: The following authors have nothing to disclose: Karla Cruz Morel, Jonathan Kass, Ziad Boujaoude, Rohan Arya, Diana Kolman, Wissam Abouzgheib No Product/Research Disclosure Information

Is the mechanism of re-expansion pulmonary oedema in a heart–lung interaction?

The mechanism of re-expansion pulmonary oedema (Re-PE) is unclear. There are multiple variables in play when evaluating the response to evacuation of pleural fluid. We present an educational case of...

Safe and Effective Bedside Thoracentesis: A Review of the Evidence for Practicing Clinicians.

Physicians often care for patients with pleural effusion, a condition that requires thoracentesis for evaluation and treatment. We aim to identify the most recent advances related to safe and effective performance of thoracentesis. We performed a narrative review with a systematic search of the literature. Two authors independently reviewed search results and selected studies based on relevance to thoracentesis; disagreements were resolved by consensus. Articles were categorized as those related to the pre-, intra- and postprocedural aspects of thoracentesis. Sixty relevant studies were identified and included. Pre-procedural topics included methods for physician training and maintenance of skills, such as simulation with direct observation. Additionally, pre-procedural topics included the finding that moderate coagulopathies (international normalized ratio less than 3 or a platelet count greater than 25,000/μL) and mechanical ventilation did not increase risk of postprocedural complications. Intraprocedurally, ultrasound use was associated with lower risk of pneumothorax, while pleural manometry can identify a nonexpanding lung and may help reduce risk of re-expansion pulmonary edema. Postprocedurally, studies indicate that routine chest X-ray is unwarranted, because bedside ultrasound can identify pneumothorax. While the performance of thoracentesis is not without risk, clinicians can incorporate recent advances into practice to mitigate patient harm and improve effectiveness. Journal of Hospital Medicine 2017;12:266-276.

Morphological Characteristics of a Rat Model of Reexpansion Pulmonary Edema

Objective: Reexpansion pulmonary edema (RPE) is a severe disorder, and its pathophysiology is not well understood. One proposed mechanism for RPE is that chemical substances such as cytokines increase alveolar permeability. Another possible mechanism is that alveolar distention during reexpansion causes physical damage. To test the hypothesis that sudden alveolar distention damages alveolar cellular structure and identify the underlying cause of RPE, we developed and evaluated the morphological characteristics of a rat RPE model. Methods: Lung from a rat model of RPE was observed by using live imaging from intravital fluorescence microscopy with fluorescein isothiocyanate labelled albumin as tracer, light microscopy, and electron microscopy (with and without horseradish peroxidase [HRP] as tracer). Results: Intravital fluorescence microscopy and light microscopy showed that RPE developed almost immediately after lung reexpansion and that blood flow in pulmonary capillaries slowed substantially. In some capillaries, however, blood flow had stopped entirely; in others, anterograde and retrograde flow alternated. Electron microscopy revealed pores in type I pneumocytes and overt fissures in alveolar walls. Electron microscopic observation with HRP revealed that HRP moved from capillaries to the inner surfaces of alveolar epithelia in reexpanded lungs. In addition, diaminobenzidine reaction products from the HRP enzyme reaction were visible in areas with pores. Conclusions: RPE occurred almost immediately after lung reexpansion. Pores developed in type I pneumocytes in alveolar epithelium. These pores, together with overt fissures in alveolar walls, allowed leakage of plasma components into alveoli. These findings appear to be important features of RPE development.

Reexpansion pulmonary edema

Key points: (a) Reexpansion pulmonary edema-RxPE– is a rare form of acute lung injury, with an incidence of approximately 1% following evacuation of a pneumothorax; (b) RxPE usually follows rapid reinflation of collapsed lung parenchyma; (c) The most common factor associated with RxPE is the duration of lung collapse– more than 3 days seems to be the critical amount of time; (d) The pathophysiologic changes associated with RxPE are complex and not yet fully understood; (e) The pathologic process results from a combination of rapid pulmonary reexpansion with concurrent mechanical alveolar injury, decrease in surfactant and regional lung tissue hypoxemia, inflammatory cell migration and release of inflammatory mediators, and the resulting changes in capillary-alveolar barrier occurring concurrently with increased capillary/hydrostatic pressures; (f) Clinical manifestations of RxPE vary from minimal symptoms to life-threatening hypoxia and cardio-respiratory collapse; (g) The patient may experience dyspnea, thoracic pain, cough with or without pink/foamy sputum, cyanosis, rales and stertors on auscultation. Other clinical symptoms may include fever, nausea, vomiting, tachycardia, and hypotension; (h) The symptoms of RxPE usually appear within the first two hours following pulmonary reexpansion, but may be delayed by as many as 24-48 h; (i) RxPE usually lasts clinically for as long as 1-2 days, but may take anywhere from 5 to 7 days to resolve; (j) Critical care practitioners should be familiar with the most common factors involved in the pathogenesis of RxPE; (k) The knowledge of these predisposing factors and the ability to effectively treat RxPE are important to prevention and treatment of this potentially fatal condition. The following core competencies are addressed in this article: Medical knowledge, Patient care. Republished with permission from: Stawicki SP, Sarani B, Braslow BM. Reexpansion pulmonary edema. OPUS 12 Scientist2008;2(2):29-31.

Koroner Baypas Sonrası Geç Dönemde Plevral Efüzyon Drenajından Kaynaklanan Reekspansiyon Akciğer Ödemi

Reexpansion pulmonary edema usually follows rapid reinflation of lung parenchyma which collapsed more than three days and can be fatal in up to 21% of cases. A 48-year-old man who had undergone CABG (Coronary Artery Bypass Graft) three weeks ago, admitted to our hospital with a diagnosis of left pleural effusion. He had the clinical findings of pulmonary edema, respiratory insufficiency and shock after tube thoracostomy. He was mechanically ventilated in intensive care unit. During this period, fluid restriction, inotropic agent, diuretic and oxygen support therapy were applied. The patient discharged on 7th day with a full clinical and radiological recovery. The aim of this case report was present to attention the development of re-expansion pulmonary edema which may be fatal, after tube thoracostomy in a patient with pleural effusion following coronary artery bypass surgery.

Re-expansion Pulmonary Edema

Re-expansion Pulmonary Edema

Application of external suction combined with multiaperture catheter after lung bullae resection

Objective We applied external suction to carry out lung expansion after lung bullae resection, and evaluate the clinical value. Methods 122 patients undergoing video-assisted thoracoscopic pulmonary bullae resection were randomized into group A (n=65) and group B (n=57). In group A, we used negative pressure suction to carry out lung expansion, while manual hyperinflation was used in group B. The development of pulmonary atelectasis, reexpansion pulmonary edema and non-surgical side pneumothorax were recorded, and the chest tube drainage duration was recorded finally. Results The development of pulmonary atelectasis, reexpansion pulmonary edema and non-surgical side pneumothorax between the two groups had no statistically significant difference (P>0.05). In 58 patients (58/65) chest tube was removed within 7 days in group A, and 48 patients (48/57) in group B. For these patients, the mean duration of chest tube (days) was shorter in group A [(3.71±1.20) days] than in group B [(4.58±1.27) days] (P 0.05). Conclusion External suction combined with multiaperture catheter is safe and effective for lung expansion after lung bullae resection. This treatment shortens the duration of chest tube placement, but it can not reduce the incidence of postoperative complications. Key words: Pulmonary bullae; Negative pressure suction; Manual lung expansion; Complication

Re-expansion Pulmonary Edema after Drainage of Pleural Effusion in a Pediatric Patient with a Large Anterior Mediastinal Mass

Clinical case presentation of a 13 year old male with a newly diagnosed anterior mediastinal mass who developed rapid respiratory distress after drainage of a pleural effusion. We include a discussion of the incidence, natural history, and peri-operative management of children with re-expansion pulmonary edema.

気管支肺胞洗浄液中の CA19-9 が高値を呈した両側性再膨張性肺水腫の 1 例

気管支肺胞洗浄液中の CA19-9 が高値を呈した両側性再膨張性肺水腫の 1 例

Complications of thoracentesis: incidence, risk factors, and strategies for prevention.

Although thoracentesis is generally considered safe, procedural complications are associated with increased morbidity, mortality, and healthcare costs. In this article, we review the risk factors and prevention of the most common complications of thoracentesis including pneumothorax, bleeding (chest wall hematoma and hemothorax), and re-expansion pulmonary edema. Recent data support the importance of operator expertise and the use of ultrasound in reducing the risk of iatrogenic pneumothorax. Although coagulopathy or thrombocytopenia and the use of anticoagulant or antiplatelet medications have traditionally been viewed as contraindications to thoracentesis, new evidence suggests that patients may be able to safely undergo thoracentesis without treating their bleeding risk. Re-expansion pulmonary edema, a rare complication of thoracentesis, is felt to result in part from the generation of excessively negative pleural pressure. When and how to monitor changes in pleural pressure during thoracentesis remains a focus of ongoing study. Major complications of thoracentesis are uncommon. Clinician awareness of risk factors for procedural complications and familiarity with strategies that improve outcomes are essential components for safely performing thoracentesis.

Manometry in pleural drainage: essential practice or over-rated gadget?

About 1.5 million people are diagnosed with pleural effusion each year in the USA with approximately 180,000 thoracenteses performed each year. The measurement of pleural pressure during therapeutic thoracentesis has been proposed as a useful benchmark to guide therapeutic thoracentesis. The proposed benefits of pleural manometry include diagnosis of unexpandable lung, prevention of re-expansion pulmonary edema (REPE), and pneumothorax ex vacuo, as well as prediction of successful pleurodesis in malignant effusions. Although pleural manometry undeniably offers insights into pleural space physiology, the paucity of data on improved clinical outcomes and the absence of standardized methodology and teaching opportunities have hampered its widespread adoption by pulmonologists.

Reexpansion pulmonary edema following tube thoracostomy for spontaneous pneumothorax in an elderly male

Reexpansion pulmonary edema (RPE) is an important cause of unilateral pulmonary edema that rarely occurs following drainage of pleural effusion or pneumothorax. Most patients develop symptoms within an hour of lung expansion. The presentation is usually rapid and dramatic and may be fatal at times. The duration of lung collapse more than 3 days, large-size pneumothorax, rapidity of lung expansion, and application of negative pleural suction are well-known risk factors for the development of RPE. We present here an elderly male with diabetes mellitus who presented with a large pneumothorax and developed RPE shortly after insertion of a chest tube.

Reexpansion pulmonary edema after treatment of secondary spontaneous pneumothorax

Reexpansion pulmonary edema is an unusual, but commonly fatal, clinical state. It is denoted by the occurrence of unilateral pulmonary edema in a lung that has been speedily reinflated following a variable duration of collapse secondary to a pleural effusion or pneumothorax. Unilateral pulmonary edema is connected with a variable degree of hypoxia and hypotension, occasionally needing intubation and mechanical ventilation, and at times causing lethality. The exact pathophysiologic anomalies linked with this disorder are still not known, although reduced pulmonary surfactant levels and a proinflammatory status are supposed mechanisms. Early diagnosis is important because prognosis is based on early recognition and right treatment. Preventive means are still the best applicable approach for patient handling. Here, we report a case of a 25-year-old male patient who developed reexpansion pulmonary edema after intercostal drainage for secondary spontaneous pneumothorax.

Unilateral re-expansion pulmonary edema following drainage of spontaneous massive pneumothorax of short duration

Re-expansion pulmonary edema (RPE) is a rare complication of thoracentesis. Mortality has been reported in 20% of cases. We present a 25-year-old male with 2 days history of right sided chest pain with imaging suggestive of right-sided extensive pneumothorax. Patient developed symptoms consistent with RPE 12 h after placement of intercostal tube which was documented by imaging. Patient received symptomatic management in respiratory care ward with improvement of his symptoms within 24 h and normalization of chest X-ray after 3 days.

Peer review report 2 on “Reexpansion pulmonary edema after surgery for spontaneous pneumothorax in a patient with anorexia nervosa”

Peer review report 2 on “Reexpansion pulmonary edema after surgery for spontaneous pneumothorax in a patient with anorexia nervosa”

Peer review report 1 on “Reexpansion pulmonary edema after surgery for spontaneous pneumothorax in a patient with anorexia nervosa”

Peer review report 1 on “Reexpansion pulmonary edema after surgery for spontaneous pneumothorax in a patient with anorexia nervosa”

Reexpansion pulmonary edema following thoracentesis

Reexpansion pulmonary edema is an uncommon complication of the treatment of lung atelectasis, pleural effusion or pneumothorax and pathogenesis is unknown. An elderly male patient presented to us with right-sided pleural effusion. 2 h after thoracentesis, he felt chest discomfort and increased breathlessness. His chest examination showed right-sided crackles. Chest radiograph showed right-sided heterogeneous opacity in right lower zone consistent with unilateral pulmonary edema. He was managed conservatively along with bilevel positive airway pressure ventilator support. His condition improved gradually and was discharged successfully after 2 days.