The authors present a patient with emphysema who developed pulmonary hematomas as a consequence of anticoagulation and rapid lung re-expansion after tube thoracostomy.
An 80-year-old African American male with emphysema was admitted to the hospital for a one week history of shortness of breath. On admission, a CT pulmonary angiogram revealed chronic emphysematous changes without bullae, as well as a filling defect within the left main pulmonary artery consistent with pulmonary embolism. Intravenous unfractionated heparin was administered. On hospital day four, the patient developed sudden respiratory distress and hypotension, and a chest X-ray demonstrated a large right-sided secondary spontaneous pneumothorax. A chest tube was placed emergently and immediately connected to a pleural drainage system and 20 cm of wall suction. At the time, the protime and platelet count were normal, and the partial thromboplastin time was 86.4 seconds. A chest X-ray done after tube thoracostomy showed complete expansion of the right lung and scattered right-sided infiltrates thought to represent re-expansion pulmonary edema. Three hours later, another chest film showed two well-demarcated masses within the right lung (Figure 1). A repeat CT scan revealed two large intraparenchymal pulmonary hematomas measuring 10.5 x 6.6 cm and 9.1 x 6.1 cm, and the chest tube positioned within the pleural space (Figure 2). The patient’s hemoglobin subsequently dropped from 12.7 to 9.6 g/dl over 48 hours. Anticoagulation was reversed, and an inferior vena cava filter was placed. The size of the hematomas remained stable, and the patient was able to be discharged home after chest tube removal.
Pulmonary hematomas commonly occur due to blunt or penetrating thoracic trauma or after thoracic surgery1. These hematomas have been infrequently reported as a complication of systemic anticoagulation2,3, thrombocytopenia4, and subclavian vein catheterization. Bullous emphysema is often a concomitant factor. To our knowledge, pulmonary hematomas occurring after tube thoracostomy and rapid lung re-expansion have not yet been reported. The most common presenting symptoms of pulmonary hematoma include hemoptysis, chest pain, and transitory dyspnea. Radiographically they commonly present as discrete bizarrely shaped masses5 or “coin lesions.” The pathogenesis of pulmonary hematomas depends upon the underlying cause. In blunt thoracic trauma, parenchymal tearing due to transmitted sheer forces results in rupture of small vessels, capillaries, and alveoli, leading to interstitial hemorrhage1. We propose that similar sheer forces can be generated when a lung is rapidly re-expanded following treatment of pneumothorax with tube thoracostomy. Underlying emphysema and anticoagulation were contributing factors in this case. Pulmonary hematomas usually resolve within two to four weeks, but some may remain for an extended period of time. These blood collections can become infected, presenting as an abscess requiring antimicrobials and drainage1.
Underlying emphysema, anticoagulation, and excessive sheer forces induced by rapid lung expansion after chest tube placement contributed to the development of pulmonary hematomas in this patient. Avoiding the immediate use of suction in treating pneumothorax may prevent this complication, especially in anticoagulated emphysema patients.
Jason Graff, None.