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Reexpansion Pulmonary Edema Following Local Anesthetic ThoracoscopyReexpansion Pulmonary Edema Postthoracoscopy: Correlation and Evolution of Radiographic and Ultrasonographic Findings FREE TO VIEW

John P. Corcoran, BMBCh; Ioannis Psallidas, PhD; Graham Barker, MBBS; Anny Sykes, PhD; Robert J. Hallifax, BMBCh; Fergus V. Gleeson, MD, FCCP; Najib M. Rahman, DPhil
Author and Funding Information

From the Oxford Centre for Respiratory Medicine (Drs Corcoran, Psallidas, Sykes, Hallifax, and Rahman), the Department of Critical Care (Dr Barker), and the Department of Radiology (Dr Gleeson), Oxford University Hospitals NHS Trust, Oxford, England.

CORRESPONDENCE TO: John P. Corcoran, BMBCh, Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, OX3 7LE, England; e-mail: jpcorcoran@doctors.org.uk


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(2):e34-e37. doi:10.1378/chest.13-2989
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Local anesthetic (medical) thoracoscopy is used with increasing frequency by pulmonologists worldwide for both diagnostic and therapeutic purposes, notably in comorbid patients who may not be physiologically robust enough for general anesthesia. Understanding the complications that can arise and how to manage them is crucial for any physician performing this procedure. Reexpansion pulmonary edema is a rare but recognized complication of draining pleural effusions and pneumothoraces that has not been described previously in association with physician-led thoracoscopy. This case provides an opportunity for an overview of what is known about this unusual but potentially fatal condition. Data correlating ultrasonographic, radiographic, and clinical progression are also presented to highlight the potential usefulness of ultrasonography in identifying lung parenchymal abnormalities such as extravascular lung water.

Figures in this Article

Reexpansion pulmonary edema (REPE) is a rare but potentially lethal complication that can arise in the reexpanding lung following drainage of pleural effusions or pneumothoraces. This phenomenon was first described by Pinault in the mid-19th century but its incidence following pleural intervention remains unknown, even > 150 years later. Symptoms include cough, chest discomfort, dyspnea, tachypnea, hypoxemia, and cardiovascular instability, although asymptomatic (radiographic) REPE may be diagnosed incidentally on postprocedure chest radiograph (CXR). Identifying patients at risk of REPE is virtually impossible, and prevention strategies such as limiting the volume of pleural fluid drained to 1 L on any one occasion are of uncertain benefit.1 Thoracoscopy, whether under general or local anesthetic, requires the drainage of all pleural fluid to facilitate visualization of the intrathoracic anatomy prior to lung reexpansion. This case describes the postprocedure development of REPE, its identification using traditional radiographic and novel ultrasonographic techniques, and its subsequent management.

A 52-year-old man underwent local anesthetic thoracoscopy (LAT) for a recurrent cytology-negative exudative pleural effusion (Fig 1A). His medical history included a familial cardiomyopathy with features of hypertrophy and dilatation, and an implantable cardioverter defibrillator in situ for episodes of ventricular tachycardia. The procedure lasted 75 min and was uneventful, with oxygen saturations >94% on room air throughout; 3,100 mL of serosanguinous fluid was drained from the right hemithorax prior to performing pleural biopsies. There were no macroscopic features of malignancy, although the right middle and lower lobes appeared hypoxic. Talc poudrage was not performed, and lung reexpansion was facilitated using a 24F drain connected to an underwater seal without suction.

Figure Jump LinkFigure 1  A, Prethoracoscopy chest radiograph (CXR) showing a right-sided pleural effusion. B, CXR 3 h after thoracoscopy showing opacification in the right mid and lower zones, consistent with localized reexpansion pulmonary edema (REPE). C, CXR 48 h later showing near-total radiographic resolution of REPE.Grahic Jump Location

Three hours after the procedure, medical review was requested because of hypoxemia and increasing oxygen requirements; arterial blood gas measurements (Fio2, 0.35) demonstrated pH of 7.44, Po2 of 7.5 kPa (56.3 mm Hg), and Pco2 of 4.6 kPa (34.5 mm Hg). The patient was hemodynamically stable and felt comfortable, although he was noted to be mildly tachypneic (respiratory rate, 20/min). Transthoracic echocardiogram showed moderate impairment of global systolic function consistent with the known cardiomyopathy, but no acute pathology. CXR (Fig 1B) showed hazy opacification localized to the right hemithorax, whereas contemporaneous thoracic ultrasound (Figs 2A, 2B) demonstrated features consistent with an alveolar-interstitial syndrome and increased extravascular lung water.

Figure Jump LinkFigure 2  A, B-mode thoracic ultrasound after thoracoscopy demonstrating multiple B lines (white arrows) and an alveolar-interstitial pattern (AC in the absence of lung tissue hepatization) in keeping with increased lung water. B, B-mode thoracic ultrasound after thoracoscopy with color Doppler demonstrating pulmonary vascular flow within edematous lung (multiple B lines and alveolar-interstitial pattern again labeled as in A). C, B-mode thoracic ultrasound 48 h later showing ultrasonographic resolution. Note small basal PE, with adjacent NL and HD) not clearly visible on contemporaneous chest radiograph. AC = alveolar consolidation; HD = hemidiaphragm; NL = normal lung; PE = pleural effusion.Grahic Jump Location

A diagnosis of REPE was made, and the patient was transferred to a high-dependency respiratory care unit. Treatment with high-flow humidified oxygen and IV diuretics resulted in clinical improvement, with CXR and thoracic ultrasound (Figs 1C, 2C) at 48 h after the procedure demonstrating resolution of the previously observed changes. The patient was discharged home 3 days after his LAT, the pleural biopsies having demonstrated chronic inflammation and fibrosis with no evidence of either malignancy or infection.

There is an increasing evidence base relating to the diagnostic use of thoracic ultrasonography and its capacity to identify lung parenchymal abnormalities; this includes the correlation of B lines with the presence of extravascular lung water and the alveolar-interstitial syndrome.2,3 The majority of the published research is centered on the critical care setting,4,5 although there are growing data to support clinical use in acute emergency and medical admissions.6 Further robust studies are needed to clarify how and whether this tool may positively impact clinical diagnosis, treatment, and outcomes.

Despite a known cardiomyopathy, the presence of unilateral B lines would not be consistent with congestive cardiac failure (where ultrasonographic changes should be present bilaterally) and, as in this case, this should prompt the physician to consider alternative diagnoses. Unilateral B lines are associated most commonly with infection, although unilateral pulmonary edema is a rarely recognized entity, for example, in conjunction with acute severe mitral regurgitation7 and now REPE.

REPE represents a rare but dangerous complication of draining pleural effusions or pneumothoraces; it is reported to occur in < 1% of cases but has a mortality rate as high as 20%.8,9 The pathophysiology underlying REPE is not fully understood; proposed mechanisms include excess negative pleural pressure causing mechanical stress, hypoxic damage to the chronically atelectatic lung, increased alveolar capillary permeability, and reperfusion injury.9 Proposed risk factors for developing REPE include younger age, longer duration of lung collapse, rapid reexpansion, and cardiac dysfunction. REPE usually develops within 2 to 3 h of the lung having reexpanded, although it can be delayed for as much as 48 h. Purely radiographic REPE that may be identified on CXR or ultrasound following thoracentesis (through the increased presence of B lines in the reexpanded lung) does not necessarily require any intervention; instead, patient symptoms and physiologic observations should guide the decision to initiate therapy.1 Management is supportive, with supplementary oxygen, diuresis, and, if necessary, vasopressor support and positive pressure ventilation, either noninvasive or invasive depending on physiologic status.9

Although REPE has been described following video-assisted thoracoscopic surgery,10 we believe this to be the first report of it occurring in association with physician-led thoracoscopy. Given the increasing use of LAT to provide diagnostic and therapeutic solutions for pleural disease,11 notably in patients considered unfit for general anesthesia, this case provides a reminder of an unusual but important complication that requires rapid recognition and treatment. It also reinforces the point-of-care diagnostic potential of lung ultrasonography, correlating these findings with clinical and more traditional radiographic progression.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts: Dr Psallidas is the recipient of a European Respiratory Society Fellowship (LTRF 2013-1824). Dr Rahman is funded by the NIHR Oxford Biomedical Research Centre. Drs Corcoran, Barker, Sykes, Hallifax, and Gleeson have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions:CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

CXR

chest radiograph

LAT

local anesthetic thoracoscopy

REPE

reexpansion pulmonary edema

Feller-Kopman D, Berkowitz D, Boiselle P, Ernst A. Large-volume thoracentesis and the risk of reexpansion pulmonary edema. Ann Thorac Surg. 2007;84(5):1656-1661. [CrossRef] [PubMed]
 
Lichtenstein D, Mézière G, Biderman P, Gepner A, Barré O. The comet-tail artifact. An ultrasound sign of alveolar-interstitial syndrome. Am J Respir Crit Care Med. 1997;156(5):1640-1646. [CrossRef] [PubMed]
 
Noble VE, Murray AF, Capp R, Sylvia-Reardon MH, Steele DJ, Liteplo A. Ultrasound assessment for extravascular lung water in patients undergoing hemodialysis. Time course for resolution. Chest. 2009;135(6):1433-1439. [CrossRef] [PubMed]
 
Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008;134(1):117-125. [CrossRef] [PubMed]
 
Volpicelli G, Elbarbary M, Blaivas M, et al; International Liaison Committee on Lung Ultrasound (ILC-LUS) for International Consensus Conference on Lung Ultrasound (ICC-LUS). International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012;38(4):577-591. [CrossRef] [PubMed]
 
Koenig S, Chandra S, Alaverdian A, Dibello C, Mayo PH, Narasimhan M. Ultrasound assessment of pulmonary embolism in patients receiving CT pulmonary angiography. Chest. 2014;145(4):818-823. [CrossRef] [PubMed]
 
Roach JM, Stajduhar KC, Torrington KG. Right upper lobe pulmonary edema caused by acute mitral regurgitation. Diagnosis by transesophageal echocardiography. Chest. 1993;103(4):1286-1288. [CrossRef] [PubMed]
 
Mahfood S, Hix WR, Aaron BL, Blaes P, Watson DC. Reexpansion pulmonary edema. Ann Thorac Surg. 1988;45(3):340-345. [CrossRef] [PubMed]
 
Neustein SM. Reexpansion pulmonary edema. J Cardiothorac Vasc Anesth. 2007;21(6):887-891. [CrossRef] [PubMed]
 
Yim APC, Liu HP. Complications and failures of video-assisted thoracic surgery: experience from two centers in Asia. Ann Thorac Surg. 1996;61(2):538-541. [CrossRef] [PubMed]
 
Rahman NM, Ali NJ, Brown G, et al; British Thoracic Society Pleural Disease Guideline Group. Local anaesthetic thoracoscopy: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(suppl 2):ii54-ii60. [PubMed]
 

Figures

Figure Jump LinkFigure 1  A, Prethoracoscopy chest radiograph (CXR) showing a right-sided pleural effusion. B, CXR 3 h after thoracoscopy showing opacification in the right mid and lower zones, consistent with localized reexpansion pulmonary edema (REPE). C, CXR 48 h later showing near-total radiographic resolution of REPE.Grahic Jump Location
Figure Jump LinkFigure 2  A, B-mode thoracic ultrasound after thoracoscopy demonstrating multiple B lines (white arrows) and an alveolar-interstitial pattern (AC in the absence of lung tissue hepatization) in keeping with increased lung water. B, B-mode thoracic ultrasound after thoracoscopy with color Doppler demonstrating pulmonary vascular flow within edematous lung (multiple B lines and alveolar-interstitial pattern again labeled as in A). C, B-mode thoracic ultrasound 48 h later showing ultrasonographic resolution. Note small basal PE, with adjacent NL and HD) not clearly visible on contemporaneous chest radiograph. AC = alveolar consolidation; HD = hemidiaphragm; NL = normal lung; PE = pleural effusion.Grahic Jump Location

Tables

References

Feller-Kopman D, Berkowitz D, Boiselle P, Ernst A. Large-volume thoracentesis and the risk of reexpansion pulmonary edema. Ann Thorac Surg. 2007;84(5):1656-1661. [CrossRef] [PubMed]
 
Lichtenstein D, Mézière G, Biderman P, Gepner A, Barré O. The comet-tail artifact. An ultrasound sign of alveolar-interstitial syndrome. Am J Respir Crit Care Med. 1997;156(5):1640-1646. [CrossRef] [PubMed]
 
Noble VE, Murray AF, Capp R, Sylvia-Reardon MH, Steele DJ, Liteplo A. Ultrasound assessment for extravascular lung water in patients undergoing hemodialysis. Time course for resolution. Chest. 2009;135(6):1433-1439. [CrossRef] [PubMed]
 
Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008;134(1):117-125. [CrossRef] [PubMed]
 
Volpicelli G, Elbarbary M, Blaivas M, et al; International Liaison Committee on Lung Ultrasound (ILC-LUS) for International Consensus Conference on Lung Ultrasound (ICC-LUS). International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012;38(4):577-591. [CrossRef] [PubMed]
 
Koenig S, Chandra S, Alaverdian A, Dibello C, Mayo PH, Narasimhan M. Ultrasound assessment of pulmonary embolism in patients receiving CT pulmonary angiography. Chest. 2014;145(4):818-823. [CrossRef] [PubMed]
 
Roach JM, Stajduhar KC, Torrington KG. Right upper lobe pulmonary edema caused by acute mitral regurgitation. Diagnosis by transesophageal echocardiography. Chest. 1993;103(4):1286-1288. [CrossRef] [PubMed]
 
Mahfood S, Hix WR, Aaron BL, Blaes P, Watson DC. Reexpansion pulmonary edema. Ann Thorac Surg. 1988;45(3):340-345. [CrossRef] [PubMed]
 
Neustein SM. Reexpansion pulmonary edema. J Cardiothorac Vasc Anesth. 2007;21(6):887-891. [CrossRef] [PubMed]
 
Yim APC, Liu HP. Complications and failures of video-assisted thoracic surgery: experience from two centers in Asia. Ann Thorac Surg. 1996;61(2):538-541. [CrossRef] [PubMed]
 
Rahman NM, Ali NJ, Brown G, et al; British Thoracic Society Pleural Disease Guideline Group. Local anaesthetic thoracoscopy: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(suppl 2):ii54-ii60. [PubMed]
 
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