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A Case of Reexpansion Pulmonary Edema After Resection of a Large Teratoma, Treated With Extracorporeal Membrane Oxygenation FREE TO VIEW

Vikramjit Khangoora, MD; Matthew McLaughlin, DO; Joshua Sill, MD
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Eastern Virginia Medical School, Norfolk, VA

Chest. 2015;148(4_MeetingAbstracts):281A. doi:10.1378/chest.2280385
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SESSION TITLE: Critical Care Student/Resident Case Report Posters III

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Reexpansion pulmonary edema (REPE) is a rare complication after reexpansion of chronically collapsed lung. It is associated with significant mortality. Treatment is mainly supportive.

CASE PRESENTATION: A 32-year-old African American male with history of a metastatic nonseminomatous malignant germ cell tumor, who had undergone chemotherapy, right radical orchiectomy, and retroperitoneal lymph node dissection 18 months before, presented with 4 months of chest pain and dyspnea. CT scan revealed a large mixed solid and cystic mass causing complete right lung atelectasis, mediastinal shift, and mass effect upon the IVC and right atrium. CT-guided biopsy revealed fibromyxoid tissue with hyalinized fibrous tissue. Shortly after admission, the patient developed respiratory failure requiring intubation. Surgical resection of the mass was performed, with the removal of 4.5 kilograms of tumor and 6.5 liters of fluid. Post-operatively the patient developed refractory hypoxia on mechanical ventilation. CXR revealed increasing right lung opacities consistent with REPE. Due to severe hypoxia, refractory to all other interventions, extracorporeal membrane oxygenation (ECMO) was initiated. After four days, oxygenation improved and ECMO was discontinued. Pathology was consistent with a teratoma. The patient fully recovered and was discharged home.

DISCUSSION: REPE is a rare complication that most commonly occurs after drainage of pleural effusions or pneumothoraces. It has only rarely been reported after surgical resection of large thoracic tumors. REPE is reported to have an incidence of less than 1 percent but carries a mortality rate of up to 20 percent. It is believed to be caused by an abnormality in the pulmonary microvasculature and mechanical stress placed on the rapidly reexpanding lung. Treatment is mostly supportive but may consist of administration of diuretics and positive pressure ventilation.

CONCLUSIONS: Reexpansion pulmonary edema is a rare, but potentially deadly complication after procedures that result in reexpansion of chronically collapsed lung. To our knowledge, this is only the third reported case of REPE that has been treated with ECMO. Given the high mortality associated with this condition, ECMO should be considered as a treatment option in severe, refractory cases.

Reference #1: CASE 4—2009 Severe Reexpansion Pulmonary Edema After Minimally Invasive Aortic Valve Replacement: Management Using Extracorporeal Membrane Oxygenation. Shires, Adam L. et al. Journal of Cardiothoracic and Vascular Anesthesia, Volume 23, Issue 4, 549 - 554

Reference #2: Bilateral Developing Reexpansion Pulmonary Edema Treated With Extracorporeal Membrane Oxygenation Tung, Yung-Wei et al. The Annals of Thoracic Surgery, Volume 89, Issue 4, 1268 - 1271

Reference #3: Sohara, Y. Reexpansion Pulmonay Edema. Annals of Thoracic and Cardiovascular Surgery 14 (4): 205-209.

DISCLOSURE: The following authors have nothing to disclose: Vikramjit Khangoora, Matthew McLaughlin, Joshua Sill

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