Unilateral Re-expansions Pulmonary Edema after Thoracic Drainage Insertion in Patient with Extensive Para-pneumonic Pleural Effusion

In presence of extensive pleural effusion, there is usually a largely atelectatic lung. After thoracic drainage insertion and immediate expansion of the lung, there is a risk of re-expansion pulmonary edema. The following case, described as a rare, life-threatening complication, describes the development of a pulmonary edema after insertion of a chest tube in a completely atelectatic lung as a result of compression due to large pleural effusion.


Unilateral Re-expansions Pulmonary
Edema after Thoracic Drainage Insertion in Patient with Extensive Para-pneumonic Pleural Effusion

Abstract
In presence of extensive pleural effusion, there is usually a largely atelectatic lung. After thoracic drainage insertion and immediate expansion of the lung, there is a risk of re-expansion pulmonary edema. The following case, described as a rare, life-threatening complication, describes the development of a pulmonary edema after insertion of a chest tube in a completely atelectatic lung as a result of compression due to large pleural effusion.   Journal of Universal Surgery ISSN 2254-6758

Therapy
As therapy, the immediate insertion of a 24 CH chest tube in local anesthesia in the 6 th ICR was performed in the middle axillary line with an initial suction of -20 cm H 2 O. It spontaneously deflated nearly 950 ml of putrid secretions (Figure 2).

Follow
The X-ray chest radiograph after chest tube insertion showed fully extended lungs on both sides without evidence of pneumothorax and correct location of chest tube. In the first 24 h, the drainage pumped about 2000 ml purulent secretions.
After 24 h, the condition worsened and the patient complained of increased dyspnoea, tachypnoea, tachycardia, respiratory insufficiency, with necessary for intubation and mechanical ventilation. The X-ray thorax follow-up showed a pronounced ipsilateral (left) shadow. Thoracic drainage was open and not stenotic with fibrin or old blood coagulation; bronchoscopic revealed a few mucous secretions endobronchially left. This confirmed the diagnosis of the full image of re-expansion pulmonary edema (Figure 3). The weight-adapted administration of prednisolone, mechanical ventilation, PEEP of 7, a FiO 2 of 45% and diuretic therapy showed a significant improvement in the generalized status of the patient.
The X-ray done on the following day showed a complete extended lung with significantly declining shadowing without infiltration (Figure 4).
After stabilization of the patient's condition, an operation has been done, as VATS (Video Assisted ThoracoScopy) left sides with decortication. Because of further respiratory insufficiency it has been performed a plastic tracheotomy.

Discussion
The occurrence of re-edema is a rarity (<1%), although in some international literature it has been described in some case reports.
Unilateral re-expansive edema is described as a rare complication in pneumothoracic therapy as well as in the treatment of extensive pleural effusion, with a lethality of up to 20% [1].
The clinical and radiographic manifestations vary from a pale radiographic finding with an asymptomatic patient to a fulminant course with respiratory insufficiency and shock symptoms. Main risk factors are: -Young patient age.
-Relative total lung atelectasis pleura effusion or empyema-related compression.
-Rapid re-expansion of the lungs.
In case of fulminant progressions as in the case described; however, invasive or non-invasive CPAP ventilation may become necessary.
With a corresponding risk profile, it is recommended for Figure 2 Ventilated lung left after the chest drainage system insertion.

Figure 3
Clear evidence of re-expansion pulmonary edema left sides within 24 hours of chest drainage system insertion.

Figure 4
Significant restored shadowing on the left (pulmonary edema) after CPAP due to ventilation, antibiotics, diuretics and cortisone therapy.