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Interact CardioVasc Thorac Surg 2008;7:485-489. doi:10.1510/icvts.2008.178087 © 2008 European Association of Cardio-Thoracic Surgery
Does re-expansion pulmonary oedema exist?
a Department of Medicine, Sunderland Royal Hospital, Sunderland SR4 7TP, UK Received 15 February 2008; accepted 19 February 2008
*Corresponding author. Tel.: +44 (0) 0191 565 6256.
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: does re-expansion pulmonary oedema exist? Altogether 233 papers were found using the reported search, of which 13 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that re-expansion pulmonary oedema (REPO) does occur following re-expansion of a lung in pneumothorax and pleural effusion. The incidence of REPO following pneumothorax and effusion is between 0 and 1% in most studies. The British Thoracic Society guidelines suggest <1.5 l pleural fluid should be drained at a time. Provided no respiratory symptoms occur it is not unreasonable to drain larger volumes to dryness: caution should be taken to avoid high negative intrapleural pressures. Patients who appear to be at higher risk, which may warrant more gradual evacuation, are: those who have had large pneumothoraces; young patients; patients in whom the lung has been down for >7 days; and possibly those who need >3 l of pleural fluid drained.
Key Words: Chest tubes; Pleural effusion; Pulmonary oedema; Thoracic surgery
A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1]
In [patients with lung collapse] can [re-expansion of the lung] result in the development of [pulmonary oedema]?
You are asked to drain the large bilateral pleural effusions of a 32-year-old lady who is having chemotherapy for a large mediastinal lymphoma. She is otherwise well and you feel that it would be in her interest if she had them quickly drained and then was returned to her cancer ward for continued treatment. You place a 12Fr Seldinger chest drain in each pleura under ultrasound guidance and open the drains. Within 10 minutes there is 1600 ml in the left drain and 2500 ml from the right drain. You continue to leave the drains open and another litre drains over half an hour. Two hours later you are urgently called to her as her oxygen saturations are 80% on 100% oxygen and she has widespread bilateral crepitations. She is intubated and ventilated and taken to the intensive care unit. Despite her WCC dropping to 0.8 the next day she makes a good recovery and is extubated three days later. The oncologist rather abruptly suggests that you look up the evidence for re-expansion pulmonary oedema (REPO) and its relationship to the volume removed.
Medline 1950–Jan 2008 using OVID interface [Pulmonary oedema.mp. OR pulmonary edema.mp or Pulmonary edema/] AND [re-expansion.mp. OR re-expansion.mp.] Review of BTS guidelines and uptodate.com
Two hundred and thirty-three papers were found using the reported search. From these, 13 papers were identified that provided the best evidence to answer the question. These are presented in Table 1.
Mill and Balsch [2] and Brooks [3] looked at a large case series of spontaneous pneumothorax. The former looked at 400 patients, the latter 375. Neither showed any cases of REPO. Feller-Kopman et al. [4] looked at 185 patients who had from 1 l to >3 l of fluid removed at thoracocentesis. Only one patient suffered clinical REPO (1.4 l drained) and four patients had radiographic, asymptomatic REPO. This supports their statement that terminating thoracocentesis after removing 1 l of fluid may be reconsidered, as there are significant clinical benefits to removing more, provided that there is no chest discomfort or that the end-expiratory pleural pressures do not fall below –20 cm H2O. Pihlajamaa et al. [5] looked retrospectively at 212 medical records in which 264 US-guided thoracocenteses were performed. Even in 29 of the patients in whom >1500 ml of fluid was drained no REPO occurred. Jones et al. [6] performed a total of 941 thoracenteses: REPO was seen in two patients who had 1000 and 1200 ml of fluid removed, respectively. More than 1000 ml of fluid was removed in 201 procedures, >1500 ml in 119, and >2000 ml in 53 procedures. They attributed the low level of REPO to cessation of the procedure if symptoms developed. Adegboye et al. [7] reported the largest series of patients with REPO. Of 1678 patients, they saw REPO in 101 (6%). In the REPO group the mean volume drained was 2196±1103 ml and in the control group it was 1060±115 ml (P<0.05). Also lung collapse for more than seven days was significantly correlated. They recommend gradual drainage of pneumothoraces or effusions. De Campos et al. [8] reviewed cases of thoracoscopy and talc poudrage in 614 consecutive patients. Twelve cases of REPO occurred. Eleven of twelve all had thoracocentesis with drainage of more than 3 l of fluid (the twelth was a recurring pneumothorax). There were a number of patients excluded from evaluation due to failure of expansion of the lung or mortality (unrelated to the procedure). Rozenman et al. [9] looked at REPO in 320 episodes of pneumothorax treated with chest tube drainage. Three cases of REPO occurred, two of which required treatment with oxygen. Yim and Liu [10] saw only two cases of REPO in 1337 patients who received video-assisted thoracic surgery. Matsuura et al. [11] looked at 146 cases of spontaneous pneumothorax that were treated by thoracocentesis or continuous low negative pressure suction drainage (–12 cm H2O). Twenty-one developed REPO, and the rate was higher in younger patients with larger pneumothoraces. In the group of patients with moderate lung collapse, longer duration of symptoms had higher rates of REPO. Mahfood et al. [12] reviewed 53 cases of REPO, 11 of which were fatal (20%). They contend that contrary to the idea that REPO occurs only when chronically collapsed lungs are re-expanded rapidly, it is seen with short duration collapse and re-expansion without suction (in 15 of 47 cases available for assessment). Most cases were following pneumothoraces; 7 following effusion drainage. The volumes were between 1000 ml and 4500 ml. Laws et al. [13] and Antunes et al. [14] documented the BTS's advice on the evacuation of pneumothoraces and pleural effusions. The former says ‘good practice suggests that no more than about 1.5 l should be drained at one time...’ There is certainly evidence at thoracoscopy that much larger volumes of fluid can be safely drained. The latter paper notes that, ‘caution should be taken if removing >1.5 l on a single occasion’. There are cases of REPO occurring with <1.5 l, which may be related to the negative intrapleural pressure, the amount of time that the lung has been down and the age of the patients. Caution – for example in avoiding high intrapleural pressures – should be applied irrespective of the amount of fluid drained, with vigilance to the development of any respiratory symptoms. If no symptoms occur, then there is little good evidence to prohibit draining an effusion to dryness.
REPO does occur following re-expansion of a lung in pneumothorax and pleural effusion. The incidence of REPO following pneumothorax and effusion is between 0 and 1% in most studies. The BTS guidelines suggest <1.5 l pleural fluid should be drained at one time. Provided no respiratory symptoms occur it is not unreasonable to drain larger volumes to dryness: caution should be taken to avoid high negative intrapleural pressures. Patients who appear to be at higher risk, which may warrant more gradual evacuation, are: those who have had large pneumothoraces; young patients; patients in whom the lung has been down >7 days; and possibly those who have >3 l of pleural fluid drained.
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Abstract
1. Introduction
