Morning Report: 4/27/2012

Thanks to Dr. Nadir for today’s Morning Report (originally presented on 4/20/2012)!

76 year old male with hx of emphysema presents with slowly progressive SOB, over the last 10 days. VS: HR 110, RR 28, O2 sats 93%, BP 110/76. Exam reveals decreased BS over the left lung field. US and CXR show pneumothorax. After appropriate needle decompression, a chest tube is placed. Shortly after chest tube placement patient becomes tachypneic to 35 and his O2 sats decrease to 89%. Before and after chest tube images are shown below:

So what’s the diagnosis?

Re-expansion Pulmonary Edema

Continue below for further discussion. . .

Definition

Edema in the collapsed lung within a few hours of re-expansion.
Can also occur when a large pleural effusion is evacuated by tube thoracostomy.

Risk factors

Age, male gender, a collapsed lung > 3 days

Pathophysiology

Unclear however hypothesis that lung collapse leads to basement membrane thickening and stiffening. Rapid re-expansion stretches thus tears membrane causing the wall to become leaky. Reperfusion injury also results causing further increase in permeability. There is also decreased surfactant production which also contributes to the pulmonary edema.

Management

Be prepared for it.

ABCs, IV, O2

NIPPV, however be prepared to intubate

Lasix has been used – however no good data since limited studies

Reference

Sohara,Y. Reexpansion pulmonary edema. Ann Thorac Cardiovasc Surg 14(4)2008

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