Re-Expansion Pulmonary Edema

Re-expansion pulmonary edema (RPE) is a rare complication of therapeutic thoracentesis. Unfortunately, there is no definitive treatment modality for RPE. The high mortality rate, reported up to 21%, presses the issue for finding adequate prevention and treatment. Here we report a new management modality that is very useful for a patient with RPE. Case Report: An 80-year-old man with a history of hypertension, atrial fibrillation, congestive heart failure with preserved ejection fraction, and sacral decubitus ulcer, who was admitted for surgical debridement of his ulcer. He developed hospital-acquired pneumonia and was resolved with antibiotics and aggressive hydration. He became hypoxic, and his chest imaging revealed bilateral pleural effusions refractory to diuresis. He underwent right-sided thoracentesis with removal of 2.5 liters of transudative fluid. He immediately improved, and his chest x-ray post-thoracentesis showed a significant reduction in the right pleural effusion. Later that night, the patient developed dyspnea and hypoxia. Lung auscultation revealed new crackles on the right side extending to the apex. Repeated chest x-ray showed diffuse right-sided infiltrates, consistent with re-expansion pulmonary edema. We started him on BiPAP ventilation as well as diuresis. Repeated imaging within five hours demonstrated a significant reduction in the pulmonary edema, and his clinical condition improved markedly. He was transitioned to supplemental oxygen via nasal cannula at 2L/min within 24 hours. Discussion: RPE occurs due to increase permeability of pulmonary capillary vessels secondary to rapid reduction in the pleural cavity pressure and sudden lung expansion. The severity of the intra-pleural negative pressure is thought to contribute to the risk of developing RPE. A recent study has proved a correlation between the amount of volume removed from the pleural cavity and the chance of developing RPE. Treatment for RPE is supportive, with oxygen supplementation and diuresis. However, we found dramatic clinical and radiological changes after applying BiPAP and thereby increasing the intra-pleural pressure. Conclusion: Clinicians should be encouraged to place patients who develop RPE on BiPAP for six to twelve hours to prevent worsening of pulmonary edema. As presented in our case, this management modality had desirable outcomes in as little as five hours. Further studies require to assess the effectiveness of BiPAP to decrease the progression and mortality of RPE