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Clinical Analysis of Reexpansion Pulmonary Edema
Clinical Analysis of Reexpansion Pulmonary Edema* Yuichiro Matsuura, M.D., Ph.D., F.C.C.R;t Takayuki Nomimura, M.D.;t Hironobu Murakami, M.D., Ph.D.;t Takeshi Matsushima, M.D., Ph.D.;t Masayuki Kakehashi, Ph.D.;* and Hiroki Kajihara, M.D., Ph.D.§ 1\venty-ooe of 146 cases of spontaneous pneumothorax that were treated by thoracentesis or continuous low negative pressure suction drainage (-12 em 1Is0) of the pleural space developed REPE. The rate of REPE was higher in patients 10 to 39 years of age than in those over the age of 40, and the rate progressively increased in proportion to the extent of pneumothorax, as assessed by roentgenographic criteria. It is postulated that age-related changes
incidence of spontaneous pneumothorax has increased. 1 Mild cases are managed conservatively with rest, while on ,the other hand, large pneumothorax or tension pneumothorax is typically treated with thoracentesis or continuous low negative pressure drainage of the pleural space. It has been cautioned that rapid reexpansion of long-tenn collapsed lung leads occasionally to reexpansion pulmonary edema which can be fatal. 2 •3 Since detailed clinical studies of REPE are scarce, the authors analyzed respectively 164 cases of spontaneous pneumothorax treated at the Hiroshima Prefectural Hospital from 1974 to 1985. Of these, 146 were treated by thoracentesis, suction drainage ofthe pleural space, or thoracotom~ Twenty-one patients (14 percent) subsequently exhibited evidence of REPE and were treated actively with a variety of modalities and drugs, including oxygen, steroids, diuretics, sedatives, and inotropic agents without any fatal outcome.
in the lung may afford some degree of protection against developing REPE. It is also suggested that the treatment ofpneumothorax with thoracentesis aodIor suction drainage in young patients, or in the face of a large pneumothorax, requires careful consideration in view of a relatively high incidence of REPE in such individuals. (Chat 1991; 100:1562-66)
ecentl~ the
R
*From tthe 1st De~ent of Surgery and *Depar!!Dent of Public Health, School of Medicine, and the §Organizing Office for College of Medical Technology, Hiroshima University, Hiroshima, Japan Manuscript received November 8; revision accepted March 26. Beprint requut&: Dr. Matsuura, 1st Department of Surgery, Hiro-
slUma UnWersUy School of Medicine, 1-2-3 Ktuumi, Minamiku, HiroslUma City 734, japan
MATERIALS AND METHODS
The subjects in this study were 164 patients with spontaneous pneumothorax, 146 of whom were treated by thoracentesis or continuous low negative pressure drainage (-12 em H.O) of the pleural space. Subsequently, 113 underwent a thoracotomy for bleb excision and/or pleurectom~ The remaining 18 pati~nts received conservative treatment (bedrest), and the condition was allowed to resolve spontaneousl~ Among the 146 patients who received active treatment, 21 developed REPE. The criteria used to diagnose REPE included the following: (1) clinical status with serious cough, foaming sputum, agitation, tachycardia, and tachypnea; and (2) extensive ground glass-like shadow in the chest x-ray film following lung reexpansion. The rate of REPE among subgroups classified by age, sex, underlying diseases, signs and symptoms, frequency of previous attacks of pneumothorax, and presumed duration of lung collapse or side of the involved lung was compared to find factors associated with higher REPE rates. Statistical comparisons were made by Xl test, Fisher exact test, and multiple logistic regression. RESULTS
Treatment modalities utilized are outlined in Table 1. Initial treatment consisted of thoracentesis or continuous negative pressure drainage. The most frequently performed surgical treatment was excision of bleb with parietal pleurectomy in patients under the age of 50. Patients who were over 60 years old
Table 1-ltema of Treatment of Spontaneoua PneumotlaortJ% According to Age·
Age, yr
Conservative Rest
-19 20-29 30-39 40-49
3 (12.5) 4 (7.3) 3 (8.8)
50-59 60-69
4 (33.3)
70Total No.
o
(0)
1 (10.0) 3 (23.1) 18
Thoracentesis or Suction Drainage 3 8 2 5 3
(12.5) (14.5) (5.9) (31.3) (25.0)
5 (50.0)
7 (53.8) 33
Excision of Bleb, Partial Ple.urectomy 15 40 26 10 3 1 1
(62.5) (72.7) (76.4)
(62.5) (25.0) (10.0) (7.7) 96
Excision of Bleb, Extended Pleurectomy 3 3 3 1 2 3 2
(12.5) (5.5) (8.8) (6.3) (16.7) (30.0) (15.4) 17
Total No. 24 55 34
16 12 10 13 164
*Percentages in parentheses.
1582
CInicaI Analysis of Reexpansion Pulmonary Edema (Matsuura et 81)
Age
I
-l9yrs 20-39yrs
~~\\~
~\1:J
40- yrs
o
Percent
50
100
Extent of lung oollapse
Mild _
~ate severe IZ2SJ
were most commonly treated by simple continuous low negative pressure suction drainage. Figure 1 shows the rate of cases of subgroups classified by severity of pneumothorax according to age. There was no relationship between age and the rate of cases of subgroups. Table 2 shows the incidence of REPE in relation to age, sex, underlying diseases, signs and symptoms, frequency of attacks, and presumed duration of lung collapse. The rate of REPE in the group aged 20 to 39 years was significantly higher than in other groups (p
Tensioo
FIGURE 1. The rate of cases ofsubgroups pnetmDt:h:>rax classified by severity of pneumothorax c=J according to age.
c:s:sJ
to the presence of underlying disease, signs and symptoms, previous pneumothorax, nor presumed duration of pneumothorax. The rate of REPE increased in proportion to the extent of lung collapse as judged by the roentgenographic appearance of the chest (p
Table !-ComptJriIon of Age, Sa, Untlerlying DitJeGae, Signland SyrapIorraI, FreqaencfI t{ Aaaclc, and Lang CollspJe Duration BmDeera in lbtienta tDitIa BEPE and tDidaout BEPE Patients
with REPE ('I» Age
Sex Underlying disease
Signs and symptoms
-19yr 20-39 40Male Female Bronchial asthma Bleb Bronchial asthma + bleb Bleb + pulmonary emphysem Pulmonary emphysem Others Chest oppression Chest oppression + dyspnea
Cough
Dyspnea Dyspnea + chest pain Chest pain Frequency of attack
1 2 3-5
Lung collapse duration
6-9 10-1 day 2-4 5-8 9-
2 18 1 18 3 1 20 0 0 0 0 1 0 1 8 5 6 14 7 0 0 0 9 7 4 1
(8.6)~
(23.4)--t (2.2)-.J (13.8) (18.8) (25.0) (17.0)
(14.3) (25.0) (12.9) (13.6) (16.7) (17.7) (11.5)
(13.2) (18.9) (20.0) (4.8)
Patients Without REPE ('I»
(91.3) (76.6) (97.8) (86.2) (81.2) (75.0) (93.0) (100.0) (100.0) (100.0) (100.0) (85.7) (100.0) (75.0) (97.1) (86.1) (83.3) (82.3) (88.5) (100.0) (100.0) (100.0) (86.8) (81.1) (80.0) fD (95.2)
21 :59 45 112 13 3 98 5 1 16 1 6 1 3 54 31 30 65 54 4 1 1 :59 30 16
CHEST I 100 I 8 I DECEMBER. 1991
Total 23
77 46
130 16 4 118 5 1 16 1 7 1 4 62
36 36 79 61 4 1 1 68
37 20
21
1583
Table 3-Compariaon ojCIaeat X-Bay Finding. and the Involved Side Between in Patienta with BEPE and tDitIaout BEPE Patients with REPE Extent of lung collapse
Side of lung collapse
Mild* Moderate Severe Tension Pneumothorax Left Right Both
Patients Without REPE (If,)
0 5 (7.2)~-, 8 (17.4)~ • 8 (44.4)--J.-J
13 64 38 10
10 (15.9) 11 (15.1) 0
Total
(100.0) (92.3) (82.6) {55.6)
13 69 46 18
53 (84.1) 62 (84.9) 10 (100.0)
63 73 10
*Mild, lung collapse less than one third of the lung field; moderate, lung collapse more than one third of the lung field; and severe, complete collapse of the lung.
frequency of REPE according to the extent of lung collapse and the duration of symptoms. There was a tendency that in patients with moderate extent oflung collapse, cases with longer duration of symptoms had higher rates of REPE as compared with those with less than one day's duration of symptoms. Also, in patients with severe and tension pneumothorax, those with less than four days' duration of symptoms had higher rates of REPE than those with more than five days' duration of symptoms. Thus, since severity of collapse appears to be a major determining factor in promoting REPE, the role of duration of collapse as an independent determinant ofthe incidence ofREPE may be offset or overshadowed by the active treatment. This may explain why the duration ofcollapse appears to be ofsome relevance under controlled experimental conditions but may be less relevant clinically as a predictor ofREPE. It was also revealed that two factors associated with a high rate ofREPE (ie, age class and severity of lung collapse) were independent of each other using a multiple logistic regression model. The regression coefficients for the age classes 20 to 39 and 40 to 79 were 1.287 and -1.576 (p=0.015) if we set that for the age class 0-19 to be 0.0. The coefficients for the extent of lung collapse (ie, mild/moderate or severe!
tension pneumothorax) were 0.0116.224118.284, respectively (p =0.006). DISCUSSION
It has been suggested that the incidence of REPE is a rare condition. 4 However, Hosokawa and associatesS reported that they experienced three cases of REPE among 12 treated cases of spontaneous pneumothorax, and Takamura and his associates& found a 27 percent incidence ofREPE in experimental stud~ In our series, 21 of 146 (14.4 percent) cases treated by thoracentesis or suction drainage or both ofthe pleural space developed REPE. Mahfood and associates7 reported 11 fatalities among 53 cases of REPE, while there were no fatalities among the 21 cases of REPE identified in this stud~ The etiology of REPE remains speculative. It is thought to be caused by increased pulmonary capillary penneabili~ Factors that have been postulated to contribute to altered permeability include lung hypoxia,1.8 chronicity of pulmonary collapse, rapid reexpansion9•10 and subsequent occurrence of strong negative pressure in the thorax,l1 application of excessive intrathoracic suction pressure,12 rapid increase in blood flow to the involved lung during reexpansion, an increase in the pressure gradient between the alveolar space and the pulmo-
Extent of
lung ex>llapse
Mild lb3erate
severe Tension
pneUItDtOOrax
liliiiiiiiiiijiiiiiiiiiiiipiiiiiiiiiiiiii~piiiiiiiiiii
o
50
100
Percent
1Amg oollapse duratial FIGURE 2. The relationship between the extent of lung collapse and the duration of symptoms.
1584
-1 -
2-4
5-8
9- days
I2S2SI
[DJ
c::J
Frequency
I
30
25 20
15
case
without REPE
case with
REPE
10
-1 day
2-4 days
LUn
3. The frequency of REPE accordin~ to the extent oflun~ collapse and the duration of symptoms.
nary capillary, disturbance oflymph flow in the lung,13 and destruction of lung surfactant. 12.13 Usually REPE occurred in the lung that was collapsed, but occasionally it occurred in the contralateral lung. 6.14 In these instances, it was possible that vasoactive substances, such as histamine, prostaglandin, or neurogenic factors, might have been involved in the development ofREPE.6.14 The authors found that the group of patients 20 to 39 years of age had a higher incidence ofREPE than the older age group, and they postulate that the lung might be altered by aging in a manner that protects it against the occurrence of REPE in the older age group. Such differences might include changes in the mechanics of the lung or the permeability characteristics of the alveolar-capillary barrier. To date, it has been believed that REPE was most likely to occur in patients who were symptomatic for more than three days. Sewell and associates15 reported that changes occurred in the alveolar-capillary basement membrane after 72 h of collapse, rendering it more permeable. On the contrary, in our series, prolonged duration of collapse did not appear to promote the occurrence ofREPE. The authors regard this as a consequence of the fact that patients who were actively treated after a short duration of symptoms had a greater magnitude of pneumothorax in comparison with other groups, which may have overshadowed any effect of duration of collapse. The potentially serious consequences of developing REPE have been suggested by Mahfood and associates,7 who reported that 11 of 53 patients with REPE died. It is, therefore, important to emphasize that
prevention of REPE is of prime importance when treating pneumothorax. It has been suggested that slow reexpansion by low negative pressure suction drainage is important in the prevention of REPE. However, even though slow reexpansion by continuous low negative pressure suction drainage was attempted in all our 146 cases of pneumothorax, 21 cases developed REPE. Repeated aspiration of <1,000 ml of air has also been recommended to prevent REPE, and Sautter and associates 13 recommended obstruction of the pulmonary artery of the involved lung using a balloon catheter if a patient begins to develop signs and symptoms ofREPE. Both ofthese methods remain to be tested and were not utilized in the patients described here. In summary, 21 of 146 cases of spontaneous pneumothorax which were treated by thoracentesis or continuous low negative pressure suction drainage (- 12 cm H20) ofthe pleural space developed REPE, and were actively treated with a variety of modalities and drugs, including oxygen, steroids, diuretics, sedatives, and inotropic agents without fatal outcome. The rate of REPE was higher in patients 20 to 39 years of age than in those over the age of 40. It is postulated that age-related changes in the lung may afford some degree of protection against developing REPE. REFERENCES 1 Nakamura H. Spontaneous pneumothorax: on atmospheric pollution as a cause of it. Jpn Med J 1975; 2677:14-19 2 Trapnell DH, Thurston JGB. Unilateral pulmonary oedema after pleural aspiration. Lancet 1970; 1:1367-69 3 Peatfield Re, Edwards PR, Johnson NM. Two unexpected CHEST 1100 I 6 I DECEMBER. 1991
1565
deaths from pneumothorax. Lancet 1979; 17:356-58
4 Murphy K, Tomlanovich M. Unilateral pulmonary edema after
5 6 7 8 9
10
drainage ofa spontaneous pneumothorax: case report and review of the world literature. J Emerg Med 1983; 1:29-24 Hoso1cawa T, Yaita A, Chiba 1: Moriyama M, Ababe K, Kalcegawa T. A case report of re-expansion pulmonary oedema after slow drainage. J Clio Surg 1989; 50:729-33 Takamura K, Takamura M, Kobayashi H. Current topics of reexpansion pulmonary edema. Respir Cire 1984; 32:133-41 Mahfood S, Hix WR, Aaron BL, Blaes ~ Watson DC. Reexpansion pulmonary edema. Ann Thorne Surg 1988; 45:340-45 Pavlin DJ. Lung reexpansion: for better or worse? Chest 1986; 89:2-3 HumphreyRL, Berne AS. Rapidre-expansionofpneumothorax: a course of unilateral pulmonary edema. Radiology 1970; 96:50912 Mahajan VIC Re-expansion pulmonary edema. Chest 1983; 83:4
11 Zisldnd MM, Well U, George RA. Acute pulmonary edema following the treatment of spontaneous pneumothorax with excessive negative intrapleural pressure. Am Rev Respir Dis
1965; 92:632-636 12 Childress ME, Moy G, Mottram M. Unilateral pulmonary edema resulting from treatment of spontaneous pneumothorax. Am Rev Respir Dis 1971; 104:119-21 13 Sautter RO, Dreger WH, Maclndoe JU, Myer WO, Magnin GE. Fatal pulmonary edema and pneumonitis after re-expansion. Chest 1971; 60:399-401 14 Fliclc MR, Kautzeler GB, Block AJ. Unilateral pulmonary edema with contralateral thoracic sympathectomy in the adult respiratory distress syndrome. Chest 1975; 68:736-40 15 Sewell ~ Fewel JG, Grover FL, Amm ~ Experimental evaluation of reexpansion pulmonary edema. Ann Thorac Surg 1978; 26:126-32
Symposium: cardiopulmonary Rehabilitation, Status '92 The University of Florida Center for Exercise Science will present this program February 17-19 at the Sheraton World Hotel, Orlando. For information, contact Michael L. Pollock, Ph.D., University of Florida Center for Exercise Science, Florida Gymnasium, Room 27, Gainesville 32611 (904:392-9575).
1518
incidence of spontaneous pneumothorax has increased. 1 Mild cases are managed conservatively with rest, while on ,the other hand, large pneumothorax or tension pneumothorax is typically treated with thoracentesis or continuous low negative pressure drainage of the pleural space. It has been cautioned that rapid reexpansion of long-tenn collapsed lung leads occasionally to reexpansion pulmonary edema which can be fatal. 2 •3 Since detailed clinical studies of REPE are scarce, the authors analyzed respectively 164 cases of spontaneous pneumothorax treated at the Hiroshima Prefectural Hospital from 1974 to 1985. Of these, 146 were treated by thoracentesis, suction drainage ofthe pleural space, or thoracotom~ Twenty-one patients (14 percent) subsequently exhibited evidence of REPE and were treated actively with a variety of modalities and drugs, including oxygen, steroids, diuretics, sedatives, and inotropic agents without any fatal outcome.
in the lung may afford some degree of protection against developing REPE. It is also suggested that the treatment ofpneumothorax with thoracentesis aodIor suction drainage in young patients, or in the face of a large pneumothorax, requires careful consideration in view of a relatively high incidence of REPE in such individuals. (Chat 1991; 100:1562-66)
ecentl~ the
R
*From tthe 1st De~ent of Surgery and *Depar!!Dent of Public Health, School of Medicine, and the §Organizing Office for College of Medical Technology, Hiroshima University, Hiroshima, Japan Manuscript received November 8; revision accepted March 26. Beprint requut&: Dr. Matsuura, 1st Department of Surgery, Hiro-
slUma UnWersUy School of Medicine, 1-2-3 Ktuumi, Minamiku, HiroslUma City 734, japan
MATERIALS AND METHODS
The subjects in this study were 164 patients with spontaneous pneumothorax, 146 of whom were treated by thoracentesis or continuous low negative pressure drainage (-12 em H.O) of the pleural space. Subsequently, 113 underwent a thoracotomy for bleb excision and/or pleurectom~ The remaining 18 pati~nts received conservative treatment (bedrest), and the condition was allowed to resolve spontaneousl~ Among the 146 patients who received active treatment, 21 developed REPE. The criteria used to diagnose REPE included the following: (1) clinical status with serious cough, foaming sputum, agitation, tachycardia, and tachypnea; and (2) extensive ground glass-like shadow in the chest x-ray film following lung reexpansion. The rate of REPE among subgroups classified by age, sex, underlying diseases, signs and symptoms, frequency of previous attacks of pneumothorax, and presumed duration of lung collapse or side of the involved lung was compared to find factors associated with higher REPE rates. Statistical comparisons were made by Xl test, Fisher exact test, and multiple logistic regression. RESULTS
Treatment modalities utilized are outlined in Table 1. Initial treatment consisted of thoracentesis or continuous negative pressure drainage. The most frequently performed surgical treatment was excision of bleb with parietal pleurectomy in patients under the age of 50. Patients who were over 60 years old
Table 1-ltema of Treatment of Spontaneoua PneumotlaortJ% According to Age·
Age, yr
Conservative Rest
-19 20-29 30-39 40-49
3 (12.5) 4 (7.3) 3 (8.8)
50-59 60-69
4 (33.3)
70Total No.
o
(0)
1 (10.0) 3 (23.1) 18
Thoracentesis or Suction Drainage 3 8 2 5 3
(12.5) (14.5) (5.9) (31.3) (25.0)
5 (50.0)
7 (53.8) 33
Excision of Bleb, Partial Ple.urectomy 15 40 26 10 3 1 1
(62.5) (72.7) (76.4)
(62.5) (25.0) (10.0) (7.7) 96
Excision of Bleb, Extended Pleurectomy 3 3 3 1 2 3 2
(12.5) (5.5) (8.8) (6.3) (16.7) (30.0) (15.4) 17
Total No. 24 55 34
16 12 10 13 164
*Percentages in parentheses.
1582
CInicaI Analysis of Reexpansion Pulmonary Edema (Matsuura et 81)
Age
I
-l9yrs 20-39yrs
~~\\~
~\1:J
40- yrs
o
Percent
50
100
Extent of lung oollapse
Mild _
~ate severe IZ2SJ
were most commonly treated by simple continuous low negative pressure suction drainage. Figure 1 shows the rate of cases of subgroups classified by severity of pneumothorax according to age. There was no relationship between age and the rate of cases of subgroups. Table 2 shows the incidence of REPE in relation to age, sex, underlying diseases, signs and symptoms, frequency of attacks, and presumed duration of lung collapse. The rate of REPE in the group aged 20 to 39 years was significantly higher than in other groups (p
Tensioo
FIGURE 1. The rate of cases ofsubgroups pnetmDt:h:>rax classified by severity of pneumothorax c=J according to age.
c:s:sJ
to the presence of underlying disease, signs and symptoms, previous pneumothorax, nor presumed duration of pneumothorax. The rate of REPE increased in proportion to the extent of lung collapse as judged by the roentgenographic appearance of the chest (p
Table !-ComptJriIon of Age, Sa, Untlerlying DitJeGae, Signland SyrapIorraI, FreqaencfI t{ Aaaclc, and Lang CollspJe Duration BmDeera in lbtienta tDitIa BEPE and tDidaout BEPE Patients
with REPE ('I» Age
Sex Underlying disease
Signs and symptoms
-19yr 20-39 40Male Female Bronchial asthma Bleb Bronchial asthma + bleb Bleb + pulmonary emphysem Pulmonary emphysem Others Chest oppression Chest oppression + dyspnea
Cough
Dyspnea Dyspnea + chest pain Chest pain Frequency of attack
1 2 3-5
Lung collapse duration
6-9 10-1 day 2-4 5-8 9-
2 18 1 18 3 1 20 0 0 0 0 1 0 1 8 5 6 14 7 0 0 0 9 7 4 1
(8.6)~
(23.4)--t (2.2)-.J (13.8) (18.8) (25.0) (17.0)
(14.3) (25.0) (12.9) (13.6) (16.7) (17.7) (11.5)
(13.2) (18.9) (20.0) (4.8)
Patients Without REPE ('I»
(91.3) (76.6) (97.8) (86.2) (81.2) (75.0) (93.0) (100.0) (100.0) (100.0) (100.0) (85.7) (100.0) (75.0) (97.1) (86.1) (83.3) (82.3) (88.5) (100.0) (100.0) (100.0) (86.8) (81.1) (80.0) fD (95.2)
21 :59 45 112 13 3 98 5 1 16 1 6 1 3 54 31 30 65 54 4 1 1 :59 30 16
CHEST I 100 I 8 I DECEMBER. 1991
Total 23
77 46
130 16 4 118 5 1 16 1 7 1 4 62
36 36 79 61 4 1 1 68
37 20
21
1583
Table 3-Compariaon ojCIaeat X-Bay Finding. and the Involved Side Between in Patienta with BEPE and tDitIaout BEPE Patients with REPE Extent of lung collapse
Side of lung collapse
Mild* Moderate Severe Tension Pneumothorax Left Right Both
Patients Without REPE (If,)
0 5 (7.2)~-, 8 (17.4)~ • 8 (44.4)--J.-J
13 64 38 10
10 (15.9) 11 (15.1) 0
Total
(100.0) (92.3) (82.6) {55.6)
13 69 46 18
53 (84.1) 62 (84.9) 10 (100.0)
63 73 10
*Mild, lung collapse less than one third of the lung field; moderate, lung collapse more than one third of the lung field; and severe, complete collapse of the lung.
frequency of REPE according to the extent of lung collapse and the duration of symptoms. There was a tendency that in patients with moderate extent oflung collapse, cases with longer duration of symptoms had higher rates of REPE as compared with those with less than one day's duration of symptoms. Also, in patients with severe and tension pneumothorax, those with less than four days' duration of symptoms had higher rates of REPE than those with more than five days' duration of symptoms. Thus, since severity of collapse appears to be a major determining factor in promoting REPE, the role of duration of collapse as an independent determinant ofthe incidence ofREPE may be offset or overshadowed by the active treatment. This may explain why the duration ofcollapse appears to be ofsome relevance under controlled experimental conditions but may be less relevant clinically as a predictor ofREPE. It was also revealed that two factors associated with a high rate ofREPE (ie, age class and severity of lung collapse) were independent of each other using a multiple logistic regression model. The regression coefficients for the age classes 20 to 39 and 40 to 79 were 1.287 and -1.576 (p=0.015) if we set that for the age class 0-19 to be 0.0. The coefficients for the extent of lung collapse (ie, mild/moderate or severe!
tension pneumothorax) were 0.0116.224118.284, respectively (p =0.006). DISCUSSION
It has been suggested that the incidence of REPE is a rare condition. 4 However, Hosokawa and associatesS reported that they experienced three cases of REPE among 12 treated cases of spontaneous pneumothorax, and Takamura and his associates& found a 27 percent incidence ofREPE in experimental stud~ In our series, 21 of 146 (14.4 percent) cases treated by thoracentesis or suction drainage or both ofthe pleural space developed REPE. Mahfood and associates7 reported 11 fatalities among 53 cases of REPE, while there were no fatalities among the 21 cases of REPE identified in this stud~ The etiology of REPE remains speculative. It is thought to be caused by increased pulmonary capillary penneabili~ Factors that have been postulated to contribute to altered permeability include lung hypoxia,1.8 chronicity of pulmonary collapse, rapid reexpansion9•10 and subsequent occurrence of strong negative pressure in the thorax,l1 application of excessive intrathoracic suction pressure,12 rapid increase in blood flow to the involved lung during reexpansion, an increase in the pressure gradient between the alveolar space and the pulmo-
Extent of
lung ex>llapse
Mild lb3erate
severe Tension
pneUItDtOOrax
liliiiiiiiiiijiiiiiiiiiiiipiiiiiiiiiiiiii~piiiiiiiiiii
o
50
100
Percent
1Amg oollapse duratial FIGURE 2. The relationship between the extent of lung collapse and the duration of symptoms.
1584
-1 -
2-4
5-8
9- days
I2S2SI
[DJ
c::J
Frequency
I
30
25 20
15
case
without REPE
case with
REPE
10
-1 day
2-4 days
LUn
3. The frequency of REPE accordin~ to the extent oflun~ collapse and the duration of symptoms.
nary capillary, disturbance oflymph flow in the lung,13 and destruction of lung surfactant. 12.13 Usually REPE occurred in the lung that was collapsed, but occasionally it occurred in the contralateral lung. 6.14 In these instances, it was possible that vasoactive substances, such as histamine, prostaglandin, or neurogenic factors, might have been involved in the development ofREPE.6.14 The authors found that the group of patients 20 to 39 years of age had a higher incidence ofREPE than the older age group, and they postulate that the lung might be altered by aging in a manner that protects it against the occurrence of REPE in the older age group. Such differences might include changes in the mechanics of the lung or the permeability characteristics of the alveolar-capillary barrier. To date, it has been believed that REPE was most likely to occur in patients who were symptomatic for more than three days. Sewell and associates15 reported that changes occurred in the alveolar-capillary basement membrane after 72 h of collapse, rendering it more permeable. On the contrary, in our series, prolonged duration of collapse did not appear to promote the occurrence ofREPE. The authors regard this as a consequence of the fact that patients who were actively treated after a short duration of symptoms had a greater magnitude of pneumothorax in comparison with other groups, which may have overshadowed any effect of duration of collapse. The potentially serious consequences of developing REPE have been suggested by Mahfood and associates,7 who reported that 11 of 53 patients with REPE died. It is, therefore, important to emphasize that
prevention of REPE is of prime importance when treating pneumothorax. It has been suggested that slow reexpansion by low negative pressure suction drainage is important in the prevention of REPE. However, even though slow reexpansion by continuous low negative pressure suction drainage was attempted in all our 146 cases of pneumothorax, 21 cases developed REPE. Repeated aspiration of <1,000 ml of air has also been recommended to prevent REPE, and Sautter and associates 13 recommended obstruction of the pulmonary artery of the involved lung using a balloon catheter if a patient begins to develop signs and symptoms ofREPE. Both ofthese methods remain to be tested and were not utilized in the patients described here. In summary, 21 of 146 cases of spontaneous pneumothorax which were treated by thoracentesis or continuous low negative pressure suction drainage (- 12 cm H20) ofthe pleural space developed REPE, and were actively treated with a variety of modalities and drugs, including oxygen, steroids, diuretics, sedatives, and inotropic agents without fatal outcome. The rate of REPE was higher in patients 20 to 39 years of age than in those over the age of 40. It is postulated that age-related changes in the lung may afford some degree of protection against developing REPE. REFERENCES 1 Nakamura H. Spontaneous pneumothorax: on atmospheric pollution as a cause of it. Jpn Med J 1975; 2677:14-19 2 Trapnell DH, Thurston JGB. Unilateral pulmonary oedema after pleural aspiration. Lancet 1970; 1:1367-69 3 Peatfield Re, Edwards PR, Johnson NM. Two unexpected CHEST 1100 I 6 I DECEMBER. 1991
1565
deaths from pneumothorax. Lancet 1979; 17:356-58
4 Murphy K, Tomlanovich M. Unilateral pulmonary edema after
5 6 7 8 9
10
drainage ofa spontaneous pneumothorax: case report and review of the world literature. J Emerg Med 1983; 1:29-24 Hoso1cawa T, Yaita A, Chiba 1: Moriyama M, Ababe K, Kalcegawa T. A case report of re-expansion pulmonary oedema after slow drainage. J Clio Surg 1989; 50:729-33 Takamura K, Takamura M, Kobayashi H. Current topics of reexpansion pulmonary edema. Respir Cire 1984; 32:133-41 Mahfood S, Hix WR, Aaron BL, Blaes ~ Watson DC. Reexpansion pulmonary edema. Ann Thorne Surg 1988; 45:340-45 Pavlin DJ. Lung reexpansion: for better or worse? Chest 1986; 89:2-3 HumphreyRL, Berne AS. Rapidre-expansionofpneumothorax: a course of unilateral pulmonary edema. Radiology 1970; 96:50912 Mahajan VIC Re-expansion pulmonary edema. Chest 1983; 83:4
11 Zisldnd MM, Well U, George RA. Acute pulmonary edema following the treatment of spontaneous pneumothorax with excessive negative intrapleural pressure. Am Rev Respir Dis
1965; 92:632-636 12 Childress ME, Moy G, Mottram M. Unilateral pulmonary edema resulting from treatment of spontaneous pneumothorax. Am Rev Respir Dis 1971; 104:119-21 13 Sautter RO, Dreger WH, Maclndoe JU, Myer WO, Magnin GE. Fatal pulmonary edema and pneumonitis after re-expansion. Chest 1971; 60:399-401 14 Fliclc MR, Kautzeler GB, Block AJ. Unilateral pulmonary edema with contralateral thoracic sympathectomy in the adult respiratory distress syndrome. Chest 1975; 68:736-40 15 Sewell ~ Fewel JG, Grover FL, Amm ~ Experimental evaluation of reexpansion pulmonary edema. Ann Thorac Surg 1978; 26:126-32
Symposium: cardiopulmonary Rehabilitation, Status '92 The University of Florida Center for Exercise Science will present this program February 17-19 at the Sheraton World Hotel, Orlando. For information, contact Michael L. Pollock, Ph.D., University of Florida Center for Exercise Science, Florida Gymnasium, Room 27, Gainesville 32611 (904:392-9575).
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