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Case report

Bilateral re-expansion pulmonary edema: an uncommon

complication of the pneumothorax drainage

Axel Benhamed*,1,2, Karim Tazarourte1,2

1Université
Claude-Bernard–Lyon-I, Lyon, France; 2Pôle urgence-Samu 69, Groupe Hospitalier
Edouard-Herriot, Hospices Civils de Lyon, Lyon, France.

Abstract
Re-expansion pulmonary edema after chest tube drainage of spontaneous pneumothorax is a very rare
complication, even more when it is bilateral. We report the case of a middle age patient presenting to our
emergency department for syncope without shortness of breath. A chest X-ray showed a complete
pneumothorax, but the treatment worsened the patient condition. The drainage leaded to a re-expansion
pulmonary edema. We discuss the mechanism and predictors of this entity and suggest treatment including
preventive measures.

Keywords: Re-expansion pulmonary edema; drainage; pneumothorax; complication.

Introduction without fever, dyspnea or chest pain

progressing for 3 days.
Pneumothorax is a well-known entity to When he arrived, the patient had low
emergency physicians and pretty easy to peripheral oxygen saturation (91% on room air)
diagnose. It is defined by the presence of air in but well tolerated. His vital signs were as
the pleural cavity. When it is spontaneous and follows: blood pressure 113/64 mmHg, heart
idiopathic, its prevalence is 1.2 to 18 cases per rate 95 beats/min, temperature 36.7°C. The
100,000 inhabitants [1] with a male prevalence. clinical examination found an abolished
The purpose of the treatment is to obtain a vesicular murmur of the right pulmonary field
complete pulmonary re-expansion. However, without sign of acute respiratory distress
there is a rare (incidence of 0 to 1% [2]) and suggesting a complete spontaneous right
little-known complication that can be fatal: the pneumothorax. The chest X-ray confirmed the
re-expansion pulmonary edema (a vacuo). diagnosis (Figure 1).
He was given oxygen via a nasal cannula
and we performed chest drainage with a
Case report Fuhrman drain equipped with a Heimlich valve.
Five hundred mL of air were removed by a soft
A 48-year-old man, with no previous and slow manual drainage. We used a drain
medical history, non-smoker, was admitted to with a non-suction backflow valve system.
the emergency department for a syncope at On the postprocedure chest radiography
work the same day. He reported a dry cough (Figure 2), the drain was well positioned, and
the lung was completely glued back to the wall.
Received: February 2020; Accepted after review: The patent benefited of a close nurse
March 2020; Published: April 2020. monitoring in the emergency department. One
*Corresponding author: Axel Benhamed, Université
Claude-Bernard–Lyon-I, F-69008 Lyon, France; Pôle hour later, the patient was out of breath and the
urgence-Samu 69, Groupe Hospitalier Edouard-Herriot, peripheral oxygen saturation dropped to 90%
Hospices Civils de Lyon, 5, Place d’Arsonval, F-69008
Lyon, France.
and then rapidly to 88% despite oxygen supply
Email: axel.benhamed@chu-lyon.fr (6L/min) via face mask.

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Fig. 1. Radiograph of chest showing a complete right pneumothorax

Fig. 2. Postprocedure chest radiography

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We performed a chest CT scan to search respiratory support with positive end-expiratory

for any complication linked to the drainage. It pressure (PEEP) and the Heimlich valve was
showed extensive bilateral alveolar removed. Instead, he benefited from a
consolidation predominating on the right side Pleurevac drainage system. The outcome was
(Figure 3). The diagnosis was a re-expansion favorable and the patient was discharged two
pulmonary edema. No fluid had been days later without any follow-up, but he did not
administered during his stay in the Emergency consult the emergency department as he was
Department. We finally admitted the patient to asked in case of shortness of breath or thoracic
the intensive care unit for closer monitoring and pain.
further care. He started on non-invasive

Fig. 3. Chest CT scan showing bilateral ranges of pulmonary edema predominating on the right side

Discussions and C reactive protein was low (6.9mg/L). Also,

the onset was sudden, following the drainage
The aspect of the CT scan showing procedure, suggesting a viral or bacterial
extensive bilateral alveolar is not specific of re- infection is less likely.
expansion pulmonary edema. Then, many The pathophysiology of the re-expansion
differential diagnoses were assessed. No pulmonary edema is poorly defined although
previous CT scan was available. But the patient several hypotheses are put forward: an
did not report any chronic heart or lung disease. increase in the permeability of pulmonary
Cardiogenic edema was excluded because he capillaries [3], the action of a pro-inflammatory
had no sign of heart congestion, CT scan did mediator released during pulmonary re-
not show any associated pleural effusion and expansion [4] or a decrease in the activity of the
the brain natriuretic peptide level was normal surfactant [5].
(20pg/mL). Its presentation is varied: the patient may
We found no infection on bloodstream be asymptomatic or have a simple cough [4]. It
culture, no lymphopenia, no hyperleukocytosis

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may also mimic a cardiogenic pulmonary Whether diuretics, bronchodilators or steroids

edema. are of added benefit is unproven [12, 14]
Almost all cases described in literature Finally, its mortality is not well defined in the
occurred on the same side of the literature.
pneumothorax. Contralateral re-expansion
pulmonary edema has been poorly described.
Our case represents the second case reported Conclusions
in the medical literature of bilateral re-
expansion pulmonary edema caused after relief Pneumothorax is a common entity in
of pneumothorax [6]. And it is the first one not emergency medicine. Much rarer however and
caused by a suctioned system. much less known, acute re-expansion
The risk factors suggested by the literature pulmonary edema is one of the complications
are: chronic collapse (>7 days [2]), pleural of drainage, even more when it is bilateral. Its
effusion associated with pneumothorax [7], presentation can be widely varied and its
trocar drainage [8], young age (Matsuura et al diagnosis not easy, but the prognosis can be
[9] report in their series a majority of re- serious and life-threatening. Particular care
expansion pulmonary edema a vacuo in the 20- should be taken in young people and diabetic
39 years old group), diabetes, pneumothorax patients, also, if the pneumothorax is chronic,
size [5] and rapid re-expansion of the collapsed associated with pleural effusion or in case of a
lung. large volume pneumothorax. Finally, rapid re-
Regarding its treatment, no expansion of the collapsed lung must be
recommendation is available at this time. avoided.
Oxygen therapy is required in case of hypoxia. This case emphasizes that the absence of
Some authors propose the use of non-invasive an aspiration system does not protect against
ventilation to apply a PEEP [4, 10, 11]. The the risk of acute re-expansion pulmonary
need for intubation has been described by edema. Moreover, after chest drainage,
some authors [10, 12]. The British Thoracic patients must be systematically monitored in
Society 2010 guidelines recommend avoiding the emergency room during a few hours by an
high intrapleural pressures during the experimented nurse.
procedures. It also emphasizes that a
maximum of 1.5 L should be drained in the first
hour after insertion of the drain. Consent
In contrast to cardiogenic pulmonary Written informed consent was obtained from the
edema, an aggressive vascular filling may be patient for publication of this case report.
needed in order to preserve hemodynamics
[13]. Preventive measures are required,
Competing interests
including progressive pulmonary re-expansion. The authors declare that they have no competing
interests.

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