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  • Dr David McCreary

Respiratory Failure following Thoracocentesis: Re-Expansion Pulmonary Oedema

Updated: Mar 25

Dr David McCreary Emergency Physician

Peer review: Dr Mike Khoury


THE CASE

A 60-year-old female presents to the Emergency Department with progressive shortness of breath over several months. On assessment in the emergency department, she had marked shortness of breath at rest and oxygen saturation of 90% on room air. A portable erect chest X-ray was performed:



Given that this patient was symptomatic, the team decided to pop in a pigtail catheter to drain the large right-sided effusion. Following this, the patient’s respiratory effort improved and all seemed well! High-fives and congratulatory statements all around…



…that is until the wee-small hours of the morning when the patient became acutely short of breath, with respiratory failure and the following repeat X-ray:



HOW WOULD YOU DESCRIBE THIS X-RAY?

Chest X-ray showing an appropriately positioned right intercostal pigtail drain in situ with associated interval change demonstrating drainage of the large right-sided pleural effusion seen in the original image. There is some alveolar airspace opacity within the right-mid and lower zones.


WHAT HAS CAUSED THESE CHANGES?

Re-expansion Pulmonary Oedema (RPO)

  • An uncommon complication following draining of a pneumothorax or pleural effusion

  • Incidence is reported between 0.2-14% (according to the British Thoracic Society), though most reports seem to be <1%


LET’S LEVEL-UP ON RE-EXPANSION PULMONARY OEDEMA (RPO)…


PATHOPHYSIOLOGY

The pathophysiology of RPO is multifactorial and poorly understood (a great caveat when writing about any condition).

The primary (or at least the easiest) theory is:

  1. Ventilation and perfusion of collapsed lung