1. Re-expansion Pulmonary Edema
Sudhir Rao

2. What is REPE?
Non cardiogenic pulmonary edema which usually occurs unilaterally after rapid re-expansion of a collapsed lung
1853 Pinault reported occurrence of pulmonary edema in a reexpanded lung after removal of 3L of pleural effusion1
1959 Carlson et al reported pulmonary edema in a reexpanded lung after thoracentesis of a pneumothorax2
Also reports of RPE occurring with evacuation of large quantities of cystic fluid from a giant hepatic cyst3
And after excision of a giant mediastinal tumor4; in the contra- lateral lung of a re-expanded lung5; and in re-expanded lung after decortication6

3. REPE Incidence- between 0 and 1%7
But widespread under-reporting, since REPE can be clinically mild and detected only radiologically
Mortality can be as high as 21%

4. Risk Factors The amount of time the lung is collapsed (> 3 days)
Volume of the thoracic space occupied by the lesion (effusion/air/mass)
Removal of large extrathoracic lesions (i.e, giant abdominal mass)
Variables associated with the reexpansion technique/procedure
Presence of bronchial obstruction
Loss of surfuctant (secondary to combination of other factors)
Alteration of pulmonary artery pressure
Application of excessive suctioning to the tracheobronchial tree
Patient age (younger patients may have greater predisposition)

5. RPE related to pneumothorax
Mahfood et al analyzed 47 pts who developed RPE after reexpansion from pneumothoraces between
Pneumothorax had been present for atleast 3 days in >80% of pts.
2/3 developed RPE within 1hr of expansion and within 24hrs in the rest
Overall mortality was 19%

6. RPE related to pleural effusion
Mahfood et al 7 pts with RPE associated with drainage of pleural effusion from
The average amount of pleural fluid drained was 2600ml (range ml)
All pts. Developed RPE within 1 day and 2 pts died eventually
Feller-Kopman analyzed 185 procedures of large volume tapping (mean 1.6L, ml) with measurement of intrapleural pressure by pleural manometry.9
There was only 1 clinical and 3 radiological case of RPE
Large volume pleural fluid can be aspirated provided intrapleural pressure was kept above -20cmH2O and pts didn’t have any chest pain during tapping

7. RPE following VATS
VATS involves one lung ventilation and collapse of the other
Large case series by Yim et al in 1996 revealed only 2 cases of RPE (0.15%) following VATS for drainage and talc pleurodesis for malignant pleural effusion 10

8. Pathophysiology

9. Clinical features Minimal or none Chest pain
Cough with pink frothy sputum
Hypotension
Dyspnoea
Tachypnoea
Often within 1 hr of reexpansion of the collapsed lung but may be delayed by 24 to 48hrs

10. Diagnosis History Clinical features Radiological features D/D-
cardiogenic edema
Pulmonary infection
Pneumonitis

11. Treatment Mainly supportive Administration of supplement oxygen
Ventilatory support [invasive/ non-invasive]
Appropriate hemodynamic monitoring
Vasopressor and/or inotropic agent
Use of careful diuresis; prostaglandin analogue misoprostil; NSAIDS; differential lung ventilation- have been reported11-13
Monoclonal antibodies against IL8 and xanthine oxidase antagonists may be useful in prevention or treatment 14-15

12. Prevention Gradual drainage of large pleural effusion or pneumothorax
BTS guidelines- a maximum of 1.5L drained on the first occasion
Any remaining fluid should be drained 1.5L at a time at 2 hr interval and to be stopped if pt develops chest pain, persistent cough or vasovagal symptoms
Avoid addition of suction too early after chest tube insertion for spontaneous pneumothorax

13. Key points
• Re-expansion pulmonary edema is an uncommon complication following drainage of a pneumothorax or pleural effusion. • Clinical presentations include cough, chest discomfort and hypoxemia; if the edema is severe, shock and death may ensue. Symptoms are usually noted within 24 hours after thoracentesis. • Treatment is generally supportive, ranging from oxygen supplementation to noninvasive and invasive ventilation. • Preventive strategies include the use of low negative pressure (< – 20 cm H2O) for suction during thoracentesis and limiting drainage of pleural fluid if the patient reports chest discomfort.

14. References
Riesman D Albuminous expectoration following thoracocentesis. Am J Med Sci 1902; 123:620-30
Carlson RI, Classen KL, Gollan F, Gobbel WG Jr, Sherman DE, et al. Pulmonary edema following the rapid reexpansion of a totally collapsed lung due to a pneumothorax: a clinical and experimental study. Surg Forum 1959;9:367-71
Fukuda T, Okutani R, Kono K, Ishida H, Yamanska N et al. A case of reexpansion pulmonary edema during fenestration of a giant hepatic cyst. Musui 1989;38:
Matsumiya N, Dohi S, Kinura T, Naito H. Reexpansion pulmonary edema after mediastinal tumor removal. Anesth Analg 1991;73: 646-8
Heller BJ, Grathwohl MK Contralateral reexpansion pulmonary edema. South Med J 2000;93:
Yamanaka A, Hirai T, Ohtake Y, Watanabe M, Nakamura K et al. Surgery for thoracic empyema concurrent with rupture of lung abscess in a child. J Pediat Surg 1998;33:

15. References Contd.
7. Echevarria C, Twomey D, Dunning J, et al. Does re-expansion pulmonary oedema exist? Interact Cardiovasc Thorac Surg 2008;7: Mahfood S, et. al. Reexpansion Pulmonary Edema Ann Thorac Surg 1998; 45: Feller-Kopman D, Berkowitz D, Boiselle P et al: Large volume thoracentesis and the risk of reexpansion pulmonary edema. Ann Thorac Surg 2007;84: Yim APC, Liu HP: Complications and failures of video-assisted thoracic surgery: experience from two centers in Asia. Ann Thorac Surg 1996;61: Trachiotis GD, Vricella LA, Aaron BL et al: Reexpansion pulmonary edema. Ann Thorac Surg 1997;63: Cho SR, Lee JS, Kim MS: New treatment method for reexpansion pulmonary edema: Differential lung ventilation. Ann Thorac Surg 2005;80: Iqbal M, Multz AS, Rossoff LJ et al: Reexpansion pulmonary edema after VATS successfully treated with continuous positive airway pressure. Ann Thorac Surg 2000;70:

16. References Contd.
14. Nakamura M, Fujishima S, Sawafuji M et al: Importance of interleukin-8 in the development of reexpansion lung injury in rabbits. Am J Respir Crit Care Med 2000;161: Wright RM, Ginger LA, Kosila N et al: Mononuclear phagocyte xanthine oxidoreductasen contributes to cytokine-induced acute lung injury. Am J Respir Cell Mol Biol 2004; 30: /

17. Thankyou