Re-expansion pulmonary oedema after spontaneous pneumothorax treatment with chest tube placement
Re-expansion pulmonary oedema after spontaneous pneumothorax treatment with chest tube placement
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DOI：
10.1136/bcr-2021-241734
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发表时间：
2021-03-01
期刊：
影响因子：
0.9
通讯作者：
Costa, Teresa
中科院分区：
文献类型：
--
作者：
Rodrigues, Denny;Valerio, Margarida;Costa, Teresa
再膨胀性肺水肿 (RPE) 是一种罕见但可能致命的并发症，可能在对胸腔积液、气胸或肺不张继发的肺萎陷进行快速减压治疗后出现。其病理生理学机制仍知之甚少，承认突然再扩张过程继发的肺微血管结构通透性增加过程背后存在多因素病因。 1 2 患者，21岁，男性，经常吸烟（三包年），无吸毒、近期外伤或病理史。 6天后，他突然出现呼吸困难、左侧胸膜炎性胸痛、心悸和干咳，并逐渐恶化，被送往急诊科。患者无明显形态异常，血压112/68 mm Hg，心率100 bpm，呼吸频率22 bpm，外周血氧饱和度99%（室内空气），无发热。听诊时，他发现左半胸腔声音亢进，肺音减弱。胸部X光检查证实左侧张力性气胸（图1）。血液样本显示血象、凝血和炎症参数正常。随后，患者接受了氧疗，并在左侧第五肋间隙放置了胸管，进行水下密封（无抽吸），症状得到改善。手术后一小时，他出现心动过速、咳嗽、呼吸困难和呼吸窘迫，对氧疗没有反应。重复胸部 X 光检查证实胸管位置正确，左肺完全扩张，但显示肺泡混浊（图 2）。假定出现 RPE，并开始使用利尿剂、皮质类固醇和持续气道正压治疗。结果，症状改善，临床稳定。患者被转移至中级监护病房并停止正压。一小时后，他出现急性呼吸衰竭，需要经口气管插管、有创机械通气并住进重症监护室。他接受有创机械通气 6 天。在重症监护室住院的第 7 天，RPE 完全消失，但发现持续漏气，因此患者通过视频辅助胸腔镜接受了胸膜固定术（胸膜磨损）。 10天后，他出院了，没有任何症状，胸部X光检查结果也正常。
Re-expansion Pulmonary oedema (RPE) is a rare but potentially fatal complication, which can arise after a rapid decompressive treatment of pulmonary collapse secondary to pleural effusion, pneumothorax or atelectasis. The pathophysiological mechanism is still poorly understood, admitting a multifactorial aetiology underlying the process of increasing the permeability of the pulmonary microvascular structure secondary to the abrupt re-expansion process. 1 2 A 21-year-old male patient, active smoker (three pack-years), without drug abuse, recent trauma or pathological history. He was admitted to the emergency department after 6 days of sudden onset of dyspnoea, left pleuritic chest pain, palpitations and dry cough, with progressive worsening. The patient had no evident morphological abnormalities, blood pressure was 112/68 mm Hg, heart rate 100 bpm, respiratory rate 22 bpm, peripheral oxygen saturation of 99%(room air) and was apyretic. He presented a hyper-resonant left haemithorax with decreased lung sounds on auscultation. Chest X-ray confirmed left tension pneumothorax (figure 1). Blood samples showed normal haemogram, coagulation and inflammatory parameters. The patient was then treated with oxygen therapy and placement of a chest tube on the fifth left intercostal space, with subaquatic seal (without suction), leading to improved symptoms. One hour after the procedure he developed tachycardia, productive cough, dyspnoea and respiratory distress, unresponsive to oxygen therapy. A repeat chest X-ray confirmed the correctly positioned chest tube, complete left lung expansion, but showed alveolar opacities (figure 2). RPE was assumed and treatment with diuretics, corticosteroids and continuous positive airway pressure was initiated. As a result, the symptoms improved, and clinical stability was achieved. The patient was transferred to intermediate care unit and positive pressure was stopped. One hour after, he underwent in to acute respiratory failure, requiring orotracheal intubation, invasive mechanical ventilation and admission into intensive care unit. He stayed on mechanical invasive ventilation for 6 days. At the 7th day of intensive care unit stay, there was a complete resolution of RPE, but a persistent air leak was noted, so the patient was submitted to surgical pleurodesis (pleural abrasion) via video-assisted-thoracoscopy. He was discharged 10 days later, asymptomatic and with a normal chest X-ray.