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Correspondence |
The Royal Wolverhampton Hospitals, Wolverhampton, UK, E-mail: mchikungwa{at}yahoo.co.uk
To the Editor:
Re-expansion pulmonary edema (REPO) is an uncommon life-threatening condition that results mostly from rapid drainage of long-standing pleural effusion or pneumothorax. We report yet another unusual cause of REPO in a surgical patient with acute abdomen.
A 24-yr-old autistic girl presented to the general surgeons with a two-day history of abdominal pain and distension. She deteriorated prior to surgery and was admitted as an emergency on the intensive care unit in extremis with severe hypoxemia and a tense grossly distended abdomen. Despite pre-oxygenation the SpO2 did not rise above 85%. Tracheal intubation was successfully performed but lung compliance was extremely poor. Despite use of high inflation pressures with positive end-expiratory pressure, the SpO2 deteriorated down to 60% on FIO2 of 1.0. With the situation becoming desperate, a decompressive laparotomy was performed in the intensive care unit. Immediately the lung compliance improved pari passu with the SpO2, which rose to 96%. However she developed pulmonary edema a few minutes later.
She was immediately transferred to the theatre for a formal extended right hemicolectomy for a massive dilatation of transverse colon secondary to a volvulus. She was electively ventilated postoperatively in the intensive care unit. Postoperative chest x-ray showed bilateral pulmonary shadowing. Gas exchange improved over the next 24 hr to allow ventilatory weaning and extubation.
Reported REPO from unusual causes include delayed repair of traumatic diaphragmatic hernia1 and excision of extra-pleural lesions such as mediastinal tumours and giant hepatic cysts.2,3 Clinical presentation ranges from asymptomatic chest radiological abnormalities to severe cardiorespiratory insufficiency and death. It is commonly ipsilateral (92.3%) and bilaterality worsens the prognosis. In about two thirds of reported cases REPO develops rapidly within an hour and typically occurs following lung collapse of three days duration or more.4
The pathophysiology is not completely understood. Mechanical and biological factors are probably involved in the pathogenesis of REPO as a consequence of ischemia of collapsed segments and their reperfusion. Using a rabbit model Sakao et al. have demonstrated an inflammatory process in segmental collapse and reperfusion.5 Mechanically, lung re-expansion generates a negative perivascular pressure with a parallel rise in hydrostatic pressure due to vascular flooding with possible capillary damage.
We postulate in this patient that marked abdominal distension which gradually worsened over three days, resulted in significant bilateral lung collapse. On decompressing the abdomen the lungs expanded rapidly, akin to rapid drainage of a large pleural effusion, with consequential REPO.
References
1 Inaba K, Snider J, Holliday RL. Re-expansion pulmonary edema after repair of a missed diaphragmatic hernia. Can J Surg 2001; 44: 295–8.[Medline]
2 Fukuda T, Okutani R, Kono K, Ishida H, Yamanaka N, Okamoto E. A case of reexpansion pulmonary edema during fenestration of a giant hepatic cyst (Japanese). Masui 1989; 38: 1509–13.[Medline]
3 Matsumiya N, Dohi S, Kimura T, Naito H. Reexpansion pulmonary edema after mediastinal tumor removal. Anesth Analg 1991; 73: 646–8.
4 Mahfood S, Hix WR, Aaron BL, Blaes P, Watson DC. Reexpansion pulmonary edema. Ann Thorac Surg 1988; 45: 340–5.[Abstract]
5 Sakao Y, Kajikawa O, Martin TR, et al. Association of IL-8 and CMP-1 with the development of reexpansion pulmonary edema in rabbits. Ann Thorac Surg 2001; 71: 1825–32.
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