Medical Image of the Month: Reexpansion Pulmonary Edema

 

Figure 1. Large right hydrothorax with mild mediastinal shift to the left.

Figure 2. Status post right pleural pigtail drain placement with interval improvement of the now small right pleural effusion with re-expansion of the right lung and early edema.

Figure 3. Moderate right pleural effusion and worsening reexpansion pulmonary edema.

A 54-year-old woman with decompensated alcoholic liver cirrhosis presented to the emergency department with exertional dyspnea. She was afebrile, tachycardic (110), with oxygen saturation of 74% on 5 liters/minute (L/min), in moderate respiratory distress and was subsequently placed on a non-rebreather. On examination, she had absent breath sounds throughout her right lung with chest radiograph revealing large right-sided pleural effusion (Figure 1). A pigtail catheter was placed, draining approximately 4 liters of fluid (Figure 2), resulting in improved oxygenation to 93% on 3 L/min. On admission to internal medicine, the chest tube was clamped immediately. In the next 24 hours, patient developed increased oxygen requirements, with worsening tachypnea and tachycardia, requiring bilevel positive airway pressure and admission to the medical intensive care unit for reexpansion pulmonary edema (Figure 3).

Hepatic hydrothorax is a complication of cirrhosis and portal hypertension, defined as pleural effusion without any underlying pulmonary or cardiac etiologies. Though the pathophysiology is not completely understood, it is widely believed that the pleural effusion is caused by negative intrathoracic pressures allowing peritoneal fluid to enter the pleural cavity through diaphragmatic defects. Management of hepatic hydrothorax includes sodium restriction, diuresis, therapeutic thoracentesis, and transjugular intrahepatic portosystemic shunt. Repeated thoracentesis is the routine procedure to remove pleural fluid in refractory hepatic hydrothorax (1).

Though relatively safe, thoracentesis is associated with reexpansion pulmonary edema (RPE). RPE is believed to occur due to increased permeability of the pulmonary capillaries as a result of inflammation caused by ventilation and reperfusion of previously collapsed lung. Symptoms of RPE include chest discomfort and cough with onset typically within 24 hours of lung reexpansion. Signs of RPE include tachypnea, tachycardia, lung crackles, and hypoxemia refractory to oxygen therapy. Risk factors are young age (20-40 years), long duration of lung collapse, use of negative pressure during thoracentesis, large volume drainage, and rapid lung reexpansion. Management is largely supportive and ranges from diuresis to endotracheal intubation with mechanical ventilation (2).

Unfortunately, the amount of fluid that can be safely removed from the pleural effusion in order to prevent RPE has not been clearly defined. Feller-Kopman (3) reported that only one patient (0.5%) of 185 participants experienced clinical RPE, while four patients (2.2%) had radiographic RPE without symptoms. Our case demonstrates that removal of large volume from the pleural effusion via the chest tube resulted in clinical and radiographic RPE, thus, necessitating the need for clearly defined guidelines.

Chelsea Takamatsu BS, Aida Siyahian MS, Ella Starobinska MD, and Anthony Witten DO

University of Arizona College of Medicine- Tucson

Tucson, AZ USA

References

1. Garbuzenko DV, Arefyev NO. Hepatic hydrothorax: An update and review of the literature. World J Hepatol. 2017 Nov 8;9(31):1197-1204. [CrossRef] [PubMed]
2. Kasmani R, Irani F, Okoli K, Mahajan V. Re-expansion pulmonary edema following thoracentesis. CMAJ. 2010 Dec 14;182(18):2000-2. [CrossRef] [PubMed]
3. Feller-Kopman D, Berkowitz D, Boiselle P, Ernst A. Large-volume thoracentesis and the risk of reexpansion pulmonary edema. Ann Thorac Surg. 2007 Nov;84(5):1656-61. [CrossRef] [PubMed]

Cite as: Takamatsu C, Siyahian A, Starobinska E, Witten A. Medical image of the month: reexpansion pulmonary edema. Southwest J Pulm Crit Care. 2019;19(1):12-4. doi: https://doi.org/10.13175/swjpcc024-19 PDF

Medical Image of the Month: Bilateral Atrial Enlargement

Figure 1. Portable chest radiograph showing elevation of the left mainstem bronchus (red arrow).

Figure 2. Thoracic CT scan showing right atrial enlargement (blue circle) and left atrium (red circle).

Figure 3. Upper Image: Static image from echocardiogram showing right atrial enlargement (white circle). Lower image: video of echocardiogram.

A 97-year-old woman was repeatedly admitted for dyspnea, hypoxemia and treated with antibiotics for presumed left lower lobe pneumonia. She has a past medical history of atrial fibrillation, congestive heart failure and sick sinus syndrome with placement of a cardiac pacemaker. Notably on physical examination, she had heart rate of 110 beats/minute, temperature of 98.8°F, blood pressure of 122/72 mm Hg, and a respiratory rate of 27 breaths/minute. She had a sternal heave, a grade 4/6 "blowing" holosystolic murmur, a loud S2, jugular venous distension and an enlarged liver. Chest x-ray showed obscuration of the left lower lobe - the left heart border cannot be seen, and the L mainstem bronchus is straightened and lifted superiorly (Figure 1). An image of the heart is shown from a CT abdomen obtained 6 months previously, showing cardiomegaly, particularly massive atrial enlargement (Figure 2). An ultrasound showed bilateral atrial enlargement with moderate mitral regurgitation and severe tricuspid regurgitation (Figure 3). The left ventricular ejection fraction was 55%, but with abnormal septal motion. She was treated with gentle diuresis to help relieve volume overload, and isosorbide dinitrate for preload and afterload reduction. Pulmonary hypertension was attributed to chronic mitral regurgitation. The cause was unclear - the patient remembered that her brother had rheumatic fever as a young recruit in WWII, but didn't know whether she had ever experienced it.

Atrial enlargement can be of prognostic significance. Left atrium size has been found to be a predictor of mortality due to both cardiovascular issues as well as all-cause mortality (1). Larger right atrium than left atrium has been associated with all-cause mortality in elderly patients with heart failure (2).

Robert A. Raschke, MD

University of Arizona College of Medicine-Phoenix

Phoenix, AZ USA

References

1. Patel DA, Lavie CJ, Milani RV, Shah S, Gilliland Y. Clinical implications of left atrial enlargement: a review. Ochsner J. 2009 Winter;9(4):191-6. [PubMed]
2. Almodares Q, Wallentin Guron C, Thurin A, Fu M, Kontogeorgos S, Thunstrom E, Johansson MC. Larger right atrium than left atrium is associated with all-cause mortality in elderly patients with heart failure. Echocardiography. 2017 May;34(5):662-7. [CrossRef] [PubMed]

Cite as: Raschke RA. Medical image of the month: bilateral atrial enlargement. Southwest J Pulm Crit Care. 2019;19(1):10-1. doi: https://doi.org/10.13175/swjpcc023-19 PDF