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LETTER TO EDITOR
Year : 2021  |  Volume : 69  |  Issue : 3  |  Page : 755-756

Re-Expansion Pulmonary Edema (RPE) in a Neurosurgical Patient


Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India

Date of Submission16-Sep-2019
Date of Decision21-Sep-2019
Date of Acceptance20-Mar-2020
Date of Web Publication24-Jun-2021

Correspondence Address:
Dr. Hitesh K Gurjar
Department of Neurosurgery, All India Institute of Medical Sciences (AIIMS), New Delhi - 110 049
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.319230

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How to cite this article:
Meena RK, Gurjar HK, Doddamani RS, Narula D, Agrawal D, Chandra P S. Re-Expansion Pulmonary Edema (RPE) in a Neurosurgical Patient. Neurol India 2021;69:755-6

How to cite this URL:
Meena RK, Gurjar HK, Doddamani RS, Narula D, Agrawal D, Chandra P S. Re-Expansion Pulmonary Edema (RPE) in a Neurosurgical Patient. Neurol India [serial online] 2021 [cited 2021 Jul 28];69:755-6. Available from: https://www.neurologyindia.com/text.asp?2021/69/3/755/319230




Sir,

A 13-year old male child was operated for a large supratentorial anaplastic ependymoma (high parietal region). The patient received a massive blood transfusion during surgery as the tumor was highly vascular. Postoperatively patient woke up without any neurological deficits. However, his extubation was delayed in view of radiological evidence of tumor bed hematoma and venous infarcts. Chest X-Ray (CXR) was within normal limits [Figure 1]a. After 24 h the patient was weaned off from the ventilator and extubated as a repeat non-contrast computed tomography (NCCT) scan of the head showed resolving edema and hematoma. After 10–12-h of extubation patient developed progressively increasing respiratory distress, CXR showed right lung pneumothorax with midline shift for which right Intercostal chest drainage (ICD) was inserted [Figure 1]b. Repeat CXR 12 h after ICD insertion showed complete white out right lung with ICD in situ [Figure 1]c. Chest CT showed multifocal areas of consolidation and surrounding ground-glass opacities involving right upper lobe and posterior and medial basal segments of the lower lobe, findings suggestive of re-expansion pulmonary edema (RPE) [Figure 1]d. He was managed conservatively with oxygen supplementation and physiotherapy. Repeat CXRs showed complete resolution of pneumothorax and pulmonary edema and ICD was removed after five days [Figure 1]e.
Figure 1: CXR of the patient. (a) Just after surgery on mechanical ventilation, (b) after extubation of patient showing right massive pneumothorax, (c) after insertion of chest tube with white out lung on right side, (d) computed tomography scan of the same patient showing evidence of re-expansion pulmonary edema, (e) CXR at the time of discharge

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RPE is a rare and potentially fatal complication that can occur after rapid drainage of fluid or air from the pleural cavity (rapid lung expansion) with a reported incidence of about 1% in the literature.[1],[2] Its occurrence in neurosurgical patients have never been reported in the literature. Risk factors include younger age (20–40 years), duration of collapse >3-4 days, timing of lung re-expansion and large pneumothorax (>30% of a single lung).[3] Pathophysiology of RPE is poorly understood, however it has been frequently attributed to increased permeability of pulmonary capillaries as a result of inflammatory changes.[3],[4] We speculate that in our patient, the surgical stress with massive blood transfusion may have induced a subclinical inflammation in the lung capillaries, and the “second hit” by the rapid expansion of the chest by the insertion of ICD may be responsible for RPE seen in our patient. Mortality from RPE is reported to be as high as 20% in the literature. Fortunately, our patient responded well to the conservative management, but a high index of suspicion should be maintained in all neurosurgical patients who had received massive blood transfusion and require an ICD insertion for the development of RPE as mortality from this condition is very high. Treatment of RPE is usually supportive with administration of oxygen, diuretics, intubation and mechanical ventilation.[2],[4]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients has/have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Neustein SM. Reexpansion pulmonary edema. J CardiothoracVasc Anesth2007;21:887-91.  Back to cited text no. 1
    
2.
Perricone G, Mazzarelli C. Images in clinical medicine. Reexpansion pulmonary edema after thoracentesis. N Engl J Med 2014;370:e19.  Back to cited text no. 2
    
3.
Meeker JW, Jaeger AL, Tillis WP. An uncommon complication of a common clinical scenario: Exploring reexpansion pulmonary edema with a case report and literature review. J Community Hosp Intern Med Perspect2016;6:32257.  Back to cited text no. 3
    
4.
Sharma S, Madan K, Singh N. Fatal re-expansion pulmonary edema in a young adult following tube thoracostomy for spontaneous pneumothorax. BMJ Case Rep 2013;2013. doi: 10.1136/bcr-2013-010177  Back to cited text no. 4
    


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