Acta Radiologica

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Re‐expansion Pulmonary Edema

A. Murat, A. Arslan & A. E. Balcı

To cite this article: A. Murat, A. Arslan & A. E. Balcı (2004) Re‐expansion Pulmonary Edema, Acta
Radiologica, 45:4, 431-433

To link to this article: https://doi.org/10.1080/02841850410005624

Published online: 09 Jul 2009.

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 CASE REPORT ACTA RADIOLOGICA

Re-expansion Pulmonary Edema

A. MURAT, A. ARSLAN & A. E. BALCI
Department of Radiology and Department of Thoracic Surgery, School of Medicine, Firat University, Elazig,
Turkey

Murat A, Arslan A, Balci AE. Re-expansion pulmonary edema. Acta Radiol 2004;45:
431–433.
Re-expansion pulmonary edema (REPE) is an uncommon complication following
re-expansion of the lung as treatment of conditions such as hemopneumothorax, large
pleural effusion, and after lobectomy, pneumothorax, or even during single-lung
ventilation. The majority of REPE complications are associated with treatment of
spontaneous pneumothorax. The etiology of REPE remains speculative, although it is
thought to be caused by increased pulmonary capillary permeability. Risk factors,
including young age, a large pneumothorax, and long duration of collapse, may help
predict the patients that might encounter this complication.
Key words: Pneumothorax; re-expansion pulmonary edema; REPE
Anıl Arslan, M.D., Department of Radiology, School of Medicine, Firat University, 23119
Elazig, Turkey (fax. z90 424 237 67 73, e-mail. anil_arslan@hotmail.com)
Accepted for publication 19 February 2004

Re-expansion pulmonary edema (REPE) is a rare
and potentially lethal complication of thoracostomy
tube placement for pneumothorax or pleural effu-
sion with severe atelectasis (10). Following drainage
of a pneumothorax or a large pleural effusion, the
re-expanded lung can become acutely edematous
(9). The mechanism is obscure; some authors
suggest it is related to surfactant depletion, others
that it results from hypoxic capillary damage,
leading to increased capillary permeability (5).
The fact that REPE is concentrated mainly in the
re-inflated lower lobes, following pleural effusion

Fig. 1. A. Chest radiograph shows completely collapsed right-side pneumothorax with REPE of the lung. B. After placement of a chest
tube the chest radiograph was normal, the right lung being fully re-expanded.

DOI 10.1080/02841850410005624 # 2004 Taylor & Francis

432 A. Murat et al.
aspiration, has led to the conclusion that hypoxic
damage, rather than mechanical stress, is the domi-
nant mechanism (12). Its onset can be sudden and
dramatic (10). Hypoxemia, hypotension, and even
death have been observed in case series. REPE is
potentially lethal, with mortality estimates as high
as 20% (3).
Case Report
A 28-year-old man presented at hospital with a 1-
week history of right-sided chest pain and dyspnea
which had occurred suddenly. The vital signs were
normal. Chest examination was notable for absent
breath sounds over the right chest. The rest of the
physical examination was normal.
Acta Radiol 2004 (4)
The patient’s chest radiograph showed a right-
side pneumothorax with complete collapse of the
right lung (Fig. 1A). The patient was treated with
tube thoracostomy. After the tube was placed in
position, the chest radiograph was normal (Fig. 1B).
Two hours later the patient developed severe cough-
ing, and became tachycardic and tachypneic. A chest
radiograph revealed widespread alveolar consolida-
tion of the right lung as evidence of unilateral
pulmonary edema (Fig. 2A). Computed tomography
(CT) of the lungs was performed (Fig. 2B), showing
increased attenuation of the lung parenchyma, with
large areas of ground-glass opacity (pulmonary
edema) on the right side. With these clinical and
radiologic signs the patient was diagnosed as having
REPE. At chest radiography 28 h later, the pulmon-
ary edema had cleared completely (Fig. 2C).
Fig. 2. A. Two hours after the tube was placed, a chest radio-
graph revealed severely increased opacity of large areas of the
right lung (pulmonary edema). B. Computed tomography shows
areas of consolidation and ground-glass opacities (pulmonary
edema) of the right lung. C. Chest radiograph 28 h later shows
that the pulmonary edema has cleared completely.

Discussion
REPE occurs, uncommonly, following expansion of
the lung during treatment of conditions such as
hemopneumothorax, a large pleural effusion, or
pneumothorax, after lobectomy or even during
single-lung ventilation. However, the majority of
cases are associated with treatment of spontaneous
pneumothorax (8).
REPE after spontaneous pneumothorax is a
rare complication of tube thoracostomy (4). Rapid
reperfusion of a lung, e.g. after thrombolysis of a
massive pulmonary embolus or following thrombo-
endarterectomy, may also cause acute pulmonary
edema (11). Risk factors, including young age, a
large pneumothorax, and longer duration of
collapse, may help predict the patients at risk of
encountering this complication (6).
The etiology of REPE remains speculative,
although it is thought to be caused by increased
pulmonary capillary permeability (1). An inflam-
matory response occurring when the lung re-
expands is believed to be secondary to expansion-
related mechanical injury to the alveolar-capillary
membrane and reperfusion injury as blood flow
returns to the now fully expanded lung (10). It has
been reported in several case series that the
likelihood of developing REPE is directly related
to the size of the pneumothorax, the rapidity at
which the pneumothorax is drained, and the
duration of symptoms before radiologic detection
(3, 4). In many patients, rapid expansion is caused
by aspiration with a high negative pressure,
although this is not always the case. Exceptional
cases of recurrent edema are reported with treat-
ment of recurrent pneumothorax (7).
The clinical picture of REPE can be dramatic.
Onset usually occurs immediately following lung
re-expansion, with 64% of patients exhibiting symp-
toms within 1 h. All reported patients became sym-
ptomatic within 24 h (3). Severe coughing often
heralds the development of pulmonary edema. The
patient becomes tachypneic and tachycardic as
hypoxia increases. Rarely, bilateral or contralateral
edeme develops (2). Young patients (under 40
Re-expansion Pulmonary Edema 433
years) have been reported to be at greater risk of
developing REPE (4).
In conclusion, REPE most commonly occurs in
the treatment of patients with a large pneumo-
thorax of longer duration, but remains a rare
complication of tube thoracostomy. Some sugges-
tions for preventing or reducing such complication
in high-risk patients are supplemental oxygen, slow
drainage, and avoidance of continuous suction (3,
4). REPE can be diagnosed and treated earlier in
high-risk patients by taking repeated radiographs
and by careful monitoring of the clinical condition.
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Acta Radiol 2004 (4)