IS Case 163: Spontaneous tension pneumothorax with re-expansion pulmonary edema
Imaging Sciences URMC 2008
Publication Date: 2009-05-21
Initial AP portable view of the chest with no prior study for comparison demonstrated tension pneumothorax of the left hemithorax with classic mediastinal shift to the right and hypoexpanded/compressed appearance of the right lung (Fig. 1). Subsequent radiograph demonstrated near complete re-expansion of the left upper and lower lobes with small residual pneumothorax in the left apex after placement of left-sided chest tube, and patchy opacification with diffuse, hazy interstitial markings of the perihilar region and left lower lobe, consistent with re-expansion pulmonary edema with residual atelectasis (Fig. 2). These findings resolved rapidly, however, with near complete resolution of re-expansion edema by the following morning (Fig. 3).
Re-expansion pulmonary edema is an acute pulmonary process of controversial etiology that is most commonly encountered following chest tube placement for tension pneumothorax. Other common situations include re-expansion of lung parenchyma following removal of an obstructing mass and following the removal of a large volume of pleural fluid (at least 1L). Radiographic changes may be near-immediate, as in the above case, but may be delayed up to 24 hours. Usually self-limiting, this condition has been historically associated with significant morbidity and mortality, with up to 20% mortality reported in some series.
Radiographic findings are typical of pulmonary edema, with distribution determined by location/extent of lung collapse, as well as clinical variables such as the rate of re-expansion and duration of collapse. Distinct from other causes of noncardiogenic pulmonary edema both by virtue of clinical history and focal appearance; contusion of lung parenchyma and reperfusion pulmonary edema following pulmonary embolism thrombolysis are important differential considerations.
- Mahfood S, Hix WR, Aaron BL, Blaes P, Watson DC. Reexpansion pulmonary edema. Ann Thorac Surg. 1988 Mar;45(3):340-5. [PMID: 3279931]