IS Case 163: Spontaneous tension pneumothorax with re-expansion pulmonary edema

Daniel T. O'Connor, MD

Imaging Sciences URMC 2008
Publication Date: 2009-05-21

History

Patient is a 35-year-old male with sudden onset of shortness of breath/respiratory distress; no other significant past medical history. Decreased left-sided breath sounds.

Findings

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).

Diagnosis

Spontaneous tension pneumothorax with re-expansion pulmonary edema

Discussion

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.

References

1. Mahfood S, Hix WR, Aaron BL, Blaes P, Watson DC. Reexpansion pulmonary edema. Ann Thorac Surg. 1988 Mar;45(3):340-5. [PMID: 3279931]