The Frequency of Reexpansion Pulmonary Edema after Trocar and Hemostat Assisted Thoracostomy in Patients with Spontaneous Pneumothorax

Abstract

PurposeSeveral risk factors for development of reexpansion pulmonary edema (REPE) after drainage of pneumothoraces have been reported, but the association between the method of thoracostomy and the development of REPE is unknown. The aim of this study was to compare the frequency of REPE after treatment of spontaneous pneumothorax with trocar or hemostat assisted closed thoracostomy.Materials and MethodsWe performed a prospective, observational study including 173 patients with spontaneous pneumothorax who visited the emergency department from January 2007 to December 2008. In 2007, patients were treated with hemostat-assisted drainage, whereas patients in 2008 were treated with trocar-assisted drainage. The main outcome was the development of REPE, determined by computed tomography of the chest 8 hours after closed thoracostomy. Outcomes in both groups were compared using univariate and multivariate analyses.ResultsNinety-two patients were included, 48 (42 males) of which underwent hemostat-assisted drainage and 44 (41 males) underwent trocar-assisted drainage. The groups were similar in mean age (24±10 vs. 26±14 respectively). The frequencies of REPE after hemostat- and trocar-assisted drainage were 63% (30 patients) and 86% (38 patients) respectively (p=0.009). In multivariate analysis, trocar-assisted drainage was the major contributing factor for developing REPE (odds ratio=5.7, 95% confidence interval, 1.5-21). Age, gender, size of pneumothorax, symptom duration and laboratory results were similar between the groups.ConclusionClosed thoracostomy using a trocar is associated with an increased risk of REPE compared with hemostat-assisted drainage in patients with spontaneous pneumothorax.

Radiographically Severe but Clinically Mild Reexpansion Pulmonary Edema following Decompression of a Spontaneous Pneumothorax

“…Trocar and small bore decompression (as used in this patient) carries a higher risk of REPE than traditional hemostat and large bore decompression (odds ratio 5.73)—this is thought to be secondary to the slower release of entrapped air with the slow dissection/hemostat method compared to the single puncture of a trocar assisted thoracostomy [2]. Application of negative pleural pressure may increase the rate of expansion, but this has not been shown to be causative.…”

“…Young age, airway obstruction (e.g., OSA) [ 1 ], chronicity of the pneumothorax beyond three days (as in this case) [ 5 , 6 ], mechanism (large versus small bore) and rate of decompression [ 2 , 7 ], and history of diabetes mellitus [ 5 ] have been identified as risk factors for the development of REPE. Trocar and small bore decompression (as used in this patient) carries a higher risk of REPE than traditional hemostat and large bore decompression (odds ratio 5.73)—this is thought to be secondary to the slower release of entrapped air with the slow dissection/hemostat method compared to the single puncture of a trocar assisted thoracostomy [ 2 ]. Application of negative pleural pressure may increase the rate of expansion, but this has not been shown to be causative.…”

“…Decreased surfactant production, especially with more subacute pneumothoraces, pulmonary nitric oxide levels [ 2 ], and rapid increase in cardiac output in the setting of increased pulmonary capillary permeability [ 8 ] have been proposed as mechanisms for REPE. Reactive oxygen species (ROS, i.e., free radicals) have been shown to be upregulated following reinflation.…”

“…Reexpansion pulmonary edema (REPE) is a clinical syndrome characterized by the development of clinical and radiographic evidence of pulmonary edema, most commonly seen after large volume (>1.5 L) therapeutic thoracentesis. However, while significantly less common (reported incidence approximately 0.8%) [ 1 , 2 ] and previously poorly recognized until the advent of routine use of computed tomography, REPE can develop following pneumothorax decompression and is associated with a mortality rate of up to 20% [ 1 ]. This is a case of a healthy 48-year-old female who developed REPE following a spontaneous pneumothorax.…”

Severe Respiratory and Hemodynamic Failures following Successful Spontaneous Pneumothorax Drainage

“…Severe reexpansion pulmonary edema (REPE) is a rare complication of pneumothorax treatment. The incidence of mild REPE seems to vary between 0.9% and nearly 75% of patients treated for spontaneous pneumothorax [ 1 ] This variation is mostly a consequence of various diagnostic criteria or radiologic procedures. Nevertheless, most clinical presentations of REPE are mild, and treatment is mostly symptomatic even if some authors have used steroids [ 2 ].…”