Clinical Analysis of Reexpansion Pulmonary Edema* Yuichiro Matsuura, M.D., Ph.D., F.C.C.R;t Takayuki Nomimura, M.D.;t Hironobu Murakami, M.D., Ph.D.;t Takeshi Matsushima, M.D., Ph.D.;t Masayuki Kakehashi, Ph.D.;* and Hiroki Kajihara, M.D., Ph.D.§ 1\venty-ooe of 146 cases of spontaneous pneumothorax that were treated by thoracentesis or continuous low negative pressure suction drainage (-12 em 1Is0) of the pleural space developed REPE. The rate of REPE was higher in patients 10 to 39 years of age than in those over the age of 40, and the rate progressively increased in proportion to the extent of pneumothorax, as assessed by roentgenographic criteria. It is postulated that age-related changes
incidence of spontaneous pneumothorax has increased. 1 Mild cases are managed conservatively with rest, while on ,the other hand, large pneumothorax or tension pneumothorax is typically treated with thoracentesis or continuous low negative pressure drainage of the pleural space. It has been cautioned that rapid reexpansion of long-tenn collapsed lung leads occasionally to reexpansion pulmonary edema which can be fatal. 2 •3 Since detailed clinical studies of REPE are scarce, the authors analyzed respectively 164 cases of spontaneous pneumothorax treated at the Hiroshima Prefectural Hospital from 1974 to 1985. Of these, 146 were treated by thoracentesis, suction drainage ofthe pleural space, or thoracotom~ Twenty-one patients (14 percent) subsequently exhibited evidence of REPE and were treated actively with a variety of modalities and drugs, including oxygen, steroids, diuretics, sedatives, and inotropic agents without any fatal outcome.
in the lung may afford some degree of protection against developing REPE. It is also suggested that the treatment ofpneumothorax with thoracentesis aodIor suction drainage in young patients, or in the face of a large pneumothorax, requires careful consideration in view of a relatively high incidence of REPE in such individuals. (Chat 1991; 100:1562-66)
ecentl~ the
R
*From tthe 1st De~ent of Surgery and *Depar!!Dent of Public Health, School of Medicine, and the §Organizing Office for College of Medical Technology, Hiroshima University, Hiroshima, Japan Manuscript received November 8; revision accepted March 26. Beprint requut&: Dr. Matsuura, 1st Department of Surgery, Hiro-
slUma UnWersUy School of Medicine, 1-2-3 Ktuumi, Minamiku, HiroslUma City 734, japan
MATERIALS AND METHODS
The subjects in this study were 164 patients with spontaneous pneumothorax, 146 of whom were treated by thoracentesis or continuous low negative pressure drainage (-12 em H.O) of the pleural space. Subsequently, 113 underwent a thoracotomy for bleb excision and/or pleurectom~ The remaining 18 pati~nts received conservative treatment (bedrest), and the condition was allowed to resolve spontaneousl~ Among the 146 patients who received active treatment, 21 developed REPE. The criteria used to diagnose REPE included the following: (1) clinical status with serious cough, foaming sputum, agitation, tachycardia, and tachypnea; and (2) extensive ground glass-like shadow in the chest x-ray film following lung reexpansion. The rate of REPE among subgroups classified by age, sex, underlying diseases, signs and symptoms, frequency of previous attacks of pneumothorax, and presumed duration of lung collapse or side of the involved lung was compared to find factors associated with higher REPE rates. Statistical comparisons were made by Xl test, Fisher exact test, and multiple logistic regression. RESULTS
Treatment modalities utilized are outlined in Table 1. Initial treatment consisted of thoracentesis or continuous negative pressure drainage. The most frequently performed surgical treatment was excision of bleb with parietal pleurectomy in patients under the age of 50. Patients who were over 60 years old
Table 1-ltema of Treatment of Spontaneoua PneumotlaortJ% According to Age·
Age, yr
Conservative Rest
-19 20-29 30-39 40-49
3 (12.5) 4 (7.3) 3 (8.8)
50-59 60-69
4 (33.3)
70Total No.
o
(0)
1 (10.0) 3 (23.1) 18
Thoracentesis or Suction Drainage 3 8 2 5 3
(12.5) (14.5) (5.9) (31.3) (25.0)
5 (50.0)
7 (53.8) 33
Excision of Bleb, Partial Ple.urectomy 15 40 26 10 3 1 1
(62.5) (72.7) (76.4)
(62.5) (25.0) (10.0) (7.7) 96
Excision of Bleb, Extended Pleurectomy 3 3 3 1 2 3 2
(12.5) (5.5) (8.8) (6.3) (16.7) (30.0) (15.4) 17
Total No. 24 55 34
16 12 10 13 164
*Percentages in parentheses.
1582
CInicaI Analysis of Reexpansion Pulmonary Edema (Matsuura et 81)
Age
I
-l9yrs 20-39yrs
~~\\~
~\1:J
40- yrs
o
Percent
50
100
Extent of lung oollapse
Mild _
~ate severe IZ2SJ
were most commonly treated by simple continuous low negative pressure suction drainage. Figure 1 shows the rate of cases of subgroups classified by severity of pneumothorax according to age. There was no relationship between age and the rate of cases of subgroups. Table 2 shows the incidence of REPE in relation to age, sex, underlying diseases, signs and symptoms, frequency of attacks, and presumed duration of lung collapse. The rate of REPE in the group aged 20 to 39 years was significantly higher than in other groups (prax classified by severity of pneumothorax c=J according to age.
c:s:sJ
to the presence of underlying disease, signs and symptoms, previous pneumothorax, nor presumed duration of pneumothorax. The rate of REPE increased in proportion to the extent of lung collapse as judged by the roentgenographic appearance of the chest (p
incidence of spontaneous pneumothorax has increased. 1 Mild cases are managed conservatively with rest, while on ,the other hand, large pneumothorax or tension pneumothorax is typically treated with thoracentesis or continuous low negative pressure drainage of the pleural space. It has been cautioned that rapid reexpansion of long-tenn collapsed lung leads occasionally to reexpansion pulmonary edema which can be fatal. 2 •3 Since detailed clinical studies of REPE are scarce, the authors analyzed respectively 164 cases of spontaneous pneumothorax treated at the Hiroshima Prefectural Hospital from 1974 to 1985. Of these, 146 were treated by thoracentesis, suction drainage ofthe pleural space, or thoracotom~ Twenty-one patients (14 percent) subsequently exhibited evidence of REPE and were treated actively with a variety of modalities and drugs, including oxygen, steroids, diuretics, sedatives, and inotropic agents without any fatal outcome.
in the lung may afford some degree of protection against developing REPE. It is also suggested that the treatment ofpneumothorax with thoracentesis aodIor suction drainage in young patients, or in the face of a large pneumothorax, requires careful consideration in view of a relatively high incidence of REPE in such individuals. (Chat 1991; 100:1562-66)
ecentl~ the
R
*From tthe 1st De~ent of Surgery and *Depar!!Dent of Public Health, School of Medicine, and the §Organizing Office for College of Medical Technology, Hiroshima University, Hiroshima, Japan Manuscript received November 8; revision accepted March 26. Beprint requut&: Dr. Matsuura, 1st Department of Surgery, Hiro-
slUma UnWersUy School of Medicine, 1-2-3 Ktuumi, Minamiku, HiroslUma City 734, japan
MATERIALS AND METHODS
The subjects in this study were 164 patients with spontaneous pneumothorax, 146 of whom were treated by thoracentesis or continuous low negative pressure drainage (-12 em H.O) of the pleural space. Subsequently, 113 underwent a thoracotomy for bleb excision and/or pleurectom~ The remaining 18 pati~nts received conservative treatment (bedrest), and the condition was allowed to resolve spontaneousl~ Among the 146 patients who received active treatment, 21 developed REPE. The criteria used to diagnose REPE included the following: (1) clinical status with serious cough, foaming sputum, agitation, tachycardia, and tachypnea; and (2) extensive ground glass-like shadow in the chest x-ray film following lung reexpansion. The rate of REPE among subgroups classified by age, sex, underlying diseases, signs and symptoms, frequency of previous attacks of pneumothorax, and presumed duration of lung collapse or side of the involved lung was compared to find factors associated with higher REPE rates. Statistical comparisons were made by Xl test, Fisher exact test, and multiple logistic regression. RESULTS
Treatment modalities utilized are outlined in Table 1. Initial treatment consisted of thoracentesis or continuous negative pressure drainage. The most frequently performed surgical treatment was excision of bleb with parietal pleurectomy in patients under the age of 50. Patients who were over 60 years old
Table 1-ltema of Treatment of Spontaneoua PneumotlaortJ% According to Age·
Age, yr
Conservative Rest
-19 20-29 30-39 40-49
3 (12.5) 4 (7.3) 3 (8.8)
50-59 60-69
4 (33.3)
70Total No.
o
(0)
1 (10.0) 3 (23.1) 18
Thoracentesis or Suction Drainage 3 8 2 5 3
(12.5) (14.5) (5.9) (31.3) (25.0)
5 (50.0)
7 (53.8) 33
Excision of Bleb, Partial Ple.urectomy 15 40 26 10 3 1 1
(62.5) (72.7) (76.4)
(62.5) (25.0) (10.0) (7.7) 96
Excision of Bleb, Extended Pleurectomy 3 3 3 1 2 3 2
(12.5) (5.5) (8.8) (6.3) (16.7) (30.0) (15.4) 17
Total No. 24 55 34
16 12 10 13 164
*Percentages in parentheses.
1582
CInicaI Analysis of Reexpansion Pulmonary Edema (Matsuura et 81)
Age
I
-l9yrs 20-39yrs
~~\\~
~\1:J
40- yrs
o
Percent
50
100
Extent of lung oollapse
Mild _
~ate severe IZ2SJ
were most commonly treated by simple continuous low negative pressure suction drainage. Figure 1 shows the rate of cases of subgroups classified by severity of pneumothorax according to age. There was no relationship between age and the rate of cases of subgroups. Table 2 shows the incidence of REPE in relation to age, sex, underlying diseases, signs and symptoms, frequency of attacks, and presumed duration of lung collapse. The rate of REPE in the group aged 20 to 39 years was significantly higher than in other groups (prax classified by severity of pneumothorax c=J according to age.
c:s:sJ
to the presence of underlying disease, signs and symptoms, previous pneumothorax, nor presumed duration of pneumothorax. The rate of REPE increased in proportion to the extent of lung collapse as judged by the roentgenographic appearance of the chest (p
