Thoracic Imaging 2003 - Society of Thoracic Radiology

Re-expansion Pulmonary Edema:
Re-expansion pulmonary edema is an uncommon, but occasionally
life-threatening complication of pleural drainage.
Many (perhaps most) patients with re-expansion edema have
only minimal symptoms. Fortunately, very few patients develop
life-threatening dyspnea. When it occurs, however, re-expansion
edema is quite difficult to treat. The best treatment is, in
fact, prevention. Risk factors include:
• Rapid re-expansion of lung
• Evacuation of more than 1500 cc of pleural fluid per day
• Prolonged collapse (> 72 hours) of subsequently reexpanded
lung
• High negative intrapleural pressure
In order to prevent re-expansion edema, we typically withdraw
only one liter of fluid when the catheter is placed. We
also stop withdrawing fluid if the patient experiences symptoms
such as cough, chest pain or increasing dyspnea. If there is a
large volume of residual fluid (two or three liters), we may
leave the catheter closed for several hours and then open it to
gravity drainage. Suction is applied by Pleur-evac only when
most of the fluid has been evacuated by gravity drainage. It
should be recognized, however, that symptomatic re-expansion
edema can occur despite careful attention to detail. These risks,
including the risk of death from re-expansion edema, should be
carefully explained to the patient during informed consent.
Ambulatory Drainage:
Selected highly functional patients can be offered ambulatory
drainage. We usually place a smaller catheter in these
patients (10.3 French APDC) and connect it to a Tru-Close 600
cc bag (UreSil, L.P. Skokie, IL 60077) for gravity drainage.
Patients are provided with home care instructions and instructed
to return to clinic for sclerotherapy when drainage falls below
200 cc per day. In clinic, a radiograph is obtained to confirm
complete fluid drainage, absence of loculations, and complete
lung re-expansion. Any remaining fluid is aspirated prior to
instillation of the sclerosing agent. Following instillation of the
sclerosing agent, the tube is clamped and the patient is instructed
to change positions frequently. After 2 hours, the tube is
reopened to gravity drainage, the patient is sent home, and is
instructed to return the following day for chest tube removal.
The Pleuryx Catheter (Denver Biomedical, Golden, CO) is a
further option for ambulatory treatment of malignant effusions.
This is a tunneled catheter placed into the pleural space using a
trocar, guidewire and a peel-away sheath. The catheter has a
Teflon cuff to prevent bacterial contamination of the pleural
space. Fluid is removed periodically (every one-two days)
using small disposable vacuum bottles (1 liter). Preliminary
results suggest that this technique is as efficacious as conventional
inpatient therapy, with few complications, and markedly
reduced cost.
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