Reexpansion pulmonary edema following thoracentesis.

Case Report An 89-year-old gentleman with a past medical history significant for severe aortic stenosis and atrial fibrillation on warfarin therapy presented to the Providence VA Medical Center for placement of a right-sided chest tube. Several weeks prior, the patient had fallen at home and developed a hemothorax after sustaining several rib fractures. At the time of his fall, he had undergone a thoracentesis with 1 liter of bloody fluid removed. He returned for a repeat thoracentesis as he had persistent symptoms of shortness of breath and a repeat chest x-ray demonstrated re-accumulation of the pleural fluid (Figure 1). The thoracentesis procedure itself went well without any significant complications and 2 liters of bloody fluid were removed. During the procedure, the chest tube was placed and attached to wall suction. The patient was subsequently admitted to the hospital for post-thoracentesis observation. A short time later, a rapid response was called due to hypoxia and respiratory distress when the patient’s oxygen saturation noted to be in the low 50’s despite being on a 100% nonrebreather. He was placed on BiPAP, given Furosemide 60mg and Morphine 2mg, both intravenously. The patient was subsequently transferred to the ICU and had a repeat chest x-ray (Figure 2) that demonstrated improvement in the size of the pleural effusion but the interval development of a new right lower lobe interstitial infiltrate in the area of the re-expanded lung. The diagnosis of reexpansion pulmonary edema was made on this basis and BiPAP was continued for a total of 24 hours. The patient’s respiratory status improved over subsequent days and serial chest x-rays demonstrated improvement of the right lower lobe opacities. During this period the patient Figure 1. Chest x-ray on day of admission demonstrating a large right pleural effusion.