Acute unilateral reexpansion pulmonary edema after pleuropulmonary decortication

The development of unilateral pulmonary edema at the time of reexpansion is a rare complication often associated with aspirational drainage of a pneumothorax. It has been described exceptionally in the postoperative course of a pleural surgery. The main involved factors are prolonged atelectasis, reexpansion pulmonary effusion, the importance and duration of pleural effusion. This complication must be known to anesthesiologist during thoracic surgery for its mortality, which is evaluated at 20% in the litterature and that an early diagnosis allows the an effective treatment. We report an acute respiratory distress in the immediate postoperative course of pleuropulmonary decortication for a recurrent tuberculous pleurisy. Keywords: Unilateral Pulmonary Edema, Pneumothorax, Pleural Effusion.
 Introduction Unilateral reexpansion pulmonary edema (RPE) is a complication described after a pleural drainage. However, it can be encountered under various clinical conditions, in particular after pleural decortication, declotting or excision of a large intrathoracic tumor mass [1, 2]. The immediate diagnosis based on radioclinical arguments should lead to a rapidly effective treatment [3]. The authors report a case of lung edema after a pleuropulmonary decortication whose evolution was favorable following the early diagnosis. The case This is a young male patient of 19 years old, smoking for 3 years. He had been followed for four months in the department of pneumology, for bilateral pleurisy which required several evacuating punctures with an exudative fluid and the pleural biopsy was inconclusive. The search for Koch's bacillus in the sputum was negative. Face to this clinical situation, surgery was decided for diagnosis and treatment. The pre-anesthetic examination found a patient in good general condition, polypneic at 19 cycles / minute, his SpO2 at 92 % in ambient air, a normal blood pressure, and a heart rate at 95 beats / minute. Thorax auscultation revealed a fluid pleural effusion syndrome throughout the right hemithorax and the left basithoracic region. The radiological assessment showed an opaque right hemithorax and a left pleural effusion with no mediastinal discharge (Figure 1). The preoperative preparation consisted of incitative spirometry and evacuation puncture of the right pleural effusion, which brought about 500 ml of yellow fluid with the same radiological images on the control chest X-ray. Page of 1 3 *Correspondence Belliraj Layla Department of thoracic surgery University hospital Hassan II Fes Morocco Email: lbelliraj@yahoo.fr 1Department of Thoracic Surgery, University Hospital Hassan II, Fes, Morocco. 2Faculty of Medicine and Pharmacy, University Sidi Mohamed Ben Abdellah, Fes, Morocco. 3Departement of Intensive Care A4, University Hospital Hassan II, Fes, Morocco. Received: Jan 19, 2019 Accepted: Apr 24, 2019 Published: May 7, 2019 Acute unilateral reexpansion pulmonary edema after pleuropulmonary decortication Belliraj L1*, Lakranbi M1,2, Lahlou A3, Ammor F Z1, Harmouchi H1, Ouadnouni Y1,2, Smahi M1,2 Case Report Open Access OA Journal of Clinical Case Reports doi: 10.33118/oaj.rep.2019.01.010 Belliraj Layla et al. OAJ Case Rep. 2019, 1:010 Figure 1.A: Chest X-ray showing a right opaque hemithorax with a left pleurisy. Figure 1.B: Thoracic CTscan showing bilateral pleurisy with right pachypleuritis (red arrow) and right lung atelectasis (yellow arrow). The patient was admitted to the operating room, with standard monitoring including a 95% saturation in the ambient air. The procedure lasted 2 hours. It consisted in a pleuro-pulmonary decortication after aspiration of 1000 ml of yellow liquid. The exploration found a thickened pleura dotted with white pleural nodules. At the end of the surgery, there was a desaturation at 75 % and a tachypnea with aspiration of foamy and pink secretions via the tracheal tube. The chest auscultation revealed the presence of crackles, and arterial blood gas (ABG) showed a PaO2 / FiO2 ratio at 270. An urgent chest X-ray showed multiple nodular alveolar opacities, poorly limited and diffuse, throughout the right lung and therefore the diagnosis of RPE was confirmed (figure2). Figure 2: Chest X-ray showing right alveolar syndrome. The patient was put on diuretics with increase in positive expiratory pressure allowing his extubation in post-interventional surveillance room. After a stay in intensive care unit for 48h, with close noninvasive ventilation sessions, a respiratory physiotherapy and diuretics, the evolution was progressively favorable with a decrease of the crackles, an improvement of the gasometric parameters and a regression of the radiological images (figure3) [2]. The histopathological study revealed an aspect of pleural tuberculosis and the patient was put on antibacillary treatment with a good clinical and radiological evolution.