A three-month old male undergoes uncomplicated closure of a ventricular septal defect. On postoperative day three he develops a right pneumothorax

 

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tube thoracostomy is placed and another radiogrpah is obtained.

 

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[size=20px]Despite complete lung re-expansion, the infant has decreasing oxygen saturation and increased work of breathing. Your treatment plan for this infant with hypoxemia and a pneumothorax is

 

A placement of left thoracostomy tube.

 

B placement of second right thoracostomy tube.

 

C cannulation for extracorporeal life support.

 

D intubate if needed and provide appropriate supportive critical care.

 

E right thoracotomy.[/size]

D

D

correct

 

Re-expansion pulmonary edema (REPE) is a rare but potentially serious complication related to rapid lung expansion after placement of a thoracostomy tube - typically for pneumothorax or pleural effusion. Mortality is reported to be as high as 20%. The diagnosis is made clinically as the patient develops respiratory distress, hypoxia and circulatory collapse. The exact pathophysiology for REPE is unknown. Mechanical distress on the alveoli or oxygen radicals produced in the collapsed lung might be contributing factors. Moreover, the activity of different cytokines such as interleukin 8 and monocyte chemoattractant protein 1 (MCP-1) or the activity of xanthine oxidase have been implicated.

 

Several risk factors have been associated with REPE: younger age (less than 40 years), longer duration of lung collapse (less than four days), large pneumothorax (greater than 30% of a single lung) and timing of lung re-expansion.

 

Treatment consists of progressive supplemental oxygen as warranted - including 100% nonrebreather mask or endotracheal intubation. Admission to a critical care unit should be considered for potential hemodynamic and ventilatory management.