Re-expansion pulmonary oedema.

I read, with great interest, the paper entitled ‘Lessons from fatal re-expansion pulmonary oedema: case series’ by Dr Nyamande and Dr Mazibuko [1].

They presented 2 cases of re-expansion pulmonary oedema, both resulting in death. Case number 2 is a classic presentation of re-expansion pulmonary oedema. However, I am concerned about the aetiology of case number 1.

The authors presented a 44-year-old patient who underwent a thoracotomy for a loculated right empyema thoracis from a transdiaphragmatic rupture of a right subphrenic abscess. After draining 3000 ml of pus, decortication and lung re-expansion, they noticed a large amount of frothy serosanguineous fluid in the patient’s endotracheal tube. I doubt that the cause of their patient death was aspiration of abscess fluid (pus) or bile through small bronchial openings, or parenchymal fistulae, as opposed to re-expansion pulmonary oedema. My reasons are as below.

The shown endotracheal tube fluid is very similar to bilious stained abscess fluid.

As a general thoracic surgeon with 27 years of experience, I have not had any patient who gets re-expansion pulmonary oedema under general anaesthesia (GA). I, like all other general thoracic surgeons, always have patients with massive (mostly malignant) pleural effusion who require video-assisted thoracic surgery for pleural biopsy. All of them get GA with double-lumen intubation and their fluid is immediately drained after thoracoports insertion. I also do video-assisted thoracic surgery for my stable patients with spontaneous pneumothorax and complete collapse without inserting a chest tube prior to surgery. They also get GA with double-lumen intubation and the air gushes out immediately after thoracoports insertion. Fortunately, none of them has ever had any re-expansion pulmonary oedema. I do know that with one-lung ventilation, in the vast majority of the above-mentioned cases, the lung is not expanded right after drainage of pleural fluid or air. However, whether it is expanded at the end of procedure, or sooner (e.g. for checking air leakage from the stapler line), I have not seen any re-expansion pulmonary oedema.

Although re-expansion pulmonary oedema may potentially happen during GA, I could not find any reports of re-expansion pulmonary oedema in a patient under GA after an extensive literature review [2-5].