Q: 84 year old male is admitted to ICU with community acquired pneumonia and on Non-invasive Positive Pressure Ventilation (NIPPV). Chest X-ray shows left sided massive accumulation of pleural effusion. You want to avoid intubation. As you start draining pleural fluid, patient developed cough and complains of chest pain?



Answer:  Re-expansion pulmonary edema

Patients with large effusions are at an increased risk of reexpansion pulmonary edema, as they may develop a significant  decrease in pleural pressure even with a small amount of pleural fluid removal. While removing pleural fluid, if patient develops coughing, or complain of chest pain and shortness of breath, or if monitor shows improved oxygenation which is followed by decreased saturation - are signs of possible risks of development of  reexpansion pulmonary edema. Ideally, tube should be clamped if any sign of  reexpansion pulmonary edema and should be waited till symptoms resolved before draining further pleural fluid. Risk of reexpansion pulmonary edema can be minimized by draining not more than one litre of fluid at a time in massive pleural effusion.



References:. 

Mahfood S, Hix WR, Aaron BL, et al. Reexpansion pulmonary edema. Ann Thorac Surg 1988