Case report 291 A case of unilateral re-expansion pulmonary oedema successfully treated with non-invasive continuous positive airway pressure Giovanni Volpicelli a , Claudio Fogliati b , Giulio Radeschi b and Mauro Frascisco a Unilateral re-expansion pulmonary oedema is a rare threatening complication of the treatment of lung atelectasis, pleural effusion or pneumothorax, the pathogenesis of which is not completely known. The clinical picture varies considerably from asymptomatic radiological findings to dramatic respiratory failure with circulatory shock. There are few literature reports of the treatment of re-expansion pulmonary oedema with non-invasive continuous positive airway pressure. We present the case of a 75-year-old man who presented in our emergency room with a large left-sided spontaneous pneumothorax and developed severe respiratory failure and circulatory collapse after drainage via a chest tube. The diagnosis of unilateral re-expansion pulmonary oedema was made and he was successfully treated with non-invasive continuous positive airway pressure. Literature data about the aetiological and pathogenetic factors of the condition are also considered. European Journal of Emergency Medicine 11:291–294  c 2004 Lippincott Williams & Wilkins. European Journal of Emergency Medicine 2004, 11:291–294 Keywords: Continuous positive airway pressure, pneumothorax, re-expansion pulmonary edema a Department of Emergency Medicine and b Division of Anesthesiology and Intensive Care, S Luigi Hospital, Orbassano, Turin, Italy. Correspondence to Giovanni Volpicelli, S.C.D.O. Medicina d’Urgenza, Ospedale San Luigi da Orbassano, Turin, Italy. Tel: + 39 11 9026227; e-mail: gio.volpicelli@tin.it Introduction Unilateral re-expansion pulmonary oedema (RPE) is a rare complication of the treatment of lung collapse secondary to atelectasis, pleural effusion or pneumothor- ax. It generally occurs after a prolonged period of total collapse of the lung or when the re-expansion treatment occurs too rapidly [1,2]. However, in the literature cases of RPE have been reported to occur when the pulmonary collapse was of short duration or when the lung was re- expanded without rapid suction [1,2]. This complication generally manifests early after the re-expansion. Its pathogenesis is still unclear and probably multifactorial. There is evidence in the literature of different possible mechanisms, but increased pulmonary microvascular permeability is the only pathogenetic mechanism that has actually been studied and proved [3,4]. The clinical presentation of RPE can vary considerably, ranging from asymptomatic radiological findings to a combination of severe cardiorespiratory insufficiency and circulatory shock. The mainstay of the treatment of RPE remains oxygenation, the maintenance of good diuresis, haemo- dynamic support and mechanical ventilation with positive end-expiratory pressure as needed. There are few literature reports of the treatment of RPE with non- invasive continuous positive airway pressure (C-PAP) [1,5]. We report the case of a patient with unilateral RPE as a complication of the chest tube suction treatment of a hypertensive unilateral pneumothorax, who was success- fully treated with C-PAP. Case report A 75-year-old man presented to our emergency room complaining of severe dyspnoea, left-sided chest pain and dry cough. The patient had a history of coronary artery disease, with recent coronary by-pass surgery and recurrent bilateral spontaneous pneumothoracies in moderate emphysema. He had developed symptoms of progressive exertional dyspnoea with dry cough evolving during the previous week. His symptoms worsened dramatically the day of admission. The clinical picture at presentation consisted of serious respiratory failure with pulse oxymetric saturation (Spo 2 ) of 60% while breathing room air, peripheral cyanosis, a respiratory rate of 40 breaths/min, blood pressure of 170/100 mmHg and a heart rate of 140 beats/min (sinus rhythm). A blood gas analysis revealed a pH of 7.12, partial pressure carbon dioxide (Pco 2 ) 59.3 mmHg, partial pressure oxygen (P o 2 ) 46.1 mmHg, hydrogen carbonate 18.7 mEq/l and base excess – 9 mEq/l. The left hemi- thorax was tympanic with no audible vesicular murmur. While ventilating the patient with supplementary oxygen maintaining Spo 2 at approximately 90%, a chest X-ray (Figure 1) revealing a complete left-sided pneumothorax was obtained. An emergency intercostal suction drainage ( – 20 cm water) was immediately inserted in the left fifth 0969-9546  c 2004 Lippincott Williams & Wilkins Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.