If the respiratory distress and hypoxemia continue on oxygen supplementation, a trial of non-invasive ventilation should follow if there are no contraindications of NIV, as evidence suggests that it lowers the need for intubation and improves respiratory parameters. Nasal cannula and face mask -> Non-rebreather mask -> Trial of non-invasive ventilation (NIV) -> Intubation and mechanical ventilation Supplemental oxygen, if necessary, should be given in the following order: Unnecessary oxygen should not be administered as it causes vasoconstriction and reduction in cardiac output. Supplemental oxygen is a requirement if the patient is at risk of hypoxemia (SPO2 less than 90% ). doi: 10.1503/cmaj.After initial airway clearance, oxygenation assessment, and maintenance, management mainly depends upon presentation and should be tailored from patient to patient. Re-Expansion pulmonary edema following thoracentesis. Kasmani R, Irani F, Okoli K, Mahajan V.Reexpansion pulmonary edema after chest drainage for pneumothorax: a case report and literature overview. Verhagen M, Van Buijtenen J, Geeraedts L.Observations on pleural fluid pressures as fluid is withdrawn during thoracentesis. Light RW, Jenkinson SG, Minh VD, George RB.Does re‐expansion pulmonary oedema exist? Interact Cardivoasc Thorac Surg. 2008 7:485-489. Echevarria C, Twomey D, Dunning J, Chanda B.Reexpansion pulmonary edema after therapeutic thoracentesis. An uncommon complication of a common clinical scenario: exploring reexpansion pulmonary edema with a case report and literature review. Re-expansion pulmonary edema, pleural effusion, thoracentesis, pneumothorax, drainage, chest tube, ventilation. 4 Close patient monitoring and early recognition of symptoms, especially in the presence of known risk factors, is paramount because delayed treatment may lead to a fatal outcome. 4 As with traditional methods of therapeutic thoracentesis, precautions are followed and fluid removal is stopped if the patient feels chest pressure or becomes hypotensive, if pleural pressure falls less than -20 cm H 2O, or if no more fluid can be aspirated. Using this methodology, the amount of fluid aspirated often exceeds the traditionally observed limits of 1000 to 1500 mL, and many patients fare well with removal above 1500 mL. 6 A more precise treatment approach may establish a “safe” volume of fluid to remove by combining symptom monitoring with serial measures of pleural pressure. 1,5 Preventive strategies include limiting drainage of pleural fluid if the patient reports chest pressure or discomfort during thoracentesis and using low negative pressure (less than −20 cm H 2O) for suction. It is important to note that RPE is usually self-limiting and treatment is generally supportive, typically ranging from oxygen support and diuretics to intubation, mechanical ventilation, hemodynamics, and steroids in more severe cases. 3 Large volume thoracenteses are characterized by removal of more than 1000 mL of pleural fluid during a therapeutic thoracentesis. 1,2 RPE pathophysiology is not fully understood however, risk factors include presence of pleural effusion in conjunction with pneumothorax, young patients (<40), large pneumothoraces, and when pneumothorax has been present for longer than one week. Re-expansion pulmonary edema (RPE) is a rare complication that can occur following thoracentesis of a pleural effusion or chest tube drainage of pneumothorax, and is a potentially fatal complication due to the resulting abrupt reduction in pleural pressure. When the patient became tachypneic, a third X-ray (chest X-ray 3) showed persistent trace apical right pneumothorax measuring 6.7 mm. Repeat chest X-ray immediately after evacuation (chest X-ray 2) shows improvement of the pleural effusion and a new trace apical right pneumothorax measuring 6.7 mm. Initial chest X-ray (chest X-ray 1) showed a right-sided pleural effusion with compressive atelectasis of the mid to lower right lung. An additional chest X-ray was performed which showed pulmonary re-expansion edema and patient was subsequently admitted for observation. A few hours later, the patient became tachypneic and oxygenation saturation dropped from 100% to 91%-92% on room air, and was found to have decreased breath sounds on the right. The patient tolerated the procedure well and a post procedural chest X-ray was performed, which is noted below. Under ultrasound guidance, 2.9 liters of cloudy yellow fluid was removed. Given the unknown etiology of the effusion, and the patient’s dyspnea, a thoracentesis was performed. A chest X-ray showed a large right-sided pleural effusion. A 95-year-old male with history of atrial fibrillation presented to the emergency department for shortness of breath for one week.
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