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re - expansion pulmonary oedema ( repe ) is a rare complication after re - inflation of a chronically collapsed lung , following pneumothorax or effusion .
it has an incidence of about 1% , but is associated with high mortality ( 20% ) .
re - expansion pulmonary oedema is usually ipsilateral and the risk is highest after rapid re - expansion of the lung , which has been collapsed for 3 or more days .
other contributory factors are large pneumothorax , young patients ( between 20 and 39 years ) and the method of re - expansion .
although most patients recover within 7 days , severe repe due to sequestration of large quantities of fluid in the lung may lead to hypoxaemia , hypotension , shock , and death .
though conventional ventilatory therapy may be useful in mild cases of repe , no definitive treatment is known for severe forms .
repe has been described following re - expansion of lung after pneumothorax , pleural effusion , resection of mediastinal tumours , thorascopies and has also been reported after diaphragmatic hernia repair .
the aim of this case report is to emphasise the possibility of repe arising after diaphragmatic hernia reduction , and the significance of differential lung ventilation ( dlv ) as a successful ventilatory management option in severe cases of repe .
a 22-year - old male presented to the hospital with a history of blunt trauma to the abdomen 3 months ago , along with respiratory distress of 3 days duration .
radiological investigations revealed left sided diaphragmatic hernia with abdominal contents in the left hemi - thorax and mediastinal shift to the right .
pre - operatively , patient was anxious , unable to lie down supine with minimal chest expansion on the left side .
he was having respiratory rate ( rr ) of 48/min , pulse rate 126/min , and blood pressure ( bp ) of 90/54 mmhg .
modified rapid sequence induction was performed in a propped up position using 60 mg intravenous ( iv ) ketamine , 2 mg iv midazolam and 75 mg iv succinylcholine and the patient was intubated with 8.0 mm internal diameter cuffed endotracheal tube ( ett ) .
right radial artery was cannulated for the purpose of invasive arterial bp monitoring and left subclavian central venous catheter was secured and ionotropic support was initiated with iv dopamine 10 g / kg / min .
surgery revealed a grossly distended stomach , transverse colon and spleen in the left hemi - thorax .
once the abdominal contents from the left hemi - thorax were reduced , re - expansion of the left lung was achieved .
the saturation improved from 94% to 98% transiently , after which it suddenly decreased to 93% along with the drop in bp .
the ionotropic support was increased and copious amount of pink frothy fluid in the ett was noticed .
there was incessant production of fluid , which was flooding the ett and the anaesthesia circuit .
since it developed dramatically after left lung re - expansion , the possibility of repe was considered . in order to avoid contamination of the right lung , we secured the airway with 39 french left sided double lumen tube ( dlt ) , confirmed the correct position of the dlt with fibreoptic bronchoscope and ventilated both lungs intraoperatively .
there was continuous drainage of the pink fluid from the bronchial lumen of the dlt , which was intermittently suctioned .
the arterial blood gas ( abg ) investigation revealed ph 7.18 , partial pressure of carbon dioxide ( pco2 ) 59 mmhg , partial pressure of oxygen ( po2 ) 117 mmhg ; bicarbonate 22 meq / l on fractional of inspired oxygen concentration ( fio2 ) of 0.8 .
rest of the intraoperative period was uneventful and the patient was shifted to intensive care unit ( icu ) for further management , with dlt in situ .
patient was sedated with continuous infusion of iv morphine and midazolam . in icu , conventional ventilation with dlt was continued for first 6 h with fio2 of 0.8 using synchronized intermittent mandatory ventilation ( simv ) with tidal volume ( tv ) of 500 ml , rr of 14/min , and positive end expiratory pressure ( peep ) of 8 mmhg .
abg revealed ph 7.34 with pco2 35 mmhg , po2 58 mmhg and bicarbonate 19.3 meq / l .
pulse oximetry showed 89 - 90% saturation and chest radiograph revealed left repe [ figure 1 ] .
chest radiograph showing left sided re - expansion pulmonary oedema as there was deterioration in oxygenation on conventional ventilation , dlv was initiated using two ventilators of the same company ( ge datex ohmeda engstrom carestation ) [ figure 2 ] .
differential lung ventilation being administered using two ventilators lung salvage ventilatory strategy was adopted for ventilating the left affected lung , with fio2 of 0.8 using simv with pressure control ( pc ) 17 cm h2o , rr 14/min , peep of 14 mmhg .
the ventilatory setting for the right lung was fio2 of 0.4 using simv , ps of 14 cmh2o , rr 14/min , and peep of 5 mmhg .
patient tolerated the dlv with morphine and midazolam infusion , without the requirement for paralysis .
the saturation and haemodynamics gradually improved , and abg after 24 h on same ventilatory settings revealed ph 7.42 with pco2 36 mmhg , po2 127 mmhg and bicarbonate 24.2 meq / l .
chest radiograph showing the resolution of left sided re - expansion pulmonary oedema after differential lung ventilation compliance of the left lung gradually improved , and dlv was continued for 72 h until both lungs were ventilated with identical ventilatory settings of fio2 0.4 using simv , ps of 14 cmh2o , rr 14/min , and peep of 5 mmhg .
there was further improvement in the clinical condition of the patient , and trachea was extubated .
after 2 days of intermittent non - invasive ventilation , patient was put on 40% venturi and was shifted to step down icu .
re - expansion pulmonary oedema is a rare but fatal complication , which occurs after rapid re - expansion of a chronically collapsed lung .
multiple possible aetiologies play a role in development of repe , but the exact cause is not yet understood .
contributory factors include increased pulmonary vasculature permeability due to anoxic damage to capillary endothelium and neovascularisation , reperfusion related free radical injury and mechanical damage to blood vessels due to overstretching during re - expansion . the patient may present with dramatic onset of respiratory failure and circulatory collapse , along with copious pink frothy secretions .
utmost vigilance is required for early recognition and optimal management of repe , as symptoms worsen rapidly for first 24 - 48 h. if mortality is prevented in the first 48 h , recovery is usually complete . in repe
, the affected lung has poor compliance , but is overperfused , whereas the unaffected lung has better compliance , yet hypoperfused .
though continuous positive airway pressure , asynchronous dlv , high frequency jet ventilation and extracorporeal membrane oxygenation have proven beneficial in the treatment of repe , a definitive treatment modality has not yet been described . as conventional mode of ventilation
a salvage strategy of ventilation was used for the affected lung with a high peep and low tv goals , whereas a lung protective strategy was adopted for the right lung with minimisation of fio2 , peep , peak inspiratory pressure and tv .
this helped in improvements in compliance and ventilation - perfusion in the affected lung , and hence we were able to gradually wean off the ventilatory support and extubate successfully .
dlt prevents the unaffected lung from being flooded with the oedema fluid from the contralateral lung , and facilitates dlv , which not only protects the affected lung with poor compliance , but also prevents the volutrauma and barotrauma to normal compliant lung .
prevention of development of repe post thoracocentesis include the use of low negative pressure ( < 20 cmh2o ) for suction during tube thoracostomy and restricting the drainage to about 1.5 l of pleural fluid .
though repe has a high mortality rate , if fatality is avoided at an early stage , patient recovery is usually complete .
dlv may be the initial ventilatory treatment strategy , and we should not wait for deterioration to occur by starting conventional lung ventilation as the pathophysiology of repe necessitates dlv .
re - expansion pulmonary oedema ( repe ) is a rare complication following re - inflation of a chronically collapsed lung , which is often fatal . we present a case of a 22-year - old male who presented to the hospital with severe respiratory distress and a history of blunt abdominal trauma 3 months back . 
 he was diagnosed to have left sided diaphragmatic hernia with a mediastinal shift to the right , and was posted for emergency repair of the same . after surgical decompression of the left hemi - thorax and reduction of the abdominal contents , 
 re - expansion of the left lung was achieved , following which patient developed repe . 
 a left sided double lumen tube was then inserted to prevent flooding and cross contamination of the right lung and ventilation of both lungs was maintained intraoperatively . 
 post - operatively , repe was successfully managed by differential lung ventilation with a lung salvage strategy to the left lung and a lung protective strategy to the right lung .