343) A 52 year old woman with history of triple-negative, metastatic breast cancer presents to the Emergency Room with increasing shortness of breath. She received multiple courses of chemotherapy in the past and her cancer has progressed despite initial response to chemotherapy. On examination, she is afebrile, respiratory rate is 24/min, Blood pressure 120/70 mm Hg and Heart Rate 106/min. Breath sounds are decreased on right side of the chest and there is dullness to auscultation. A chest X-ray shows collapsed right lung and massive right sided pleural effusion. A thoracentesis is performed followed by thoracostomy tube is placement and about 2000 ml fluid is drained. About one houar after the procedure, the patient develops severe shortness of breath and cough with pink and foamy sputum. A pulse oximetry shows Sa02 at 86%. Which of the following most likely explains her newly developed symptoms?
A) Alveolar Hemorrhage
B) Lymphangiocarcinomatosis
C) Chylothorax due to Thoracic Duct Injury
D) Pulmonary edema
E) Acute Respiratory Distress Syndrome
D) Pulmonary edema – due to sudden re-expansion of the lung
D
C sounds reasonable answer
D
Pulmonary oedema…coz cud be transfusion of fluid in to lung spaces after thoracocentesis.
Answer D. The patient has re-expansion Pulmonary Edema which is a rare complication that can occur after removal of large amounts of pleural fluid > 1.5 liters. Usually, it is recommended not to drain more than 1000ml to 1500 ml pleural fluid in order to prevent this complication. Removal of large amounts of pleural fluid > 1.5 liters in case of chronic pleural effusion can cause rapid expansion of collapsed lung resulting in pulmonary edema. This complication occurs within 1 to 2 hrs of the drainage of pleural fluid and presents with respiratory distress, productive cough and cyanosis. It can be fatal in some cases. Diagnosis is based on clinical features and chest x-ray findings of pulmonary edema occurring after pleural fluid drainage. Pneumothorax is the most common complication after thoracentesis and can present with shortness of breath after procedure. However, it is not listed in the choices
Option A is incorrect. Removal of large amount of pleural fluids should not cause alveolar hemorrhage and it is not a complication of the procedure. Alveolar hemorrhage is often seen with pulmonary-renal syndromes (Wegener granulomatosis, microscopic polyangiitis, Goodpasture syndrome), connective tissue disorders, antiphospholipid antibody syndrome, infectious or toxic exposures, and neoplastic conditions
Option B is incorrect. This entity can occur with breast cancer but would be of progressive onset rather than acute onset after procedure.
Option C. Chylothorax occurs due to injury of thoracic duct during surgical procedures such as thoracotomy or with malignancies such as lymphoma. It is not a reported complication after tube thoracostomy or thoracentesis
Option E is incorrect. ARDS is a fatal respiratory failure that can occur with any severe insult sucha s sepsis, TTP, inhalational injury, toxin exposure or severe trauma. There is no underlying cause for the patient to develop acute respiratory distress syndrome at this time.
The following are the complications of thoracentesis
Major Complications
Pneumothorax 11%
Re-expansion Pulmonary edema 1%
Splenic laceration 0.8%
Hemothorax 0.8%
Minor Complications
Pain 22%
Cough 11%
Dry tap 13%
Subcutaneous hamatoma 2%
Subcutaneous seroma 0.8%
D-re expansion pulmonary edema