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[临床影像]:复张性肺水肿
2018年08月26日 临床影像, 临床话题 暂无评论

Re-expansion pulmonary oedema

Alice Petiot, Sammy Tawk, Benoît Ghaye

Lancet 2018; 392: 507

A 46-year-old man presented to the emergency department with moderate dyspnoea and a 4-day history of cough. His medical history also included alcoholic cirrhosis with portal hypertension and ascites. On admission, a chest x-ray showed complete white-out of the right hemithorax with contralateral mediastinal deviation compatible with a large pleural effusion—presumed to be hepatic hydrothorax (figure). A chest drain was inserted into the right pleural cavity under ultrasound guidance and 2 L of clear fluid were rapidly drained over approximately 2 min.

一名46岁男性患者因中等程度呼吸困难及咳嗽4天到急诊室就诊。既往史包括酒精性肝硬化,门脉高压及腹水。就诊时,胸片显示右肺完全变白,纵隔向对侧移位,符合大量胸腔积液的表现—可能为肝性胸水(图)。在超声引导下行右侧胸腔置管引流,在大约2分钟内迅速引流2 L清亮液体。

A further chest x-ray taken the day after admission showed a large right hydropneumothorax and a partly collapsed right lung with consolidation of the upper lobe (figure). A second larger chest drain was inserted to ensure adequate drainage. A CT chest scan was then done to rule out any underlying lung disease; this showed near-complete resolution of the right hydropneumothorax and patchy consolidation, ground glass opacities, and septal thickening throughout the right lung—mainly in the upper and middle lobes (figure). Based on the clinical and radiological findings, a diagnosis of re-expansion pulmonary oedema was made. The patient recovered completely after 2 days of supportive treatment and a further chest x-ray showed clear lung fields bilaterally (figure). The total volume drained was calculated to be 5·5 L. Pleural fluid analyses showed a transudate with negative culture and cytology.

入院后次日胸片显示,右侧大量液气胸,右肺部分塌陷,上叶实变(图)。遂置入另一根粗胸管以保证引流充分。进行胸部CT扫描以排除肺部基础疾病;CT显示右侧液气胸几乎完全缓解,同时整个右肺呈斑片样实变,磨玻璃改变,及间隔增厚—主要见于上叶和中叶(图)。根据临床及影像学表现,诊断为复张性肺水肿。经过2天支持治疗后,患者完全恢复,复查胸片显示双肺野清晰(图)。胸水总引流量为5.5 L。胸水常规检查提示为漏出液,培养及细胞学均为阴性。

Re-expansion pulmonary oedema is an uncommon complication occurring in less than 1% of cases where a lung has been rapidly re-expanded after being passively collapsed by a large pleural effusion or a pneumothorax. The precise pathophysiology underlying re-expansion pulmonary oedema has not been clearly established, but alterations of vascular permeability and hydrostatic mechanisms are thought to be involved. Risk factors for the complication include pulmonary collapse for longer than 1 week, younger age, and the rapid removal of a large amount of pleural fluid over a short time period which is why the recommended rate of removal of 1–2 L every 2 h should not be exceeded. Treatment is generally conservative and supportive.

复张性肺水肿是一种罕见并发症,大量胸水或气胸压迫造成肺的塌陷时,肺迅速复张后不足1%的患者可发现复张性肺水肿。复张性肺水肿的确切病理生理机制并不完全清楚,但血管通透性及静水压改变参与其中。这一并发症的危险因素包括肺塌陷超过1周,年龄较轻,在短时间内迅速引流大量胸水。因此,推荐胸水引流速度不超过每2小时1-2 L。主要采取保守及支持治疗措施。

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