Can recent Video-Assisted Thoracoscopic (VATS) decortication cause pulmonary edema?

Video-Assisted Thoracoscopic (VATS) Decortication and Pulmonary Edema

VATS decortication can cause pulmonary edema in the immediate post-operative period due to rapid lung re-expansion and increased pulmonary blood flow to previously collapsed lung tissue. 1

Pathophysiology of Post-VATS Decortication Pulmonary Edema

The development of pulmonary edema following VATS decortication is related to several physiological mechanisms:

1. Re-expansion pulmonary edema (RPE) - When a collapsed or compressed lung rapidly re-expands, there can be sudden changes in transpulmonary pressure and increased capillary permeability

2. Inflammatory response - Surgical manipulation during decortication triggers local inflammation that increases vascular permeability

3. Altered pulmonary blood flow - Blood flow suddenly increases to previously collapsed lung segments, potentially overwhelming the lymphatic drainage capacity

4. Surgical trauma - Direct trauma to lung parenchyma during removal of fibrous peel can damage capillaries and alveoli

Risk Factors for Post-Decortication Pulmonary Edema

Several factors increase the risk of developing pulmonary edema after VATS decortication:

• Duration of lung collapse prior to decortication (longer duration = higher risk)
• Extent of decortication required
• Underlying pulmonary disease
• Advanced age
• Poor nutritional status 1
• Rapid re-expansion of collapsed lung
• Excessive perioperative fluid administration

Clinical Presentation

Pulmonary edema following VATS decortication typically presents within 24-72 hours post-procedure with:

• Progressive dyspnea
• Tachypnea
• Hypoxemia
• Pink frothy sputum (in severe cases)
• Bilateral crackles on auscultation
• Radiographic evidence of diffuse or unilateral pulmonary infiltrates

Management Approach

Prevention

1. Controlled re-expansion - Gradual re-expansion of the lung during and after surgery

2. Careful fluid management - Avoid excessive fluid administration 1

3. Lung-protective ventilation strategies during surgery

4. Consider prophylactic measures in high-risk patients:

   • Diuretics
   • Careful fluid restriction
   • Gradual chest tube suction

Treatment

1. Respiratory support:

   • Supplemental oxygen
   • Non-invasive ventilation if needed
   • Intubation and mechanical ventilation for severe cases

2. Diuretic therapy:

   • Intravenous furosemide to reduce fluid overload

3. Hemodynamic support:

   • Vasopressors if needed for hypotension
   • Careful fluid management

4. Anti-inflammatory measures:

   • Consider corticosteroids in selected cases

Evidence from Clinical Guidelines

The British Thoracic Society (BTS) guidelines recommend VATS access over thoracotomy for the surgical management of pleural infection due to:

• Similar postoperative mortality rates
• Less postoperative pain
• Shorter hospital stays
• Fewer postoperative complications 1

However, the guidelines also note that decortication surgery may be associated with a longer postoperative stay and higher mortality than less extensive surgical approaches, though it results in less breathlessness long-term 1.

Special Considerations

1. Extent of surgery should be tailored according to patient factors and empyema stage 1

2. Nutritional support is crucial as poor nutrition is associated with worse outcomes in patients with empyema 1

3. Chest tube management - Early removal of chest tubes when appropriate can reduce hospital stay and pain 1

4. Patient selection - Careful preoperative assessment is essential, especially in elderly patients who may have higher risk of complications 2

Conclusion

While VATS decortication is an effective procedure for managing pleural disease with advantages over open thoracotomy, clinicians should be vigilant for the development of pulmonary edema in the post-operative period. Early recognition and prompt management of this complication are essential to prevent further morbidity and mortality.