Fatal Presumed Re-expansion Pulmonary Edema Following Suction-Assisted Drainage of a Complete Spontaneous Pneumothorax in a Patient With Advanced Emphysema: A Case Report

Re-expansion pulmonary edema (RPE) is a rare but potentially life-threatening complication of pleural decompression. Although most reported cases are self-limiting, severe presentations may rapidly progress to respiratory failure and death. We report a fatal case of presumed unilateral RPE following drainage of a complete spontaneous pneumothorax in a patient with advanced emphysema. A 51-year-old man with chronic obstructive pulmonary disease presented to the emergency department with progressive dyspnea of approximately one week’s duration. On admission, he was ambulatory, hemodynamically stable, and maintained an oxygen saturation of 95% on room air. Computed tomography demonstrated a complete left-sided pneumothorax with near-total collapse of the left lung and advanced bilateral emphysematous changes. A 28 Fr chest tube was inserted and connected immediately to active suction at -20 cm H₂O. Approximately 30 minutes after pleural decompression, the patient developed rapidly progressive hypoxemic respiratory failure. Follow-up chest radiography demonstrated extensive unilateral alveolar-interstitial opacification involving the re-expanded left lung. Despite chest tube revision, endotracheal intubation, mechanical ventilation, and advanced life support, the patient developed recurrent pulseless electrical activity cardiac arrest and subsequently died. The temporal relationship between pleural drainage and clinical deterioration, together with unilateral radiographic infiltrates and the presence of blood-tinged frothy airway secretions, strongly suggests fulminant RPE as the most likely diagnosis. This case highlights a rare but catastrophic complication of pneumothorax treatment and emphasizes the importance of close monitoring following pleural decompression, particularly in patients with prolonged lung collapse and advanced underlying lung disease.