POINT: Stawicki and his colleagues have nicely elaborated the points and concepts on reexpansion pulmonary edema. This condition, though well documented as well as encountered by physicians at all the levels of health care, is still less appreciated and poorly managed. Some points in this article need further discussion so that the entity is better understood. The authors have advocated the use of careful diuresis as one of the treatment modalities for reexpansion pulmonary edema. Whereas, according to available literature, the condition is mainly caused by alteration in capillary permeability due to hypoxic and mechanical damage to alveolar-capillary membrane. This leads to extravasation of protein rich fluid out of the blood vessels into the lung tissue. Increased hydrostatic pressure plays less important role in the development. Moreover, due to movement of fluid out of blood vessels, there is a state of hypovolemia which presents clinically in the form of tachycardia, hypotension and oliguria. So the use of diuretics in such circumstances is not likely to be beneficial in any way. Use of diuretics in the treatment of this condition is not generally recommended and they may even deteriorate the condition. There has also been case report of fatal results with its use. Also, use of term ‘careful diuresis’ does not give clear picture to the readers.

COUNTERPOINT: We agree that empiric diuresis in the setting of RxPE may indeed be detrimental. In any clinical setting, administration of diuretics should be considered with great caution, and some combination of resuscitation endpoints (clinical; hemodynamic; laboratory – lactic acidosis, base deficit, etc.; invasive line monitoring – pressure, stroke volume measurements; echocardiographic – left ventricular status) should be followed while the patient is undergoing diuresis. Further, if a patient with acute RxPE demonstrates clinical signs of fluid sequestration and intravascular volume depletion, diuretics would clearly be contraindicated.
Just as much as we agree that diuresis should not be used in the setting of RxPE when not clinically indicated, we generally disagree with the statement that all diuresis is detrimental in the setting of RxPE. In fact, there are numerous reports of successful adjunctive use of diuresis in the setting of RxPE, with good clinical results and no reported adverse events. Because judicious and appropriate administration of diuretics in the setting of RxPE appears to be associated with satisfactory outcomes, we continue to support the use of diuresis in this setting provided that the patient does not demonstrate any signs of hypovolemia or ongoing need for volume resuscitation. Again, it is important to continue to monitor clinical, laboratory, and other endpoints of resuscitation while the patient is undergoing diuresis.

Citation: Aggarwal D, Stawicki SP, Sarani B, Braslow BM. POINT-COUNTERPOINT: The role of diuresis in management of reexpansion pulmonary edema. OPUS 12 Scientist 2008;2(3):10.

Original article: Stawicki SP, Sarani B, Braslow BM. OPUS 12 Scientist 2008;2(2):29-31.

Keywords: Diuresis, Reexpansion pulmonary edema, Risks and benefits.

Copyright 2007-2008 OPUS 12 Foundation, Inc.