C45-13 A Breath Too Far : Re-expansion Pulmonary Hemorrhage - A Rare and Underrecognized Complication of Thoracentesis

Abstract Introduction Thoracentesis is a widely performed procedure in both inpatient and outpatient settings and is generally regarded as safe. Nonetheless, it is not devoid of risk. While most complications are infrequent, pneumothorax, bleeding, and re-expansion pulmonary edema (REPE) remain the most notable, with potential to substantially increase patient morbidity, mortality, and healthcare costs. Rare adverse events such as tumor seeding along the catheter tract, catheter fracture, visceral injury, and vasovagal syncope have also been documented. Although REPE is well recognized as a post-procedural manifestation of rapid lung re-expansion, emerging evidence suggests that other, less characterized sequelae may arise from similar pathophysiologic mechanisms. Herein, we describe a rare case of re-expansion pulmonary hemorrhage (REPH) following therapeutic thoracentesis, a novel and severe complication distinct from the more commonly reported re-expansion pulmonary edema. Case A 91-year-old woman with HFpEF, severe pulmonary hypertension, chronic bilateral pleural effusions (documented on imaging over several years), and a permanent pacemaker underwent left-sided therapeutic thoracentesis for worsening dyspnea. Approximately 900 mL of serous fluid was removed before the procedure was stopped due to sudden onset of cough, dyspnea, and subcutaneous emphysema, followed within minutes by frank hemoptysis. A post-procedure chest radiograph revealed a small left apical pneumothorax and new lower-lobe opacities concerning for re-expansion pulmonary injury. The patient was admitted to the ICU with acute hypoxic respiratory failure secondary to re-expansion pulmonary hemorrhage (REPH) and pneumothorax ex vacuo. She was treated conservatively with supplemental oxygen, tranexamic acid nebulization, and aminocaproic acid infusion. Bronchial artery embolization was deferred due to a documented contrast allergy. Serial imaging showed bilateral opacities and small effusions without pneumothorax expansion. Hemoptysis gradually decreased over several days, and hemoglobin remained stable. She transitioned from high-flow oxygen to nasal cannula by hospital day 2 and was later transferred to the medical floor. Despite intermittent blood-tinged sputum and exertional dyspnea, she remained hemodynamically stable and was discharged on day 6 with home oxygen, diuretics, and pulmonology follow-up. Discussion Re-expansion pulmonary hemorrhage (REPH) represents an exceedingly rare but clinically significant complication of thoracentesis. This case highlights its potential occurrence even with meticulous technique, particularly in patients with chronic effusions, advanced age, and severe pulmonary hypertension - factors that may predispose to vascular fragility and tractional injury during rapid re-expansion. Prompt recognition and conservative management with high-flow oxygen, tranexamic acid, and aminocaproic acid stabilized our patient, emphasizing awareness and early intervention for this underrecognized entity. This abstract is funded by: None