Study objectives: To review therapeutic strategies in the management of pneumothorax in patients with AIDS.
Design: Retrospective, 7-year, single institution experience.
Patients: Forty-seven patients with AIDS were treated for 59 pneumothoraxes. Mean age was 37.4 years, and 70% of patients had prior or current infection with Pneumocystis carinii. All patients had CD4+ counts of [is less than] 100, and 28 of 47 patients (59.6%) had CD4+ counts of [is less than] 50. Of 59 pneumothoraxes, 14 pneumothoraxes (23.7%) were iatrogenic and 16 pneumothoraxes (27.1%) were bilateral. Patients were treated with conventional strategy (tube thoracostomy [TT] with or without pleurodesis, thoracotomy with blebectomy) or converted to a Heimlich valve (HV) in case of failure of conventional management.
Results: Thirty-six of 47 patients (76.6%) were discharged, and only 26 of 36 patients (72.2%) had complete pneumothorax resolution at discharge after conventional treatment. All patients discharged with an HV (10 of 36 patients; 27.8%) had pneumothorax resolution followed by valve removal as outpatients. Mean hospital stay after chest decompression was 12 days for conventional-therapy group survivors and 3 days for patients treated with an HV. Thirteen patients died (27.7%) with follow-up to 60 days. In-hospital mortality was 23.4% (11 of 47 patients), which represented a 29.7% mortality for patients treated with conventional therapy. Patients treated with an HV had no in-hospital mortality and 100% pneumothorax resolution, with two deaths occurring within 60 days of discharge but after removal of the HV.
Conclusions: Patients with advanced AIDS and pneumothorax have high associated morbidity and mortality. If no resolution is observed after simple TT, prompt conversion to an HV allows safe and early hospital discharge. (CHEST 2001; 120:15-18)
Key words: AIDS; Heimlich valve; pneumothorax
Abbreviations: BPF = bronchopleural fistula; HV = Heimlich valve; PCP = Pneumocystis carinii pneumonia; TS = tube thoracostomy with sclerosing therapy; TT = tube thoracostomy
The reported incidence of pneumothorax in patients with AIDS ranges between 2.7% and 4.9%, up to 450 times higher than that of the general, nonimmunocompromised population.[1,2] Up to 34% of pneumothoraxes are bilateral, and they frequently occur ([is greater than] 70%) in patients with prior or current pulmonary infection with Pneumocystis carinii.[3,4] Overall hospital mortality for patients with advanced AIDS and pneumothorax is reported in the literature to range between 43% and 92%. We retrospectively reviewed the hospital course of all patients with advanced AIDS and spontaneous or iatrogenic pneumothorax requiring intervention over a 7-year period, to define a safe and effective therapeutic algorithm.
MATERIALS AND METHODS
All records of patients with AIDS and pneumothorax who presented to the George Washington University Medical Center between January 1992 and January 1999 were reviewed. Forty-seven patients with AIDS (mean age, 37.4 years; age range, 23 to 56 years) were treated for 59 pneumothoraxes. Forty-six patients (97.9%) were men. Seventy percent of patients had prior or currently active history of P carinii pneumonia (PCP), and all had AIDS of [is greater than] 1-year duration (range, 1 to 12 years). All patients had a CD4+ count of [is less than]...