Chest
Volume 106, Issue 3, September 1994, Pages 693-696
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Clinical Investigations: HIV/Infections
Treatment of AIDS-Related Spontaneous Pneumothorax: A Decade of Experience

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Spontaneous pneumothorax (SP) secondary to the acquired immunodeficiency syndrome (AIDS) emerged in the decade of the 1980s. It has become an increasingly difficult condition to treat successfully both for the pulmonary internist and the surgeon. AIDS-related SP is complicated by a virulent form of necrotizing subpleural necrosis that results in diffuse air leaks that are refractory to the standard, traditional forms of therapy which enjoy good success for SP related to classic subpleural bleb disease. AIDS-related SP carries a high mortality rate despite treatment, independent of the development of primary respiratory failure. In reviewing our experience of 46 patients from a single institution treated over the past 10 years, we found that due to the high primary and secondary treatment failure rates, an aggressive stepped-care management of large-bore intercostal tube drainage, chemical pleurodesis, and early video-assisted talc poudrage is recommended in an attempt to shorten the duration of hospital stay, hospital costs, and mortality.

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Materials and Methods

A retrospective review of the medical and radiographic records of all patients admitted to Parkland Memorial Hospital, Dallas, between 1983 and 1994 with the diagnosis of AIDS and spontaneous pneumothorax was conducted. A total of 50 patients were identified over this 11-year period. Patients who had a history of trauma (traumatic injuries or iatrogenic pneumothorax due to thoracentesis or bronchoscopy) were excluded from this review; likewise, patients with barotrauma from ventilator support

Results

A total of 46 patients, all male, were identified. The mean age was 36 years (range, 20 to 57 years). The absolute lymphocyte count was obtained in 21 patients, with a mean of 474/mm3 (range, 25 to 2,460/mm3); the CD4 (helper T cell) count was obtained in 17 patients, with a mean of 52/mm3 (range, 2 to 123/mm3; normal CD4 count=494 to 1,362/mm3). Eighteen of 46 patients had a positive smoking history, yet none carried a diagnosis of chronic obstructive bronchopulmonary disease (emphysema,

Discussion

Due to the retrospective nature of this review, statistically conclusive data are difficult to extract and strong recommendations cannot be made with authority. Nevertheless, meaningful clinical insights from this report update our previous study from November 1992 and represent the largest single-institution experience with AIDS-related SP reported in the English literature (to our knowledge). Our results show that the success rate for standard therapy is poor (26 percent) for

Addendum

Since the submission of this article, four consecutive additional patients were subsequently admitted to the hospital with large, symptomatic AIDS-related SP. These four patients were successfully treated with VATS-talc poudrage as initial therapy (following emergency department placement of large-bore pleural chest tubes). After adding these patients to the present cohort of study patients, Table 3 illustrates our entire experience.

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