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Ann Thorac Surg 1997;64:290-291
© 1997 The Society of Thoracic Surgeons
Division of Thoracic Cardiovascular Surgery, University of Texas, Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd, Dallas, Tx 75235-8879
To the Editor:
I would like to comment on the recent article by Trachiotis and associates and the accompanying invited commentary by Thomas [1] regarding their retrospective review of treatment options and outcomes analysis in patients with pneumothorax (PTX) and acquired immunodeficiency syndrome (AIDS) at the George Washington University Medical Center. As was Dr Thomas, I am at variance with Trachiotis and associates' conclusions that management of AIDS-related PTX with the Heimlich valve apparatus is the most optimal option, and I do not share the pessimistic outlook they take toward sclerotherapy in treating AIDS-related PTX or in the role of video-assisted thoracoscopy and talc poudrage in the treatment of AIDS-related PTX.
Trachiotis and associates' study is a retrospective institutional review of a small number (n = 36) of AIDS patients with PTX; 11 of these patients had periprocedural (ie, nonspontaneous) PTX, and most experienced centers would agree that the treatment of these patients is relatively straightforward with predictably good results. Indeed, 9 of 11 did well with simple tube thoracostomy drainage and 2 required Heimlich valves. Twenty-five patients had subpleural necrosis from pneumocystis pneumonia severe enough to cause spontaneous pneumothorax; these patients are the subset that cause thoracic surgeons the most difficulty in obtaining a satisfactory outcome. Nine of these 25 patients died; 6 of the 16 survivors were "successfully" managed with the Heimlich valve apparatus, 2 were successfully treated with sclerotherapy (treated with talc slurry), and 1 with thoracotomy, leaving 7 patients successfully treated with tube thoracostomy. There is, however, no mention of the duration of Heimlich valve drainage in the outpatient management of these patients, nor of the ultimate outcome of their pneumothorax. The average treatment duration for the entire group was 11.5 days; this figure was favorably influenced by the 11 patients in the periprocedural PTX subgroup (average treatment duration, 8.1 days). Patients treated with a Heimlich valve were hospitalized an average of 17 days.
In contrast to these findings is the experience at Parkland Memorial Hospital (Dallas, TX), which has been previously reported [2, 3] and is updated here. To date our series includes a total of 70 cases of AIDS-related spontaneous (not periprocedural) PTX. From our early experience, patients who continue to have a significant air leak or residual pleural space after 24 hours of simple chest tube drainage are unlikely to have resolution with continued conservative therapy and should go on to more aggressive treatment [3]. Treatment outcomes relative to primary therapy with simple pleural drainage, axillary thoracotomy, secondary therapy with sclerosant therapy delivered via chest tubes, or salvage (or primary) therapy with talc poudrage delivered via video-assisted thoracoscopy (VATS) is outlined in Figure 1
. Due to our early favorable experience with talc poudrage, the past 24 consecutive patients have been treated with talc delivered by VATS as primary therapy if their PTX fails to completely resolve with simple pleural drainage. There were 30/32 successes with VATS talc (94%) with two deaths; 8 of the 32 VATS talc patients were salvage cases who had failed pleural drainage and pleural sclerosants delivered via chest tubes. The mean hospital stay after VATS talc was 3.9 ± 1.3 days for these 30 survivors, and no patient was discharged with a Heimlich valve apparatus. These two particular points compare quite favorably with the results reported by Trachiotis and associates.
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Division of Cardiothoracic Surgery, The George Washington University, 2150 Pennsylvania Ave, Nw, 6b, Washington, Dc 20037.
To the Editor:
My colleagues and I thank Dr Thomas for his commentary and Dr Wait for his response regarding our article. We would like to reemphasize to the readers that our article reports an institutional experience in patients with AIDS who are presenting with a PTX at the end-stage of their disease. Although we are treating more PTXs in end-stage AIDS patients, the actual total number of AIDS-related PTXs we are seeing is less. As we state in our article, this is likely due to earlier and more efficacious chemotherapeutic agents. A majority of patients we treat for AIDS-related PTX are extremely moribund, with minimal pulmonary reserve, and often bedridden. These patients would not tolerate any type of operative procedure, and have a complicated PTX unlikely to respond to sclerotherapy. These patients will represent more than 25% of all patients with an AIDS-related PTX, and are best managed with a Heimlich valve when the PTX is complicated by a bronchopleural fistula that has failed to respond to conventional treatment strategies. We concur with other authors that there are a number of patients with AIDS-related PTX that can be effectively managed by talc sclerotherapy (via a tube thoracostomy, video-assisted thoracotomy, or open thoracotomy). These patients are less ill and likely earlier in the disease process when their pulmonary parenchymal disease is less diffuse. As we reported and Wait comments, talc sclerotherapy will be effective as a treatment strategy in about 30% of patients with AIDS-related PTX. Our article demonstrates an experience predominantly in end-stage AIDS patients whose disease process is complicated by a PTX. We believe that a Heimlich valve is a useful, less invasive, and compassionate treatment alternative in this select group of patients. Our proposed algorithm for managing patients with AIDS-related PTX allows physicians and surgeons to select which particular treatment arm will be the most efficacious based on clinical judgment, institutional experience, and the pathologic stage of the the PTX.
This article has been cited by other articles:
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  M. H. Baumann Less Is More? Chest, July 1, 2001; 120(1): 1 - 3. [Full Text] [PDF]
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