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Ann Thorac Surg 1996;62:1613
© 1996 The Society of Thoracic Surgeons

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Invited Commentary

Invited Commentary

University of California, San Francisco, Box 807, San Francisco, CA 94143

See also page 1608.

Persistent, difficult to manage Pneumocystis carinii pneumonia (PCP)-related pneumothorax (PTX), is less frequently a severe problem than was the case a few years ago. More human immunodeficiency virus-positive (HIV+) patients or patients with acquired immunodeficiency syndrome (AIDS) have medical follow-up, and when the CD-4 count is less than 200, prophylactic medication with trimethoprim-sulfamethoxazole, if tolerated, or dapsone is given. The patients with AIDS who receive drug prophylaxis appear to have a less severe PCP, and PTX is proportionately less of a problem. The more severe cases of PCP and PTX appear to occur in patients who have not previously been under medical care, and PCP with PTX occurs as a primary manifestation of AIDS.

I do not use Heimlich valves in patients with AIDS either in or out of the hospital to treat persistent air leak, persistent effusion, or residual space problem. A Heimlich valve requires positive pleural pressure to open. It is usually possible to maintain continuous negative intrapleural pressure, which maximizes lung volume and promotes the objective of maintaining pleural surface apposition, setting the stage for the opportunity for pleurodesis. I prefer talc slurry as the sclerosing agent. Pleurodesis has been effective in reducing recurrent PTX and can be best accomplished when the sclerosing agent is thoroughly distributed over the entire pleural space. A Heimlich valve or underwater seal apparatus requires a phase of positive intrapleural pressure for air or fluid to be evacuated. Continuous negative intrapleural pressure throughout the respiratory cycle and use of talc slurry for pleurodesis, when the rate of air leak is small, ensures the best distribution of talc, and when the lung volume is adequate, pleural apposition is usually achieved. If the air leak continues, I would treat the tube tract as a controlled fistula and obliterate it as permitted in the usual ways.

I think that there are at least three undesirable features used in the management technique described in this article: (1) I am concerned about sending HIV+ patients, with different hygienic habits, into the community with open drainage. Secretions on dressings, clothing, or apparatus are contaminated and essentially draining into the community. (2) A closed system is a more effective treatment. Both a Heimlich valve and underwater seal may be successful in patients with minimal air leaks. But suboptimal distribution of a sclerosing agent may only partially obliterate the pleural space, and may encourage recurrent PTX. The opportunity for the sclerosing agent to puddle above the diaphragm is increased when a phase of the respiratory cycle is positive. (3) In patients with inadequate lung volume and residual pleural space, open chest tube drainage, such as with a Heimlich valve, invites pyogenic organism colonization of the space. A Heimlich valve can plug or act as a partial obstruction to free drainage. There would be a risk of developing an HIV+ pyogenic empyema. I think the first chance is the best chance of pleural space obliteration, and optimal circumstances to expand the lung and obliterate the pleural space should be used.

It should be mentioned that HIV+ patients with PTX are often in the same age group in which spontaneous PTX without HIV+ status can occur. Apical blebs should be identified in these HIV+ patients, and if there is minimal or undocumented PCP with PTX, these patients should be treated like other young people with spontaneous PTX.

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Gregory D. Trachiotis, Luca A. Vricella, David Alyono, Benjamin L. Aaron, and William R. Hix
Ann. Thorac. Surg. 1996 62: 1608-1613. [Abstract] [Full Text]

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This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Arthur N. Thomas Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Thomas, A. N. Search for Related Content PubMed Articles by Thomas, A. N. Related Collections Related Article