Ann Thorac Surg 1997;64:985
© 1997 The Society of Thoracic Surgeons
Invited Commentary
Invited Commentary
Richard J. Thurer, MD
Division of Cardiothoracic Surgery R-114, University of Miami School of Medicine, Box 016960, Miami, FL 33101
See also page 982.
Doctor Flum and his colleagues have reported a large experience with tracheostomy in HIV infected individuals, virtually all of whom had clinical AIDS. The mean CD4 counts were very low, 21.8 ± 3.6 cells/µL. The retrospective study spans a 7-year period and reports on poor outcomes in AIDS patients in whom tracheostomy is done, with somewhat better outcomes in certain small, well-defined groups.
Although accurately portraying the experience to date with tracheostomy in AIDS patients, past experience is of very limited value in dealing with patients today and in determining the best therapy for individual patients. With the newer protease inhibitors, reverse transcriptive inhibitors, and better sequencing of combination therapies it is beginning to appear that the natural history of HIV infection can be altered in a fundamental way and that life can be significantly prolonged. No longer is therapy aimed simply at treating or preventing opportunistic infections or neoplasms, but rather it now is aimed at improving immune status and reducing viral load. If CD4 counts are restored to normal and viral load becomes undetectable, as is now often possible, treatment of HIV-infected individuals should differ little from that offered to HIV-indeterminate individuals. With our ability to alter the course of HIV infection and reconstitute the immune system, the lessons learned in the past regarding expected outcomes of surgical therapy are no longer valid.
When faced with treatment decisions in HIV-infected individuals, it is no longer appropriate to look to the CD4 count and predict life expectancy and use this information to judge whether a surgical intervention will be worthwhile. One must now look at treatment options in concert with any expected favorable impact on the immune system of retroviral therapy that is being given or is planned.
Each patient, as usual, must be evaluated individually. Currently, in the case of HIV-infected patients, lessons of the past are of limited value and adherence to principles learned in the past will rob patients of treatments that may be of great potential benefit. It is most important that surgeons be aware of current advances in HIV treatment and stand ready to contribute to the care of these patients.
Related Article
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The Role of Tracheostomy in Acquired Immunodeficiency Syndrome
- David R. Flum, Omar S. Bholat, and Marc K. Wallack
Ann. Thorac. Surg. 1997 64: 982-985.
[Abstract]
[Full Text]
