(Chest. 2001;120:15-18.)
© 2001
American College of Chest Physicians
Heimlich Valve in the Management of Pneumothorax in Patients With Advanced AIDS*
Luca A. Vricella, MD and
Gregory D. Trachiotis, MD, FCCP
*
From the Division of Cardiothoracic Surgery, The George Washington University Medical Center, Washington, DC.
Correspondence to: Gregory D. Trachiotis, MD, Division of Cardiothoracic Surgery, The George Washington University/Veterans Affairs Medical Center, 50 Irving St, NW, Washington, DC 20422; e-mail: gregory.trachiotis{at}med.va.gov
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Abstract
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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 < 100, and 28 of 47
patients (59.6%) had CD4+ counts of < 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.
Key Words: AIDS • Heimlich valve • pneumothorax
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Introduction
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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 (> 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%.5
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.
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Materials and Methods
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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 > 1-year duration
(range, 1 to 12 years). All patients had a CD4+ count of < 100, with
28 of 47 patients (59.6%) presenting with a CD4+ count of < 50.
Fourteen pneumothoraxes (23.7%) were iatrogenic, and 45 pneumothoraxes
(76.3%) were spontaneous. Sixteen of 47 patients (34%) had bilateral
pneumothoraxes. Five patients (10.6%) were receiving mechanical
ventilation at the time when the pneumothorax occurred.
Three therapeutic modalities were utilized: (1) tube thoracostomy (TT),
(2) TT with sclerosing therapy (TS), and (3) thoracotomy with
blebectomy and pleurodesis. In case of a persistent bronchopleural
fistula (BPF), Pleurevac drainage (Deknatel; Fall River, MA) was
converted to a Heimlich valve (HV).
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Results
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Thirty-six of 47 patients (76.6%) were successfully discharged.
In only 55.3% of patients (26 of 47 patients) was conventional
treatment successful in achieving complete pneumothorax resolution. The
remaining patients were either converted to an HV and discharged
(n = 10) or died while hospitalized (n = 11) with the TT in place
for persistent BPF. Considering that all patients (including
in-hospital deaths) were initially treated with a TT, the success rate
for the different therapeutic modalities was 23 of 47 patients (48.9%)
for TT alone, 2 of 9 patients (22.2%) for TS, and 1 of 2 patients
(50%) for thoracotomy with blebectomy and pleurodesis. All 10 patients
converted to an HV for failure of BPF resolution were discharged, had
complete pneumothorax resolution, and underwent successful HV removal
in the outpatient setting within a mean of 17 days from discharge
(range, 7 to 30 days). There were no deaths specifically associated
with the use of the HV. Mean hospital stay after chest decompression
was 12 days for the conventional group and 3 days for patients with HV
conversion.
Thirteen of 47 patients (27.7%) died, with 7 of 13 patients (53.8%)
having bilateral pneumothoraxes. Six of 13 patients (46.2%) were
receiving mechanical ventilation at the time of death. Eleven patients
died in the hospital, and this represents a mortality of 29.7% (11 of
37 patients) for patients treated with conventional therapy. Although a
pneumothorax and/or persistent BPF were compounding factors, the causes
of death were due to advanced AIDS, pulmonary failure and infection,
and multisystem organ failure. Two patients with an HV died in an
outpatient setting within 60 days of discharge, but after HV removal.
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Discussion
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Patients with advanced AIDS are at high risk of pneumothorax,
resulting from either diagnostic procedures or the sequelae of chronic
cavitating parenchymal necrosis. In a review of 1,360 patients with PCP
and AIDS, Pastores and colleagues4
reported a 4.9%
incidence of pneumothorax; in this large series, 26% of pneumothoraxes
were precipitated by iatrogenic procedures, while 74% pneumothoraxes
were either spontaneous or occurred during positive-pressure
ventilation. The risk of spontaneous pneumothorax in AIDS patients with
prior or active PCP appears to be significantly greater for patients
who are treated with aerosolized pentamidine, use tobacco, or disclose
radiologic evidence of pneumatoceles. Under these circumstances as
well, the concurrent administration of a corticosteroid may have a
compounding role in the failure of pneumothorax to resolve or for a
bronchoalveolar fistula to seal.3
Ultimately, the
combination of clinical, pharmaceutical, and histologic features of the
lung pathology may influence the best therapeutic strategy for the
AIDS-related pneumothorax.
This review focused on those patients with advanced AIDS and
pneumothorax. With improved chemoprophylaxis, these patients with more
advanced disease may now represent as high as 25% of all patients with
pneumothorax and AIDS.5
6
7
Success in treating a moderate
or large pneumothorax in patients with advanced AIDS is as low as 22%.
Pneumothorax recurrence rates are also much higher, in the range of 36
to 65%. Also, for those patients with advanced AIDS in which
pneumothorax occurs as the result of positive-pressure ventilation
barotrauma, mortality is > 90%. Ultimately, in our
experience,5
6
once patients with AIDS and current or
prior history of PCP present with a spontaneous pneumothorax, survival
rarely extends beyond 3 months. Compassionate therapy aiming at safe
and prompt discharge of these patients in the terminal phase of their
disease becomes of outmost importance.
The results of conventional therapy for the treatment of
pneumothorax in patients with AIDS vary as a function of disease
progression, etiology, and magnitude of the BPF. There was a difference
in success of conventional therapy for an iatrogenically caused
pneumothorax vs a spontaneous or barotraumatic pneumothorax. In this
current review, resolution of pneumothorax after conventional treatment
was 78.6% for the 14 patients with iatrogenic pneumothorax and only
46.6% for the 45 patients with spontaneous pneumothoraxes. The
difference in results based on etiology is likely due in part to the
underlying lung pathology and in part to the clinical status of the
patient. In AIDS patients with an iatrogenic pneumothorax, there is
minimal loss of the pleuroparietal apposition, and the pneumothorax is
more likely to respond to simple TT. In AIDS patients with a
spontaneous or barotraumatic pneumothorax, a persistent BPF often
results from the "blow out" of a large subpleural cavitating
lesion, and is unlikely to heal with short-duration conventional
treatment.5
Additionally, the patients with spontaneous or
barotraumatic pneumothoraxes also tend to have more advanced
parenchymal disease, recurrent pneumothoraxes, and preterminal disease.
Sclerotherapy as a therapy for AIDS-related pneumothorax has been
relatively unsuccessful in our experience, with only 2 of 9 patients
(22.2%) achieving pneumothorax resolution after pleurodesis. In both
cases, talc slurry (5 to 10 g of sterile talc) was utilized. Talc
pleurodesis may be useful when a pneumothorax has resolved and there is
a small air leak, or when added to a surgical procedure for patients
early in their disease course. Some reports have emphasized the high
success rates (up to 94%) of thoracoscopy and video-assisted
thoracoscopic surgery to perform pleurodesis or
blebectomy.8
9
10
While proposed by some
authors,11
12
thoracotomy and resection therapy has been
limited in this series to only two patients with BPF who declined HV
conversion, with one operative death and one successful discharge.
Although there is clearly a role for operative management of a
persistent pneumothorax in patients in the early stages of AIDS,
conversion to an HV and early discharge is probably a better choice for
patients in a premoribund state and with very limited pulmonary
reserve. In these patients, any surgical procedure carries high risk
for both the patient and the operating team, as well as a potentially
prolonged postoperative stay. In our series, patients treated for a
pneumothorax with or without a BPF with early HV conversion were
successfully treated and discharged earlier than patients treated using
conventional means. And, even though overall survival is limited by the
advanced nature of their disease process, the patients treated with an
HV each had their chest tube removed as an outpatient, and no patient
died with a chest tube in place. Figure 1
summarizes our therapeutic approach to the management of patients with
advanced AIDS and pneumothorax. After TT insertion, a successful 24 to
48 h period of drainage is followed by TT removal and discharge.
In case of radiologic pneumothorax resolution but persistent small BPF,
talc pleurodesis or HV conversion with discharge can be alternatively
used. In the event of a persistent pneumothorax on chest radiograph
and/or large BPF, therapeutic alternatives largely depend on the
patient’s overall status. HV placement and early discharge should be
preferentially employed in patients with advanced AIDS or premoribund
status, while operative intervention (video-assisted thoracoscopic
surgery or thoracotomy) may be selectively utilized for patients who
are acceptable operative candidates.
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Conclusion
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Several therapeutic modalities can be utilized in the management
of AIDS-related pneumothorax. There seems to be in our opinion a lesser
role for TS, since patients with persistent BPF can alternatively and
effectively be treated with an HV. This is especially true for patients
in the advanced state of their disease, who pose a prohibitive
operative risk for both thoracotomy and thoracoscopy, and who are
likely to fail conventional therapy because of the diffuse nature of
their advanced cavitating disease. If no pneumothorax resolution is
observed after simple TT, prompt conversion to an HV allows for safe
and early discharge.
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Footnotes
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Abbreviations:
BPF = bronchopleural fistula; HV = Heimlich valve;
PCP = Pneumocystis carinii pneumonia; TS = tube
thoracostomy with sclerosing therapy; TT = tube thoracostomy
Recipient of 1999 Young Investigator Award, The CHEST Foundation,
American College of Chest Physicians.
Presented at CHEST 1999, American College of Chest Physicians,
Scientific Sessions, November 3, 1999; Chicago, IL.
Received for publication April 11, 2000.
Accepted for publication January 24, 2001.
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Abstract
Introduction
