Mechanical Ventilation for Pneumocystis сarinii Pneumonia in Patients With the Acquired Immunodeficiency Syndrome: Finally
In contrast, what is fundamental in our opinion is the duration of treatment combining TMP-SMZ and steroids prior to the instigation of MV Initial respiratory failure when PCP has not yet been treated appears to carry a much better prognosis than respiratory failure that occurs after 5 days of correctly conducted medical treatment, ie, treatment failure. In this study, five of the six survivors were intubated at the beginning of treatment with TMP-SMZ+ methylprednisolone; 50 percent of the patients in group 1 survived, whereas the mortality rate in group 3 was 95 percent. buy antibiotics online
Lung infections associated with PCP were more frequent in the nonsurvivors than in the survivors, though the difference was not significant. Such infections can be either primary, eg, CMV, or secondary nosocomial infections. In HIV-infected patients, the pathogenicity of CMV for the lung is controversial. Cytomegalovirus is found in BAL fluid, obtained for the diagnosis of pneumonia of various etiologies, in 30 to 50 percent of AIDS patients; its prevalence is even higher in autopsy series. However, it has frequently been shown that the clinical course of AIDS patients with pneumonia bears no relationship to the presence or absence of CMV in the lungs.* In addition, if one adheres to strict diagnostic criteria, “true” CMV pneumonia affects only 1 percent of AIDS patients from whom CMV is isolated in pulmonary samples, at least according to Murray and Mills. The presence of CMV was not associated in our patients with histologic signs of CMV pneumonia. Nosocomial pneumonia was diagnosed in six patients receiving MV; its role in the mortality of patients in the ICU is well-established, but histologic examination of lung tissue samples, when available, usually revealed fibrotic rather than suppurative lesions. Studies with a more important number of patients should specify the role of steroids in the development of CMV pneumonia or nosocomial pneumonia.
In conclusion, the prognosis of AIDS patients with PCP and ARF requiring M V remains poor, particularly if the MV follows the failure of antiparasitic/steroids treatment. It is probable that the early use of steroids has changed the course of PCP-associated ARF and reduced the number of patients admitted to ICUs for respiratory failure, but has also selected patients in whom antiparasitic treatment has failed and, for reasons that remain to be determined.