Mechanical Ventilation for Pneumocystis сarinii Pneumonia in Patients With the Acquired Immunodeficiency Syndrome: Methods
Pneumocystis carinii, alone or in association with other opportunistic pathogens, accounts for 85 percent of the respiratory tract infections in patients with the acquired immunodeficiency syndrome (AIDS). In France, P carinii pneumonia (PCP) occurs in 60 percent of AIDS patients during the course of the disease and is the presenting manifestation in about 35 percent of cases.2 Between 5 and 30 percent of first PCP episodes are fatal.2 Mechanical ventilation (MV) for acute respiratory failure (ARF) during PCP was initially associated with mortality rates close to 100 percent, but survival rates of 50 percent have recently been reported. These contradictory results prompted us to reevaluate the prognosis of PCP requiring MV for ARF and to question the existence of subgroups of patients with different prognosis. my canadian pharmacy online
In a retrospective study, we analyzed the files of all human immunodeficiency virus (HIV)-infected patients intubated and ventilated for ARF secondary to PCP in 2 ICUs over a 60-month period (January 1, 1987 to January 1, 1992). The admission in ICUs was guided by the presence of ARF, which was defined by clinical signs of respiratory failure and a PaO, value of 50 mm Hg or less on room air. The indications of MV were muscular weakness (appearance of hypercarbia) and/or threatening hypoxemia (tachycardia, hyperventilation, PaO <50 mm Hg) in spite of a strong flow of oxygen administered by facial mask or nasal prong. Patient s initial severity was assessed using the simplified acute physiology score.® Pneumocystis carinii was sought in bronchoalveolar lavage (BAL) fluid and/or open-chest lung biopsy (ОС LB) specimens by staining with Gomori-Grocott and Ciemsa, silver stain and, more recently, with human monoclonal anti-Pneumocystis antibodies. In addition, BAL specimens were studied for the presence of other pathogens by means of Cram staining, direct immunofluorescence for legio-nellae, and culture for Mycobacterium species, viruses, and fungi.
Patients with suspected bacterial pneumonia underwent protected specimen brushing.
Initial anti-Pneumocystis therapy was the same for all the patients, ie, trimethoprim fTMP, 20 mg/kg) + sulfamethoxazole (SMZ, 100 mg/kg) as intravenous 1-h perfusions, four times daily. Patients with PaO, values below 50 mm Hg received steroids, as follows: daily intravenous injections of methylprednisolone at tapering doses every 3 days for 9 days: 240 mg/d from day 1 to day 3, 120 mg/d from day 4 to day 6, and 60 mg/d from day 7 to day 9.
Results are expressed as the means ±SD. The x test with the correction of Yates was used to evaluate qualitative data and the Mann-Whitney U test was used to evaluate quantitative data. Twotailed p values were used. Multigroup comparisons were done with Kruskall-Wallis H test. Not significant (NS) indicates a p value >0.05.