Less is more?

An argument for the conservative management of small traumatic pneumathoraces in populations with high prevalence of HIV and tuberculosis: an evidence-based review of the literature

Background

Traumatic pneumothoraces are common. Many are managed with tube thoracostomy. However, there is a high complication rate from chest tube placement, particularly in patients with HIV, TB, or both.

Aims

We sought to investigate the literature on the conservative management of traumatic pneumothorax in patients with HIV and/or TB.

Methods

The literature search was broken into two parts. In the first part, we searched for articles comparing tube thoracostomy versus conservative management in traumatic pneumothorax. In the second part, we sought articles describing the incidence and outcome of pneumothoraces in patients with pre-existing HIV or tuberculosis. In both, relevant articles were reviewed, and citations were hand-searched.

Results

For the first portion, we identified 384 papers. From these, six studies were relevant. For the second portion, we identified 327 articles. A total of four unique articles were selected. The heterogeneity of the studies did not allow any pooled analysis. The studies of conservative management demonstrated a low percentage of patients with small pneumothoraces (most often <1.5 cm or less than 10%) later required tube thoracostomy for clinical deterioration (range 6–25%). No studies focused exclusively on pneumothoraces in patients with TB. In patients with HIV, there were no prospective trials of conservative management. Mortality for all HIV-infected patients with pneumothorax was high (25–50%), and the rate of complications from tube thoracostomy was also high. Pneumocystits carinii pneumonia (PCP) independently increased mortality.

Conclusions

A review of the literature suggests that selected small pneumothoraces may be managed conservatively and that there is a high rate of complications related to tube thoracostomy in HIV patients. We propose a trial of the safety of conservative management of traumatic pneumothoraces in an area with a high prevalence of HIV and TB.

[Pleural disease and acquired immunodeficiency syndrome]

Respiratory infections are among the most common complications in patients infected with human immune deficiency virus (HIV) and can occur at all CD4 level. Pleural complications are uncommon but they have some distinctive aspects from HIV-negative patients. The PTX occurrence in HIV-positive patients was described for the first time in 1984. The total incidence of pneumothorax (PTX) in patients with acquired immune deficiency syndrome (AIDS) varies from 2.7% to 4.9%. The great majority occurs in patients with current or previous Pneumocystis carinii infection, who present subpleural pulmonary cavities with necrosis. The treatment of spontaneous PTX in patients with AIDS is difficult, with an increased tendency to bronchopleural fistula persistence. The use of tube thoracostomy, with or without pleural sclerose, can be insufficient to resolve PTX. Other therapeutic options are attachment of a Heimlich valve or surgical intervention. The prevalence and the etiology of pleural effusion (PE) among hospitalized patients with AIDS varies widely. One reason that can contribute to this variability is the difference on risk factors associated with HIV infection, in the studied population. Parapneumonic effusions, tuberculosis and Kaposi's sarcoma are the most common causes. Empyemas are a rare pleural complication. Although Pneumocystis carinii pneumonia is a common cause of pneumonias in AIDS patients, it is an unusual cause of pleural effusion. Other possible causes of pleural effusion are non-Hodgkin's lymphoma, namely body cavity-based lymphoma.

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