Portal de Periódicos da CAPES

Pneumothorax Complicating BiPAP Therapy for Pneumocystis carinii Pneumonia

1993; Elsevier BV; Volume: 103; Issue: 4 Linguagem: Inglês

10.1378/chest.103.4.1310b

1931-3543

Gerard Sheehan, Lilly J Miedzinski, Dallas G. Schweder,

Tuberculosis Research and Epidemiology

To the Editor: Pneumothorax is increasingly recognized as a complication of Pneumocystis carinii pneumonia (PCP) in patients with AIDS. Of 20 patients with AIDS and spontaneous pneumothorax treated at the Sloan-Kettering Cancer Center in New York in a decade, 19 had concurrent PCP, and 18 had received inhaled pentamidine prophylaxis.1Sepkowitz KA Telzak EE Gold JWM Bernard EM Blum S Carrow M et al.Pneumothorax in AIDS.Ann Intern Med. 1992; 114: 455-459Crossref Scopus (116) Google Scholar We report the case of a patient who developed bilateral pneumothoraces as a complication of PCP and AIDS while receiving ventilatory support with a bilevel positive airway pressure (BiPAP) mask. There was no prior history of inhaled pentamidine use. A 32-year-old previously well homosexual man presented with a 3-day history of progressive dyspnea, nonproductive cough, and fever. He was found to have bilateral interstitial infiltrates and was treated with intravenous co-trimoxazole (trimethoprim-sulfamethoxazole), erythromycin, and methylprednisolone. Bronchoalveolar lavage revealed + 4 P carinii organisms on Giemsa stain. Over the next 2 days he developed progressively worsening hypoxemia and dyspnea and was transferred to the ICU. In the ICU, furosemide was administered intravenously, and a BiPAP mask was applied with an inspiratory pressure of 10 cm H2O, an expiratory pressure of 5 cm H2O, and an oxygen flow rate of 12 L/min. The patient had a spontaneous respiratory rate of 24 breaths per minute. The patient became less dyspneic and had adequate oxygenation (Po2, 11.2 mm Hg; Pco2, 5.72 mm Hg; and [H +], 4.52 mm Hg), but after 12 h he suddenly developed increased dyspnea and fatigue. A chest radiograph showed bilateral pneumothoraces, which had not been evident 12 h previously. He was endotracheally intubated. Bilateral thoracostomy tubes were placed, and tension pneumothoraces were drained. Over the next 7 days he remained intubated and ventilated. His temperature normalized, and his gas exchange and infiltrates improved. He was weaned from the ventilator and discharged to the ward and was subsequently sent home 10 days later. His corticosteroid dosage was tapered, and he completed 20 days of intravenous co-trimoxazole and an additional week of oral co-trimoxazole as an outpatient. An enzyme-linked immunosorbent assay was positive for antibody to HIV We believe this to be the first report of pneumothorax associated with noninvasive intermittent positive-pressure ventilation by face mask in the treatment of acute respiratory failure due to PCP in an AIDS patient. It was tried in this patient as a temporizing measure to avoid endotracheal intubation. It is likely that pneumothorax would have arisen had any other form of positive-pressure ventilation, such as conventional assist mode, been used. Pneumothorax is an important adverse effect of BiPAP and/or PCP that can produce rapid deterioration and can occur without prior prophylactic inhaled pentamidine therapy. Giant T-Wave Inversion in Patients With Acute Coronary InsufficiencyCHESTVol. 103Issue 4PreviewTo the Editor: Full-Text PDF