Management of AIDS-related pneumothorax.

BACKGROUND: Pneumothorax (PTX) occurs in 5% of patients with acquired immunodeficiency syndrome (AIDS) infected with Pneumocystis carinii pneumonia, and up to 50% of those will die during hospitalization. The treatment strategies for managing AIDS-related PTXs are often complex and ineffective at treating the PTX, and they can prolong hospitalization. METHODS: We reviewed our experience with 36 male patients with AIDS treated for 44 PTXs over a 2.5-year period to determine if a particular therapeutic approach could allow for an earlier recovery and effective treatment of the PTX. All patients had current or prior history of Pneumocystis carinii pneumonia infection, and the CD4+ T-lymphocyte counts were less than 100/microL in 100%. RESULTS: Twenty-seven patients with 31 PTXs were discharged from the hospital. Of these 31 PTXs, 21 had resolved at the time of the patient's discharge from the hospital, and the other 10 PTXs were converted from Pleurevac (Deknatel, Inc, Fall River, MA) drainage to a Heimlich valve for persistent bronchopleural fistula after more than 15 days of conventional treatment. The PTXs were effectively managed by tube thoracostomy alone in 18/44 PTXs (41%), tube thoracostomy plus sclerosing therapy in 2/8 PTXs (25%), and thoracotomy with blebectomy and pleurodesis in 1/3 PTXs (33%). Nine of 11 of the procedure-related PTXs responded to tube thoracostomy alone; the other 2 PTXs were converted from Pleurevac drainage to a Heimlich valve and allowed for patient discharge from the hospital in less than 10 days. Nine patients with 13 PTXs died during hospitalization. Four of these 9 patients (44%) had bilateral PTXs, and 8/9 (89%) were being treated by tube thoracostomy with Pleurevac suction for persistent bronchopleural fistula in the intensive care unit at the time of death. The 8 patients treated for 10 PTXs with a Heimlich valve had effective management of the PTX, had no morbidity associated with the Heimlich valve and no in-hospital mortality, and were discharged from the hospital to home or a hospice setting. CONCLUSIONS: The management of AIDS-related PTXs is complex and often associated with a destructive pulmonary process and other systemic disease conditions related to AIDS that result in ineffective resolution of the PTX, a prolonged hospitalization, and a high mortality. In our experience, there is a lesser role for managing the PTXs with sclerosing therapy or thoracotomy. Patients with advanced AIDS complicated by PTXs with bronchopleural fistula can be converted from a Pleurevac drainage system to a Heimlich valve with no apparent morbidity or mortality, and managed as an outpatient, thereby potentially shortening hospitalization and facilitating an earlier discharge from an acute care setting.

The shooting of President Reagan: a radiologic chronology of his medical care.

Radiography of the chest played a central role in the care of President Ronald Reagan who, in 1981, became the only president of the United States to survive being struck by a would-be assassin's bullet. These radiographs not only illustrate the medical events that followed the gunshot wound to the president's chest, but also provide graphic documentation of the president's medical care, suspected complications, and recovery following this near-fatal wound. This report constitutes the only complete pictorial record of the care of President Reagan during that historic episode.

The attempted assassination of President Reagan. Medical implications and historical perspective.

In 1981, President Ronald Reagan became the first incumbent president of the United States to survive being struck by a would-be assassin's bullet. Had President Reagan not survived, the history of this country and the world most certainly would have been changed. This report is the only first-hand account of the details of his medical care and complications following the assassination attempt, an event that emphasizes the vulnerability of presidents to would-be assassins and the importance of readily available expert medical care and facilities to their survival.

Tension pyopneumothorax. Rare presentation of ruptured Barrett's esophagus.

Tension pneumothorax following esophageal rupture is very rare. We report a case in which a perforated Barrett's esophagus rapidly developed a spontaneous tension pyopneumothorax. The mechanism for the tension remains obscure. Knowing that a tension pneumothorax can occur with esophageal rupture can help prevent misdiagnosis.

Diagnosis of paraesophageal omental hiatal hernia by magnetic resonance imaging.

We present a case of an enlarging retrocardiac mass lesion in which we observed the magnetic resonance imaging (MRI) finding of a fatty tumor with contiguous blood vessels extending from the abdominal portion into the thoracic portion of the tumor. These surgically verified findings provide an MRI indication of the presence of a paraesophageal omental hiatal hernia.

Role of open lung biopsy in diagnosing pulmonary complications of AIDS.

Over a 4-year period, 25 patients with pulmonary complications of acquired immunodeficiency syndrome underwent open lung biopsy for diagnosis. Results of the biopsy led to a change in therapy in 15, and of this group, 8 patients improved clinically and were discharged. We believe that a select group of acquired immunodeficiency syndrome patients with pulmonary disease will benefit from open lung biopsy. Our indications for open lung biopsy are (1) a nondiagnostic bronchoscopy, (2) failed medical therapy after a diagnostic bronchoscopy, (3) failed empiric medical therapy after a nondiagnostic bronchoscopy or after a second nondiagnostic bronchoscopy, and (4) when any of the forementioned are accompanied with a worsening chest roentgenogram. Patients with acquired immunodeficiency syndrome who have a deteriorating respiratory status or require mechanical ventilation should not undergo open lung biopsy.

Solitary pulmonary nodule. What should be included in the workup?

Rapid, thorough diagnostic workup of patients with solitary pulmonary nodules is imperative. The optimal management for these patients is exploratory thoracotomy for biopsy and appropriate resection. Preliminary fiberoptic bronchoscopy and transthoracic needle aspiration do not rule out malignant tumors if negative and add only unnecessary complexity, delay, expense, and risk to the patient's management.

Malignant pleural effusion treated by tetracycline sclerotherapy. A comparison of single vs repeated instillation.

Fifty patients with malignant pleural effusion were randomized to receive one or two doses of tetracycline sclerotherapy. We found that a single sclerotherapy treatment with tetracycline at a dose of 20 mg/kg was as effective as two sclerotherapy treatments and provided symptomatic relief in 46 of the 50 patients.

Reexpansion pulmonary edema.

Unilateral reexpansion pulmonary edema (RPE) is a rare complication of the treatment of lung collapse secondary to pneumothorax, pleural effusion, or atelectasis. Although RPE generally is believed to occur only when a chronically collapsed lung is rapidly reexpanded by evacuation of large amounts of air or fluid, in this review 15 of 47 cases of RPE available for assessment occurred when the pulmonary collapse was of short duration or when the lung was reexpanded without suction. The pathogenesis of RPE is unknown and is probably multifactorial. Implicated in the etiological process of RPE are chronicity of collapse, technique of reexpansion, increased pulmonary vascular permeability, airway obstruction, loss of surfactant, and pulmonary artery pressure changes. Since the outcome of RPE was fatal in 11 of 53 cases reviewed (20%), physicians treating lung collapse must be aware of the possible causes and endeavor to prevent the occurrence of this complication.

Azygos lymph node enlargement as initial manifestation of underlying disease.

Azygos lymph node enlargement is usually an indication of advanced bronchogenic carcinoma, although it may occur in benign pulmonary disease. Often it is found in conjunction with enlargement of hilar and other mediastinal lymph nodes. Isolated azygos lymph node enlargement is unusual and demands tissue diagnosis. Four patients without other evidence of underlying disease were evaluated because of roentgenographic finding of azygos lymph node enlargement. Three had malignant disease and one reactive lymphoid hyperplasia. Current concepts of mediastinal lymphatic drainage are presented. Because of the likelihood of underlying malignancy, biopsy examination of an enlarged azygos node by cervical mediastinoscopy is indicated.

Intraoperative retrograde balloon-catheter dilatation to augment myocardial revascularization.

When bypass graft surgery is planned, it is appreciated that sequential coronary artery stenoses often entrap the origins of arterial branches that have a significant, but subgraftable, diameter. These branches are routinely not perfused by saphenous vein grafts implanted beyond the second lesion. Data are presented on improving perfusion of such branches in 26 patients by the technique of retrograde intraoperative balloon-catheter dilatation. During coronary artery surgery, specially designed angioplasty catheters, 2 to 3 mm in diameter, were introduced through the coronary arteriotomy and passed retrogradely across the distal lesion. Balloon inflation was performed two to four times at 4 to 7 atm. Lesion size was assessed before and after angioplasty with the use of graduated coronary probes. Probe-determined lesion diameter increased from 1.1 +/- 0.4 to 2.0 +/- 0.4 mm (percent increase, 109 +/- 8). In selected patients, intraoperative balloon-catheter dilatation is a promising technique adjunctive to coronary surgery. Clinical significance and long-term effectiveness of this procedure require further evaluation.

Intraoperative retrograde balloon angioplasty of the left anterior descending coronary artery for reperfusion of jeopardized proximal branches.

Sequential left anterior descending artery stenoses often entrap diagonal and septal branches of significant but subgraftable diameter. These branches are routinely not perfused by middle or distal left anterior descending saphenous vein grafts implanted beyond the second lesion. We attempted to improve perfusion of such branches in nine patients using retrograde intraoperative balloon angioplasty. During coronary surgery, specially designed angioplasty catheters 2-3 mm in diameter were introduced through the coronary arteriotomy and passed retrogradely across the distal lesion. The balloon was inflated two to four times at 4-7 atmospheres. The size of the lesion was assessed before and after angioplasty using graduated coronary probes. Dilatation was successful in all cases. Probe-determined lesion diameter increased from 1.1 +/- 0.4 mm to 2.0 +/- 0.4 mm, an increase of 109 +/- 8%. In selected patients, intraoperative balloon angioplasty is a promising adjunct to coronary surgery. The clinical significance and long-term effectiveness of this procedure require further evaluation.

A comparison of synthetic absorbable suture with synthetic nonabsorbable suture for construction of tracheal anastomoses.

This study compares the use of synthetic absorbable suture (SAS, Vicryl) with that of synthetic nonabsorbable suture (SNS, Ticron) for construction of cervical tracheal anastomoses in the dog. Fourteen mongrel dogs underwent resection of one to four tracheal rings. Paired tracheal anastomoses were constructed, using 10 SAS or 10 SNS. After two months each anastomosis was removed and analyzed. All animals survived with intact anastomoses. There were no visible reactions to the SAS. Twenty-six of 70 SNS developed gross suture granulations. Significant stenosis developed in one of seven SAS and in four of seven SNS anastomoses. Histologic examination revealed no residual inflammatory reaction in the SAS specimens, while the SNS demonstrated a spectrum of inflammatory response that directly correlated in intensity with the gross appearance. These findings support the continued evaluation for the use of SAS in clinical tracheobronchoplastic procedures.