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 Zambia HIV National Guidelines
 


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 Guide Editors
 Editor In Chief
    Joel E. Gallant, MD, MPH

Pharmacology Editor
    Paul Pham, PharmD, BCPS

Zambia Guideline Team
   Peter Mwaba MMed PhD FRCP
   Alywn Mwinga MMed
   Isaac Zulu MMed MPH
   Velepie Mtonga MMed
   Albert Mwango MBChB
   Jabbin Mulwanda MMed FCS
 

 

 

Diagnosis>Organ System>
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Pneumothorax

Joel E. Gallant, M.D., M.P.H. and Patrick R. Sosnay, M.D.
03-24-2008

  • No specific data on incidence/prevalence from Zambia or Africa, but expected causes primarily PCP , TB , pulmonary cryptococcosis, and LIP.
  • As in other countries, Dx of PTX in Zambia based on CXR.
  • Tube thoracostomy (chest tube) in Zambia usually reserved for large PTX or significant sx/respiratory compromise.
Zambia Information Author: David Riedel, M.D.

CLINICAL

  • Pneumothorax (PTX) defined by air in pleural space, either due to entry from outside chest wall or leakage from lung parenchyma.
  • In HIV, occurs most often in setting of Pneumocystis pneumonia (PCP). Spontaneous PTX in AIDS pt should prompt workup for PCP.
  • PCP-associated PTX independently associated with greater mortality.
  • Spontaneous PTX in pts with AIDS can also occur with TB, COPD, pulmonary cryptococcosis, and lymphoid interstitial pneumonitis.
  • Iatrogenic causes: central venous line placement, thoracentesis, bronchoscopy
  • Presenting Sx: pleuritic chest pain, dyspnea, cough
  • PE: Tachycardia, tachypnea, hypoxia, hyper-resonance or decreased breath sounds over one lung field. Some pts may not have any signs or Sx beyond those of pneumonia.
  • Higher incidence in males, cigarette smokers, pts on aerosolized pentamidine prophylaxis, pts w/ pneumatoceles on CXR, injection drug users, pts on mechanical ventilation.

DIAGNOSIS

  • CXR line or rim of air seen at apex of lung, beyond which there are no lung markings.
  • Dx can be difficult in pts w/ pre-existing lung disease, lateral decubitus x-rays or CT can increase yield.
  • CT can distinguish PTX from bullous lung disease.
  • Size of PTX can be estimated based on rim of air. >2 cm correlates with >50% of hemithorax

TREATMENT

Asymptomatic/Small pneumothorax

  • Small PTX (<1 cm rim) can be observed in asymptomatic pt.
  • Any chest pain or dyspnea requires evaluation.
  • PTX in setting of PCP has higher morbidity and mortality; requires inpt management.
  • Treatment with 100% oxygen can speed resolution of small PTX without chest tube.
Symptomatic

  • Needle or catheter aspiration less likely to succeed in pts with secondary PTX from underlying lung disease
  • Intercostal tube thoracostomy (chest tube) should be performed by a qualified surgeon, emergency medicine physician, or trained critical care physician.
  • Bubbling seen in a containment system is sign of continued air leak, and tube should be left in place.
  • PTX should be followed with serial CXR.
  • Tube can be removed when no air leak on water seal, and CXR shows no ongoing PTX.
Persistent Bronchopleural Fistula (BPF)

  • Steroids for treatment of PCP have been associated w/ longer time to resolution of PTX.
  • Heimlich valve can be adapted to chest tube, which allows outpt management.
  • Medical pleurodesis with talc or tetracycline can be performed at bedside through chest tube as non-operative means of managing a persistent BPF.
  • Lowest recurrence rate w/ surgical pleurodesis/pleurodectomy for persistent BPF

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