Intensive Care for Patients with Pneumocystis carinii Pneumonia and Respiratory Failure: Are We Prepared for Our New Success?

Abstract

The approach toward intensive care for patients with the acquired immunodeficiency syndrome (AIDS) and respiratory failure caused by Pneumocystis carinii pneumonia (PCP) has changed over time. During the first phase of the AIDS epidemic (1981 to mid-1984), clinicians and patients lacked the data on which to base decisions regarding intubation, mechanical ventilation, and other procedures performed in the intensive care unit (ICU). All potentially life-extending treatments were pursued; thus, intensive care utilization and costs were high.1Wachter RM Luce JM Turner J Volberding P Hopewell PC Intensive care of patients with the acquired immunodeficiency syndrome: outcome and changing patterns of utilization.Am Rev Respir Dis. 1986; 134: 891-896Crossref PubMed Scopus (144) Google Scholar In the second phase (mid-1984 to 1987), several series1Wachter RM Luce JM Turner J Volberding P Hopewell PC Intensive care of patients with the acquired immunodeficiency syndrome: outcome and changing patterns of utilization.Am Rev Respir Dis. 1986; 134: 891-896Crossref PubMed Scopus (144) Google Scholar, 2Murray JF Felton CP Garay SM Gottlieb MS Hopewell PC Stover DE et al.Pulmonary complications of the acquired immunodeficiency syndrome.N Engl J Med. 1984; 310: 1682-1688Crossref PubMed Scopus (482) Google Scholar, 3Stover DE White DA Romano PA Gellene RA Robeson WA Spectrum of pulmonary diseases associated with the acquired immune deficiency syndrome.Am J Med. 1985; 78: 429-437Abstract Full Text PDF PubMed Scopus (247) Google Scholar, 4Schein RM Fischl MA Pitchenik AE Sprung CL ICU survival of patients with the acquired immunodeficiency syndrome.Crit Care Med. 1986; 14: 1026-1027Crossref PubMed Scopus (76) Google Scholar, 5Rosen MJ Cucco RA Teirstein AS Outcome of intensive care in patients with the acquired immunodeficiency syndrome.Intensive Care Med. 1986; 1: 55-60Crossref Scopus (39) Google Scholar, 6Baggott LA Baggott BB Pneumocystis carinii pneumonia in AIDS patients in intensive care [Abstract].Chest. 1987; 92: 132SCrossref Scopus (36) Google Scholar reported the outcome of ICU care for patients with AIDS, PCP, and respiratory failure. In response to the hospital survival rates of 0 to 15 percent reported in these series, patients and clinicians increasingly declined ICU care.7Steinbrook R Lo B Moulton J Saika G Hollander H Volberding PA Preferences of homosexual men with AIDS for life-sustaining treatment.N Engl J Med. 1986; 314: 457-460Crossref PubMed Scopus (126) Google Scholar, 8Wachter RM Cooke M Hopewell PC Luce JM Attitudes of medical residents regarding intensive care for patients with the acquired immunodeficiency syndrome.Arch Intern Med. 1988; 148: 149-152Crossref PubMed Scopus (31) Google Scholar In the past two years, a small number of reports have generated hope that the prognosis of AIDS patients with PCP and respiratory failure may be improving.9Wachter RM Luce JM Lo B Raffin TA Life-sustaining treatment for patients with AIDS.Chest. 1989; 95: 647-652Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar Montaner et al10Montaner JSGJA Ruedy J Lawson L Acute respiratory failure (ARF) secondary to Pneumocystis carinii pneumonia (PCP) in the acquired immunodeficiency syndrome (AIDS): a potential role for systemic corticosteroids [Abstract].Chest. 1987; 92: 133SGoogle Scholar and El-Sadr and Simberkoff11El-Sadr W Simberkoff MS Survival and prognostic factors in severe Pneumocystis carinii pneumonia requiring mechanical ventilation.Am Rev Respir Dis. 1988; 137: 1264-1267Crossref PubMed Scopus (78) Google Scholar reported hospital survival rates of 50 and 42 percent, respectively, in two cohorts of such patients. In reviewing our experience from 1986 to 1988 at San Francisco General Hospital, we also found an improved outcome, with a hospital survival rate of 40 percent after intubation for severe PCP.12Wachter RM, Russi MB, Hopewell PC, Luce JM. The improving survival rate after intensive care for P. carinii pneumonia and respiratory failure [Abstract]. Fifth International Conference on AIDS, Montreal, Canada, 1989Google Scholar In this issue of Chest (see p 862), Friedman et al report the outcome of 33 patients with PCP and respiratory failure. They found a hospital survival rate of 36 percent, consistent with other recent optimistic studies. No clinical or demographic factors predicted survival, and the authors were unable to explain the improved outcome. Given these new data, three important questions arise. First, is the prognosis of AIDS patients with PCP and respiratory failure really improving? Second, if so, what factors explain the better outcome? Third, what are the consequences of the new optimism surrounding intensive care for patients with PCP? Given the possibility that new studies were being published primarily because they differed from earlier studies demonstrating a poor outcome (publication bias), we were initially skeptical of the reports of improved outcomes for AIDS patients with PCP and respiratory failure.13Luce JM Wachter RM Hopewell PC Intensive care of patients with the acquired immunodeficiency syndrome: time for a reassessment?.Am Rev Respir Dis. 1988; 137: 1261-1263Crossref PubMed Scopus (31) Google Scholar However, the consistent results of most recent studies provide convincing evidence of an improving short-term survival. It should be noted that, even in recent studies, the one-year survival rate in AIDS patients with severe PCP continues to be less than 10 percent.12Wachter RM, Russi MB, Hopewell PC, Luce JM. The improving survival rate after intensive care for P. carinii pneumonia and respiratory failure [Abstract]. Fifth International Conference on AIDS, Montreal, Canada, 1989Google Scholar Thus, long-term survival appears not to have changed. To what can these improvements in short-term hospital survival be attributed? A number of explanations have been posited. Although it is possible that earlier diagnosis of PCP and use of intensive care are responsible for the improvement, no published evidence supports these hypotheses. Therapy for PCP, primarily trimethoprim-sulfamethoxazole and pentamidine, remains unchanged. In a number of recent studies, the adjuvant use of corticosteroids has been associated with a beneficial trend in hospital survival rates.10Montaner JSGJA Ruedy J Lawson L Acute respiratory failure (ARF) secondary to Pneumocystis carinii pneumonia (PCP) in the acquired immunodeficiency syndrome (AIDS): a potential role for systemic corticosteroids [Abstract].Chest. 1987; 92: 133SGoogle Scholar, 11El-Sadr W Simberkoff MS Survival and prognostic factors in severe Pneumocystis carinii pneumonia requiring mechanical ventilation.Am Rev Respir Dis. 1988; 137: 1264-1267Crossref PubMed Scopus (78) Google Scholar, 12Wachter RM, Russi MB, Hopewell PC, Luce JM. The improving survival rate after intensive care for P. carinii pneumonia and respiratory failure [Abstract]. Fifth International Conference on AIDS, Montreal, Canada, 1989Google Scholar However, in the absence of randomization, blinding, and adequate controls, we are unable to confirm the salutary effect of steroids, even though we often advocate their use in PCP and respiratory failure. Since many patients with PCP forgo life-sustaining treatments,14Wachter RM Luce JM Hearst N Lo B Decisions about resuscitation: are patients with different diseases but similar prognoses approached equitably?.Ann Intern Med. 1989; (in press)Google Scholar selection of healthier patients for admission to the ICU is another possible explanation for the improved outcome. However, in our recent study, we found no evidence to support this hypothesis.12Wachter RM, Russi MB, Hopewell PC, Luce JM. The improving survival rate after intensive care for P. carinii pneumonia and respiratory failure [Abstract]. Fifth International Conference on AIDS, Montreal, Canada, 1989Google Scholar Finally, a change in the virulence of the organism or the attributes of the host occurring over time may be operative, although here again the evidence is lacking. The consequences of the improved outlook for respiratory failure due to PCP are far reaching for patients, clinicians, insurers, and policy makers. Until recently, decisions by informed AIDS patients to forgo life-sustaining treatments kept ICU utilization low1Wachter RM Luce JM Turner J Volberding P Hopewell PC Intensive care of patients with the acquired immunodeficiency syndrome: outcome and changing patterns of utilization.Am Rev Respir Dis. 1986; 134: 891-896Crossref PubMed Scopus (144) Google Scholar and postponed consideration of difficult questions regarding ICU resource availability and distributive justice.15Englehardt HT Rie MA Intensive care units, scarce resources, and conflicting principles of justice.JAMA. 1986; 255: 1159-1164Crossref PubMed Scopus (84) Google Scholar As the prognosis improves, however, one would expect patients and clinicians to favor the use of intensive care in increasing numbers. For instance, ICU utilization for patients with PCP and respiratory failure increased fourfold at San Francisco General Hospital during the past two years (M.B. Russi and R.M. Wachter, unpublished data), presumably because clinicians and patients alike became aware of the improved prognosis for AIDS patients with severe PCP. Unless prophylactic therapy for PCP proves so efficacious and popular that this disease does not require intensive care, ICUs in areas where AIDS is prevalent may become filled with patients suffering from PCP The cost of each hospitalization for PCP and respiratory failure treated with mechanical ventilation is approximately $35,000 (R.M. Wachter, unpublished data). Thus, the day of reckoning for the allocation of increasingly scarce resources may soon arrive. The need for better data is obvious, and a prospective multicenter study to answer some of the questions regarding outcome and prognostic factors is underway. Until it is completed, we continue to agree with Friedman et al that informed, competent patients should be allowed to make their own choices regarding life-sustaining treatments, including intensive care for respiratory failure due to PCP, in consultation with clinicians.13Luce JM Wachter RM Hopewell PC Intensive care of patients with the acquired immunodeficiency syndrome: time for a reassessment?.Am Rev Respir Dis. 1988; 137: 1261-1263Crossref PubMed Scopus (31) Google Scholar What to do if and when such choices cannot be honored because of constrained ICU bed or resource availability may prove to be one of the most difficult questions we face in caring for patients with AIDS. Improved Survival in Patients with AIDS, Pneumocystis carinii Pneumonia, and Severe Respiratory FailureCHESTVol. 96Issue 4PreviewPneumocystis carinii pneumonia (PCP) causing acute respiratory failure (ARF) in patients with acquired immunodeficiency syndrome (AIDS) has been reported in several studies to have a mortality of 84 to 100 percent. A recent report found a 42 percent survival rate. We followed 58 patients with AIDS who required positive pressure ventilation and identified 33 patients with PCP and ARF who had a PaO1/FIo2 level <150 mm Hg. We report the survival of 12 of these 33 (36 percent). The mean duration of survival after discharge from the hospital was 7.9 ± 1.8 months, which is an improvement over previous reports. Full-Text PDF