ABSTRACT
The use of mechanical ventilation (MV) for AIDS-related Pneumocystis carinii pneumonia (PCP) has varied over time. The introduction of adjunctive corticosteroid therapy has changed the pathophysiology of PCP. In the present study, we attempted to identify factors predictive of severe respiratory failure requiring MV amongst patients with PCP treated in the era of adjunctive corticosteroid therapy. Furthermore, we studied factors associated with survival in relation to MV. Of 170 consecutive patients with AIDS-related PCP, 18 (11%) required MV. Thirteen of 18 ventilated patients died (72%). In a logistic regression analysis, higher age, increased bronchoalveolar lavage (BAL) neutrophilia and a positive BAL cytomegalovirus CMV culture were associated with the need of MV. In multivariate analyses, only BAL neutrophilia remained independently predictive of mechanical ventilation. In conclusion, short-term mortality remained high after the introduction of adjunctive corticosteroid therapy. BAL neutrophilia may be a useful prognostic marker to identify patients at high risk of requiring mechanical ventilation.
Subject(s)
AIDS-Related Opportunistic Infections/mortality , Bronchoalveolar Lavage Fluid/immunology , Neutrophils/physiology , Patient Selection , Pneumonia, Pneumocystis/mortality , Respiration, Artificial , AIDS-Related Opportunistic Infections/immunology , AIDS-Related Opportunistic Infections/therapy , Adult , Aged , Bronchoalveolar Lavage Fluid/virology , Chi-Square Distribution , Cohort Studies , Cytomegalovirus/isolation & purification , Female , Humans , Male , Middle Aged , Multivariate Analysis , Pneumonia, Pneumocystis/immunology , Pneumonia, Pneumocystis/therapy , Risk Factors , Statistics, Nonparametric , Survival RateABSTRACT
Hepatic encephalopathy (HE) is the neuropsychiatric syndrome that occurs as a complication to liver failure in patients with acute or chronic liver disease. Mental status in this syndrome can range from subtle deficits to coma, with respiratory insufficiency and aspiration to the lungs. The mortality is high. The pathogenesis of HE is not clearly understood. One theory is that it reflects a metabolic disorder of the brain, developed from neuroactive nitrogenous metabolites in the gut that accumulate in plasma when there is an impaired hepatocellular extraction or porto-systemic shunting. Transient improvement of the condition is seen in a subgroup of patients after administration of flumazenil, a specific benzodiazepine antagonist. The group of patients with a positive response to flumazenil therapy may have a better prognosis. Flumazenil may be used in patients in the pretransplantation phase.
