Caring for AIDS Patients in the ICU

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Caring for AIDS Patients in the ICU Expanding Horizons Health-care providers in the United States are well aware that HIV patients who have access to treatment and adhere to antiretroviral treatment (ART) have a vastlyimproved quality and duration of survival compared to 1 or 2 decades ago. With 1.2 million patients with HIV infection currently alive in the United States, I essentially all ICUs will manage patients with HIV infection over the course of a year. ICUs see three very distinct populations of patients. Patients with opportunistic infections, such as Pneunwcy¥is jirovecii pneumonia (PCP), toxoplasma encephalitis, or cryptococcal meningitis, continue to present to ICUs with severe disease. Some of these patients have known of their HIV infection, but have either been unable to access care or failed ART, and thus have low CD4 counts. A substantial fraction of these patients with opportunistic infections, however, present to emergency departments with life-threatening AIDS manifestations as the first indication of their HIV infection and have severe disease leading to ICU admission. These patients, socalled "late testers," are not diagnosed with HIV until their CD4 counts are < 200 cells/p.L. Such patients constitute approximately 35% of total new diagnoses annually, but in some cities, such as Washington DC, these patients represent 65% of the new diagnoses.2 ,3 Failure to get patients into care early in the course of their disease, when their CD4 counts are well > 200 cells/p.L, subjects these patients to debilitating and potentially lethal problems that are largely avoidable with earlier intervention with ART and prophylactic antimicrobials. With 56,300 new cases of HIV infection estimated to have occurred in the United States in 2006,1 and prevention programs showing little impact, this population of late testers will continue to be substantial, especially in major urban centers of this country. Clinicians need to be cognizant of current standards for management of opportunistic infections: new guidelines are available from that National Institutes www.chesqournal.orq

Editorials CHEST IVolume 1351 Number 1 IJanuary 2009

of Health-Centers for Disease Control and PreventionInfectious Diseases Society of America (www.aidsinfo. nih.gov). There is clearly a need for these guidelines: during the first 2 months they were posted, the adult and pediatric guidelines were downloaded >430,000 times (Cynthia Cadden, MSN; personal communication; November, 2008). ICUs see a second population of HIV patients: those who are admitted for critical care services for medical and surgical conditions that have no link to HIV/AIDS. HIV patients admitted to the ICU following trauma, elective surgery, pancreatitis, or GI bleeding may have as good a prognosis as patients without HIV, especially if their CD4 counts are in normal range. Clinicians need to understand how to manage 2 months ART during hospitalization in the ICU, how to recognize ART toxicities, and how to recognize drug interactions between ART and nonHIV-related drugs. Excellent text and tables summarize current data in the Department of Health and Human Services "Use of Antiretroviral Agents" (www. aidsinfo.nih.gov). ICUs care for a third population of HIV patients, those who have complications unique to long-term survivalwith HIV infection or long-term ART. More and more patients are being seen with diseases that are causally related to HIV or its therapy, such as accelerated atherosclerosis, diabetes, lipid disorders, pulmonary hypertension, emphysema, or stroke.v f These patients may also have a good short-term prognosis. However we are learning more about the natural history and treatment of these disorders. In this issue of CHEST (see page 11), Powell et al? describe changing patterns over time in the clinical manifestations and outcomes in the HIVIAIDS patient population in the San Francisco General Hospital critical care unit. Respiratory failure remained the most common cause for admission to the ICU, emphasizing that Pneumocystis and Streptococcus pneumoniae continue to play important roles in patients with HIV/AIDS. The proportion of HIVI AIDS admissions caused by respiratory failure has diminished, as has the proportion with PCP and other AIDS-associated diseases. This supports the concept that patients are entering the ICU with other life-threatening issues, some related to HIV CHEST/ 135 / 1 / JANUARY, 2009

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infection. some unrelated. Finally, their data indicate that the prognosis for patients with HIV/AIDS, independent of ART use, has continued to improve in recent years, presumably due to improvements in both critical care medicine and HIV medicine. Thus, clinicians need to consider HIV infection as one of many factors in assessing short-term and long-term prognosis, and no longer consider HIV infection necessarily as the driving factor for determining outcome. A remarkable feature of thls article is the continuity of institutional focus at ~an Francisco General Hospital over almost 3 de~ades.8-11 Longitudinal studies in a single communities or groups of communities provide powerful opportunities for analysis. It is unfortunate that there has been no continuous funding for a multicenter study of pulmonary and critical care manifestations over these 3 decades: some very productive, funded studies were discontinued, perhaps on the assumption that pulmonary and critical care manifestations would no longer be major problems.P In fact, pulmonary and critical care problems continue to be substantial, and we need large, contemporary databases in order to understand the current epidemic. For intensivists, the clinical challenges of HIVI AIDS are changing. Providers must understand which CD4 counts place a patient at substantially higher risk for complications ' and which counts suggest that the patient should have little elevated risk. Clinicians must be familiar with AIDS-related infections, but they must keep abreast of new syndromes such as immune reconstitution inflammatory syndrome, accelerated atherosclerosis, and pulmonary hypertension. They must recognize life-threatening drug toxicities and drug interactions. We have made great progress in treating patients with HIV/AIDS more effectively over the past 25 years. Over the next 25 years, however, we must carefully document and understand the new manifestations and complications of HIV/AIDS and develop strategies to further improve our ability to minimize the effects of this epidemic on quality and duration of patient survival. Henry Masur, MD Bethesda, MD Dr. Masur is Chief, Critical Card Medicine Department, National Institutes of Health Clinical 'Center. The author has no conflicts of interest to declare. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.cliestjournal. orglmisc/reprints.shtml). Correspondence to: Henry Masur, MD, Critical Care Medicine Department, National Institutes df Health Clinical Center, 10 Center Dr, Room 2C-145, Bethesda, MD 20892-1662; e-mail: [email protected] DOl: 10.13781chest.08-2199 2

REFERENCES 1 Hall I, Song R, Rhodes P, et al. Estimation of HIV incidence in the United States. JAMA 2008; 300:520--529 2 Centers for Disease Control and Prevention. Late versus early testing of HIV: 16 Sites, United States, 2000-2003. MMWR Morb Mortal Wkly Rep 2003; 52:581--586 3 Castel AD, Jolaosho T, Woolfork M, et al. Late to test: concurrent diagnoses in a city with high AIDS prevalenceWashington DC, 1997-2006. Presented at: 15th Conference on Retroviruses and Opportunistic Infections; February 2008; Boston, MA. 4 Crothers K. Chronic obstructive pulmonary disease in patients who have HIV infection. Clin Chest Med 2007; 28:575587 5 Barnett CF, Hsue PY, Machado RF. Pulmonary hypertension: an increasingly recognized complication of hereditary hemolytic anemias and HIV infection. JAMA 2008; 299:324331 6 Friis-Meller N, Reiss P, Sabin CA, et al. Class of antiretroviral drugs and the risk of myocardial infarction. N Engl J Med 2007; 356:1723-1735 7 Powell K, Davis J, Morris A, et al. Survival for patients with human immunodeficiency virus admitted to the intensive care unit continues to improve in the current era of highly active antiretroviral therapy. Chest 2009; 135:11-17 8 Wachter RM, Luce JM, Turner J, et al. Intensive care of patients with the acquired immunodeficiency syndrome: outcome and changing patterns of utilization. Am Rev Respir Dis 1986; 134:891-896 9 Luce JM, Wachter RM. Intensive care for patients with the acquired immunodeficiency syndrome. Intensive Care Med 1989; 15:481-482 10 Wachter RM, Russi MB, Bloch DA, et al. Pneumocystis carinii pneumonia and respiratory failure in AIDS: improved outcomes and increased use of intensive care units. Am Rev Respir Dis 1991; 143:251-256 11 Huang L, Quartin A, Jones D, et al. Intensive care of patients with HIV infection. N Engl J Med 2006; 355:173-181 12 Rosen MJ, Clayton K, Schneider RF, et al. Intensive care of patients with HIV infection: utilization, critical illnesses, and outcomes. Pulmonary Complications of HIV Infection Study Group. Am J Respir Crit Care Med 1997; 155:67-71

Primum Non Nocere How To Cause Chaos With a Bronchoscope in the ICU hevalier Jackson, the father figure of bronchosC copy, once famously remarked that if doubt

existed whether a bronchoscopy should be performed, then a bronchoscopy ought to be performed. Had he the opportunity to perform fiberoptic bronchoscopy in pediatric and neonatal ICUs, he may well have sung a different song. The performance of a bronchoscopy is deceptively easy: the patient is intubated, there is no upper airway to traverse, no esophagus lying in wait for the inexperienced to enter by mistake, coughing or agitation (except in the bronchoscopist) is unlikely to be an issue; but in no other context is there the need to carefully weigh risk Editorials