An argument for the conservative management of small traumatic pneumathoraces in populations with high prevalence of HIV and tuberculosis: an evidence-based review of the literature

BACKGROUND Traumatic pneumothoraces are common. Many are managed with tube thoracostomy. However, there is a high complication rate from chest tube placement, particularly in patients with HIV, TB, or both. AIMS We sought to investigate the literature on the conservative management of traumatic pneumothorax in patients with HIV and/or TB. METHODS The literature search was broken into two parts. In the first part, we searched for articles comparing tube thoracostomy versus conservative management in traumatic pneumothorax. In the second part, we sought articles describing the incidence and outcome of pneumothoraces in patients with pre-existing HIV or tuberculosis. In both, relevant articles were reviewed, and citations were hand-searched. RESULTS For the first portion, we identified 384 papers. From these, six studies were relevant. For the second portion, we identified 327 articles. A total of four unique articles were selected. The heterogeneity of the studies did not allow any pooled analysis. The studies of conservative management demonstrated a low percentage of patients with small pneumothoraces (most often <1.5 cm or less than 10%) later required tube thoracostomy for clinical deterioration (range 6-25%). No studies focused exclusively on pneumothoraces in patients with TB. In patients with HIV, there were no prospective trials of conservative management. Mortality for all HIV-infected patients with pneumothorax was high (25-50%), and the rate of complications from tube thoracostomy was also high. Pneumocystits carinii pneumonia (PCP) independently increased mortality. CONCLUSIONS A review of the literature suggests that selected small pneumothoraces may be managed conservatively and that there is a high rate of complications related to tube thoracostomy in HIV patients. We propose a trial of the safety of conservative management of traumatic pneumothoraces in an area with a high prevalence of HIV and TB.