JR Curtis, DL Greenberg, LD Hudson, LD Fisher, MR Krone and AC Collier
Robert Wood Johnson Clinical Scholars Program, Department of Medicine, University of Washington, Seattle 98105.

Clinicians' approach to acute respiratory failure from Pneumocystis carinii pneumonia (PCP) is hypothesized to have gone through three phases: aggressive management due to an absence of data on prognosis (1981-84), withholding of intensive care based on a few small studies showing high case fatality (1985-87), and an increase in intensive care to an intermediate level (1988 forward). Unfortunately, studies of survival from acute respiratory failure among such patients have been small and have been limited to patients in the intensive care unit. To determine whether this three-phase scenario has empirical support, we performed a retrospective chart review of all patients with human immunodeficiency virus (HIV) infection and PCP at a university- affiliated municipal hospital from 1983 to 1990. We identified 180 patients, representing 218 episodes of PCP. The previously hypothesized relationship between intensive care and year of diagnosis was confirmed: intubation rates were 30% before 1985, 0% in 1987, and 12% after 1988 (p = 0.03). Among all patients, the percentage dying in the hospital without intensive care had the opposite relationship with year of diagnosis, increasing from 0% in 1984 to 21% in 1987 and then declining to 0% in 1990 (p = 0.001). Overall mortality from an episode of PCP was 25% and did not change significantly over time. Disease severity also did not change significantly over time. In summary, the significant swings in the use of intensive care for HIV-infected patients with PCP suggest that judgments about the futility of intensive care were strongly influenced by incorrect perceptions of survival.

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