new studies have suggested that failure of pentamidine prophylaxis against Pneumocystis carinii pneumonia (PCP) may be owing to reduced deposition of pentamidine in the upper lobes.

new studies have suggested that failure of pentamidine prophylaxis against Pneumocystis carinii pneumonia (PCP) may be owing to reduced deposition of pentamidine in the upper lobes. In this studious mood we performed bronchoalveolar lavage from the apical portion of the upper lobe and the middle lobe in 51 HIV-positive patients, all of whom were receiving prophylaxis with aerosolized pentamidine, who had currented with acute respiratory symptoms. Lavage fluid from each lobe was assayed for pentamidine using high-performance liquid chromatography (HPLC) The number of clusters of P carinii were casted after staining with a Wright-Giemsa stain. The patients were subclassified as PCP-positive (32 patients) and PCP-negative (19 patients) upon the basis of the presence/absence of P carinii clusters in their BAL fluid. The concentration of pentamidine in the upper lobe compared with the middle lobe was no different (using paired Student's t tests) for either PCP-positive patients or PCP-negative patients. In comparing the positive with the negative make liables using unpaired Student's t examples there was no difference in the concentration of pentamidine in the upper lobe or the middle lobe. For PCP-positive patients, the numbers of P carinii clusters were onward average higher in the upper lobes (mean [+ or -] SD: upper = 149 [+ or -] 166 middle 75 [+ or -] 108 p = 0013 paired Student's t test) unless there was no correlation between lobar P carinni cluster esteems and pentamidine levels. We close that the absence of a relationship between cluster consider and pentamidine level, the similarity in regional pentamidine on a levels between upper and middle lobes, as well as the similarity in pentamidine horizontals between the PCP-positive and PCP-negative form into groupss indicate that the regional dose of pentamidine is not the determining factor as to whether aerosolized pentamidine prophylaxis will succe or fail.

The clinical characteristics of Pneumocystis carinii pneumonia (PCP) have changed since the introduction of prophylaxis with aerosolized pentamidine (AP).[1,2] Prior to prophylaxis, 80 percent of patients with AIDS cause to growed at least one episode of PCP and mortality from PCP episodes could be as high as 30 percent[3] With the advent of prophylaxis, the incidence of PCP has decreased significantly.[3,4] Further, when PCP perform the operations indicated ins in patients receiving AP, the clinical illness may be les severe[1] It has been reported that patients who disclose PCP while receiving AP are more likely to current with patchy infiltrates in the upper lobes forward chest radiograph than patients with PCP not treated with AP.[2] Because it is known that in normal exposes the upper lobes receive relatively les ventilation than the lower lobes,[5] it was speculated that failure of AP prophylaxis was fit to reduced upper lobe deposition of aerosol.[2,6] To improve upper lobe deposition, Baskin et al[6] have advocated treating patients in a supine position. However, clinical studies have not related failure to inadequate plains in upper lobes. In addition, PCP confined radiologically to the upper lobes has been described in patients not receiving AP.[7,8]

The view of the present study was to determine the regional distribution of pentamidine flats between upper and middle lobes in patients receiving AP and to relate lobar flushs of pentamidine to the lobar P carinii cluster thinks In addition, regional pentamidine horizontals would be compared between those patients erect to have evidence of breakthrough PCP and those who did not.

METHODS

Patient Population

Fifty-one human immunodeficiency virus (HIV)-positive patients were studied. The subject of attention had been approved by the hospital ethics committee and informed written compliance obtained from each patient. All were receiving primary or secondary prophylaxis with AP at the University of Cincinnati Medical Center Pentamidine, 300 mg was delivered monthly using a nebulizer (Respirgard II, Marquest, Englewood Colo) Patients inhaled the physic in a sitting position. inlet requirements consisted of a history of AP prophylaxis and clinical presentation with acute respiratory symptoms. Patients were recruited consecutively from one side of to the other a 4-month period. None of the patients had received intravenous pentamidine for at least 6 month prior to the cogitation The patients were subdivided into those who had detectable P carinii clusters in bronchoalveolar lavage (BAL) fluid (32 PCP-positive subjects) and those in whom P carinii was not detectable (19 PCP-negative subjects)

Bronchoalveolar Lavage

The BAL was performed using a bronchoscope that was wedged in the portion to be lavaged, as part of the patient's diagnostic evaluation. In each subject, BAL was performed in the right middle lobe and the apical part of the right upper lobe, leave out for those patients who had predominantly left-sided disease, in whom BAL was performed in the lingula and apical-posterior section The PCP-positive and PCP-negative subdues had a similar proportion of left-sided BAL (4/32 and 3/19 p = N [[chi].sup.2]).

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