Primum Non Nocere

To the Editor:

I welcome the clarification by Sihoe et al on the balance between optimal patient outcomes and risks to staff caring for patients with contagious diseases. In their original report on pneumothorax in severe acute respiratory syndrome (SARS),¹ Sihoe et al stated that the risk of transmission of SARS to operating room staff was the most important reason why pneumothoraces were not repaired with surgical procedures. In their letter, they have clarified that physicians are obligated to make management and treatment decisions that are likely to provide the best possible outcomes for patients.

The authors asserted that clinical outcomes in their six patients were not compromised despite the fact that none of the pneumothoraces were repaired. I question how anyone can know that. Two of the six patients died. One 82-year-old woman developed a 20% pneumothorax on the 37th day after hospital admission. She refused chest drainage and died 4 days later. A 32-year-old woman who had been hospitalized for 25 days developed pneumothoraces on both sides of the lung, with one of them displacing 50% of the lung volume. A chest tube was inserted to treat the large pneumothorax, and the lung was reexpanded. The pneumothorax recurred on this side 6 days later, and this was also managed conservatively. The patient developed progressive respiratory failure necessitating mechanical ventilation, which exacerbated persistent air leakage. She then developed refractory hypoxia and died. Four other patients had persistent air leakage for 14 days to 1 month. These patients had substantial morbidity, and it is conceivable that surgical repair of the air leaks would have improved their outcomes. I agree with the authors that it is impossible to know, without a controlled trial, whether surgical repair would have benefited these patients. Expert opinions that were developed in a consensus of experts convened by the American College of Chest Physicians² have advised that most or all of the six patients described by Sihoe et al should have undergone thorascopic repair.

The contribution by Sihoe et al is important in that it described pneumothorax in SARS in detail and raised some of the provocative ethical issues surrounding the care of patients with SARS or other contagious diseases. In their original report¹ and subsequent letter, Sihoe et al poignantly described the considerable anxiety that clinicians experienced during this frightening epidemic. Fortunately, experience with SARS and other contagious diseases has demonstrated that strict adherence to modern infection control practices protects staff very well. The authors and I agree that pneumothoraces should be repaired surgically in patients with SARS if such repair is judged likely to improve their outcomes.