Insuffisance respiratoire aiguë chez le patient infecté par le virus de l'immunodéficience humaine

Acute respiratory failure (ARF) accounts for 25 % to 50 % of ICU admissions in HIV-infected patients and reveals HIV infection in up to one third of cases. More than 80 % of these ARF are of infectious origin, mainly bacterial pneumonia (35-50 %, with Streptococccus pneumoniae as the most common pathogen), Pneumocystis jirovecii pneumonia (25-40 %, and up to 70 % of inaugural ARF) and tuberculosis (5-10 %). Non-infectious pulmonary involvements such as chronic obstructive pulmonary disease and heart failure are increasingly reported, notably in patients receiving antiretroviral therapy (ART), and are mostly associated with AIDS-unrelated co-morbidities. ARF commonly results from multiple aetiologies. Therefore, a comprehensive diagnostic approach is warranted, including bronchoscopy and broncho-alveolar lavage in severely immunocompromized patients. Hospital survival depends on the extent of organ failures, but not on HIV-related characteristics. Increased survival to a current rate of 70-80 % stands on intensive care advances, e.g., non-invasive pressure support, lung protective ventilation strategy in patients with the acute respiratory distress syndrome and aggressive management of severe sepsis. Conversely, long-term prognosis is related to AIDS progression and response to ART. Early introduction of ART in the ICU appears beneficial. However, this still needs to be appraised in prospective, controlled trials.