Nonventilatory strategies for patients with life-threatening 2009 H1N1 influenza and severe respiratory failure

Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA.
Critical care medicine (Impact Factor: 6.31). 04/2010; 38(4 Suppl):e74-90. DOI: 10.1097/CCM.0b013e3181cc5373
Source: PubMed


Severe respiratory failure (including acute lung injury and acute respiratory distress syndrome) caused by 2009 H1N1 influenza infection has been reported worldwide. Refractory hypoxemia is a common finding in these patients and can be challenging to manage. This review focuses on nonventilatory strategies in the advanced treatment of severe respiratory failure and refractory hypoxemia such as that seen in patients with severe acute respiratory distress syndrome attributable to 2009 H1N1 influenza. Specific modalities covered include conservative fluid management, prone positioning, inhaled nitric oxide, inhaled vasodilatory prostaglandins, and extracorporeal membrane oxygenation and life support. Pharmacologic strategies (including steroids) investigated for the treatment of severe respiratory failure are also reviewed.

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    • "Indeed, such efforts have been largely justified by the substantial risk of death even in young and apparently healthy subjects developing fulminant ARDS [1,20]. Given these premises, the application of current state-of-the-art ECMO technologies has been proposed as a promising means to reduce the morbidity and mortality of ARDS, complicating suspected or confirmed H1N1 influenza [2,21]. Despite the availability of several recent studies focusing on the risk-benefit balance of ECMO in this setting, the vast majority of such publications are case reports or very small series. "
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    ABSTRACT: Introduction H1N1 influenza can cause severe acute lung injury (ALI). Extracorporeal membrane oxygenation (ECMO) can support gas exchange in patients failing conventional mechanical ventilation, but its role is still controversial. We conducted a systematic review and meta-analysis on ECMO for H1N1-associated ALI. Methods CENTRAL, Google Scholar, MEDLINE/PubMed and Scopus (updated 2 January 2012) were systematically searched. Studies reporting on 10 or more patients with H1N1 infection treated with ECMO were included. Baseline, procedural, outcome and validity data were systematically appraised and pooled, when appropriate, with random-effect methods. Results From 1,196 initial citations, 8 studies were selected, including 1,357 patients with confirmed/suspected H1N1 infection requiring intensive care unit admission, 266 (20%) of whom were treated with ECMO. Patients had a median Sequential Organ Failure Assessment (SOFA) score of 9, and had received mechanical ventilation before ECMO implementation for a median of two days. ECMO was implanted before inter-hospital patient transfer in 72% of cases and in most patients (94%) the veno-venous configuration was used. ECMO was maintained for a median of 10 days. Outcomes were highly variable among the included studies, with in-hospital or short-term mortality ranging between 8% and 65%, mainly depending on baseline patient features. Random-effect pooled estimates suggested an overall in-hospital mortality of 28% (95% confidence interval 18% to 37%; I2 = 64%). Conclusions ECMO is feasible and effective in patients with ALI due to H1N1 infection. Despite this, prolonged support (more than one week) is required in most cases, and subjects with severe comorbidities or multiorgan failure remain at high risk of in-hospital death.
    Critical care (London, England) 02/2013; 17(1):R30. DOI:10.1186/cc12512 · 4.48 Impact Factor
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    • "Severe cases of influenza infection are often associated with multisystem organ failure and hypoxemic respiratory failure, including acute lung injury/acute respiratory distress syndrome (ALI/ARDS) requiring advanced mechanical ventilatory support 24, 25. Affected individuals may receive 'rescue' therapies, including iNO, in an attempt to improve outcome 25. "
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    ABSTRACT: In vitro, nitric oxide (NO) has been shown to have antimicrobial activity against a wide range of viruses, including influenza A virus. Therefore, we hypothesized that inhaled nitric oxide (iNO) would increase survival in vivo by reducing the viral load in C57Bl/6 mice infected with a lethal dose of influenza A/WSN/33 (H1N1; WSN/33) virus. NO was delivered to influenza-infected mice either continuously or intermittently at 80 or 160 ppm, respectively, using both prophylactic and post-infection treatment strategies. Murine survival and weight loss were assessed, and lung viral load was quantified via plaque assay. Here, we report that iNO administered prophylactically or post-influenza infection failed to improve survival of infected mice. No difference in lung viral load was observed between experimental groups. Although NO has antiviral activity against influenza A virus in vitro, iNO therapy provided no apparent benefit when used for treatment of influenza A virus infection in vivo.
    International journal of medical sciences 01/2012; 9(2):157-62. DOI:10.7150/ijms.3880 · 2.00 Impact Factor
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    ABSTRACT: Pandemic influenza: intensive care management of adults and children The clinical course of pandemic H1N1 infection has been quite different from seasonal influenza in- fection. It has mostly affected young and healthy population. Depending on outbreak's course till to- day and the previous outbreaks 12-30% of the population was expected to become ill and among them 4% was expected to be hospitalised throughout the pandemic. It was estimated for all inten- sive care unit (ICU) beds to be occupied with patients infected with H1N1 virus in the first period of the pandemic. Fortunately, without being confronted with this situation, pandemic has been mil- der than expected. Any how, in southern hemisphere as in Australia and New Zeland which were
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