Enfermeria

Intensive Care Med (2010) 36:33–41 DOI 10.1007/s00134-009-1727-6

ORIGINAL

Adolfo Maximo Quispe-Laime Jonas Daniel Bracco Patricia Alejandra Barberio Claudio German Campagne ´ Veronica Edith Rolfo Reba Umberger Gianfranco Umberto Meduri

H1N1 influenza A virus-associated acute lung injury: response to combination oseltamivir and prolonged corticosteroid treatment

Abstract Purpose: Duringthe 2009 H1N1 influenza A virus pandemic, a minority of patients developed rapidly progressive pneumonia leading to acute lung injury (ALI)—acute respiratory distress syndrome (ARDS). A recent metaanalysis provides support for prolonged corticosteroid treatment in ALI-ARDS. We prospectively evaluated the response to oseltamivir and prolonged corticosteroid treatment in patients with ALI-ARDS andsuspected H1N1 influenza. Methods: From June 24 through 12 July A. M. Quispe-Laime Á J. D. Bracco Á 2009, 13 patients with suspected P. A. Barberio Á C. G. Campagne Á H1N1 pneumonia and ALI-ARDS V. E. Rolfo Medical Intensive Care Unit, Dr. Leonidas were admitted to the intensive care Lucero Acute Municipal Hospital, unit (ICU) of a tertiary care hospital. Universidad Nacional del Sur, H1N1 influenzawas confirmed with Bahia Blanca, Argentina real-time reverse transcriptase-polymerase chain reaction assay in eight R. Umberger Á G. U. Meduri Memphis Veterans Affairs Medical Center, patients. Oseltamivir and corticosteroid treatment were initiated Memphis, TN, USA concomitantly at ICU admission; G. U. Meduri ()) those with severe ARDS received Division of Pulmonary, Critical Care,methylprednisolone (1 mg/kg/day), and Sleep Medicine, and others received hydrocortisone University of Tennessee Health Science (300 mg/day) for a duration of Center, 956 Court Avenue, Room E222B, 21 ± 6 days. Results: Patients with Memphis, TN 38163, USA and without confirmed H1N1 e-mail: umeduri@utmem.edu
Received: 19 September 2009 Accepted: 30 October 2009 Published online: 19 November 2009 Ó Copyrightjointly hold by Springer and ESICM 2009

influenza had similar disease severity at presentation and a comparable response to treatment. By day 7 of treatment, patients experienced a significant improvement in lung injury and multiple organ dysfunction scores (P \ 0.001). Twelve patients (92%) improved lung function, were extubated, and discharged alive from the ICU. Hospital length of stay andmortality were 18.7 ± 9.6 days and 15%, respectively. Survivors were discharged home without oxygen supplementation. Conclusions: In ARDS patients, with and without confirmed H1N1 influenza, prolonged low-to-moderate dose corticosteroid treatment was well tolerated and associated with significant improvement in lung injury and multiple organ dysfunction scores and a low hospital mortality. These findingsprovide the rationale for developing a randomized trial. Keywords H1N1 influenza A virus Á Acute respiratory distress syndrome Á Corticosteroid treatment Á Mechanical ventilation Á Mortality

Introduction

and multiple organ dysfunction (MODS), associated with prolonged intensive care unit (ICU) stay and high During the 2009 H1N1 influenza A virus pandemic, a (17–54%) mortality [1–7]. In influenza,including minority of patients have developed severe pneumonia H1N1, experimental and clinical studies have identified leading to acute respiratory distress syndrome (ARDS) dysregulated systemic inflammation as an important

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pathogenetic mechanism correlating with disease severity and progression [1, 8–11]. There has been significant advancement in our understanding of the cellular mechanismsof corticosteroid action [12] and the interaction between corticosteroids and transcription factors for inflammatory cytokines in critical illness and ARDS [13, 14]. Within this new pathogenetic construct [15], an extensive rationale was recently provided for low-tomoderate dose prolonged corticosteroid treatment as an adjunct to antiviral therapy in severe cases of H5N1 influenza [8]. In the...