title: Systematic approach for severe respiratory failure due to novel A (H1N1) influenza.
abstract: OBJECTIVE
  In April 2009, a novel influenza A (H1N1) virus appeared in Mexico. It rapidly acquired the characteristics of a pandemic disease. Our objective is to present a case series of mechanically ventilated patients with severe influenza, treated with a systematic approach.
  
  
  METHODS
  Prospective, observational, single-center study in a University Hospital. A (H1N1) virus was confirmed by rRT-PCR. In this report, we only considered patients that required mechanical ventilation (MV). All patients received antibiotics, steroids and oseltamivir from the time of admission. The main strategies incorporated in the systematic approach were a lung-protective strategy, PEEP adjusted for each patient, protocol-guided sedoanalgesia, restrictive fluid management, weaning protocol, and prolonged prone ventilation and extracorporeal membrane oxygenation (ECMO) as rescue therapies.
  
  
  RESULTS
  We studied 19 patients: age 41 ± 13 years old, APACHE II 16 ± 7 and SOFA 8 ± 4. All patients presented PaO2/FiO2 ≤ 200 before connection to MV. Their worst values within the first 24 hours for oxygenation index, PaO2/FiO2, and PaCO2 on MV were 21.8 ± 13, 98 ± 39, and 48 ± 16 mmHg, respectively. Sixteen patients achieved ARDS; three exhibited acute lung injury criteria. Ten required a prone position, and two required ECMO (one patient required both therapies). Time on MV was 16 ± 13 days. Length of stay in the ICU and in hospital was 18 ± 12 and 28 ± 17 days, respectively. Mortality was 21%.
  
  
  CONCLUSIONS
  Severe hypoxemia and a high rate of rescue therapies were observed among our patients. Nevertheless, mortality was lower than previously reported in comparable populations, which may be related to the management by a critical care team and the use of a systematic approach for ventilatory and non-ventilatory therapeutic strategies.
authors.affiliation: Intensive Care Unit, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago, Chile. racornej@gmail.com
authors.forename: R
authors.initials: R
authors.lastname: Cornejo
authors.forename: E
authors.initials: E
authors.lastname: Tobar
authors.forename: G
authors.initials: G
authors.lastname: Díaz
authors.forename: C
authors.initials: C
authors.lastname: Romero
authors.forename: O
authors.initials: O
authors.lastname: Llanos
authors.forename: L R
authors.initials: LR
authors.lastname: Gálvez
authors.forename: A
authors.initials: A
authors.lastname: Zamorano
authors.forename: L
authors.initials: L
authors.lastname: Fábrega
authors.forename: W
authors.initials: W
authors.lastname: Neira
authors.forename: D
authors.initials: D
authors.lastname: Arellano
authors.forename: C
authors.initials: C
authors.lastname: Repetto
authors.forename: D
authors.initials: D
authors.lastname: Aedo
authors.forename: J Carlos
authors.initials: JC
authors.lastname: Díaz
authors.forename: R
authors.initials: R
authors.lastname: González
mesh_terms: D000293:Adolescent; D000328:Adult; D002677:Chile; D002985:Clinical Protocols; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D053118:Influenza A Virus, H1N1 Subtype; D007251:Influenza, Human / Q000150:complications* / Q000628:therapy* / Q000821:virology; D008297:Male; D008875:Middle Aged; D010100:Oxygen / Q000097:blood; D011175:Positive-Pressure Respiration; D012121:Respiration, Artificial; D012131:Respiratory Insufficiency / Q000209:etiology* / Q000628:therapy*; D015656:Respiratory Mechanics / Q000502:physiology; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D010100:Oxygen