title: Lung function and organ dysfunctions in 178 patients requiring mechanical ventilation during the 2009 influenza A (H1N1) pandemic.
abstract: BACKGROUND
  Most cases of the 2009 influenza A (H1N1) infection are self-limited, but occasionally the disease evolves to a severe condition needing hospitalization. Here we describe the evolution of the respiratory compromise, ventilatory management and laboratory variables of patients with diffuse viral pneumonitis caused by pandemic 2009 influenza A (H1N1) admitted to the ICU.
  
  
  METHODS
  This was a multicenter, prospective inception cohort study including adult patients with acute respiratory failure requiring mechanical ventilation (MV) admitted to 20 ICUs in Argentina between June and September of 2009 during the influenza A (H1N1) pandemic. In a standard case-report form, we collected epidemiological characteristics, results of real-time reverse-transcriptase--polymerase-chain-reaction viral diagnostic tests, oxygenation variables, acid-base status, respiratory mechanics, ventilation management and laboratory tests. Variables were recorded on ICU admission and at days 3, 7 and 10.
  
  
  RESULTS
  During the study period 178 patients with diffuse viral pneumonitis requiring MV were admitted. They were 44 ± 15 years of age, with Acute Physiology And Chronic Health Evaluation II (APACHE II) scores of 18 ± 7, and most frequent comorbidities were obesity (26%), previous respiratory disease (24%) and immunosuppression (16%). Non-invasive ventilation (NIV) was applied in 49 (28%) patients on admission, but 94% were later intubated.Acute respiratory distress syndrome (ARDS) was present throughout the entire ICU stay in the whole group (mean PaO2/FIO2 170 ± 25). Tidal-volumes used were 7.8 to 8.1 ml/kg (ideal body weight), plateau pressures always remained < 30 cmH2O, without differences between survivors and non-survivors; and mean positive end-expiratory pressure (PEEP) levels used were between 8 to 12 cm H2O. Rescue therapies, like recruitment maneuvers (8 to 35%), prone positioning (12 to 24%) and tracheal gas insufflation (3%) were frequently applied. At all time points, pH, platelet count, lactate dehydrogenase assay (LDH) and Sequential Organ Failure Assessment (SOFA) differed significantly between survivors and non-survivors. Lack of recovery of platelet count and persistence of leukocytosis were characteristic of non-survivors. Mortality was high (46%); and length of MV was 10 (6 to 17) days.
  
  
  CONCLUSIONS
  These patients had severe, hypoxemic respiratory failure compatible with ARDS that persisted over time, frequently requiring rescue therapies to support oxygenation. NIV use is not warranted, given its high failure rate. Death and evolution to prolonged mechanical ventilation were common outcomes. Persistence of thrombocytopenia, acidosis and leukocytosis, and high LDH levels found in non-survivors during the course of the disease might be novel prognostic findings.
authors.affiliation: Sociedad Argentina de Terapia Intensiva, The Registry of the Argentinian Society of Intensive Care, Niceto Vega 4617, C1414BEA Ciudad de Buenos Aires, Argentina. fernandrios@gmail.com
authors.forename: Fernando G
authors.initials: FG
authors.lastname: Ríos
authors.forename: Elisa
authors.initials: E
authors.lastname: Estenssoro
authors.forename: Fernando
authors.initials: F
authors.lastname: Villarejo
authors.forename: Ricardo
authors.initials: R
authors.lastname: Valentini
authors.forename: Liliana
authors.initials: L
authors.lastname: Aguilar
authors.forename: Daniel
authors.initials: D
authors.lastname: Pezzola
authors.forename: Pascual
authors.initials: P
authors.lastname: Valdez
authors.forename: Miguel
authors.initials: M
authors.lastname: Blasco
authors.forename: Cristina
authors.initials: C
authors.lastname: Orlandi
authors.forename: Javier
authors.initials: J
authors.lastname: Alvarez
authors.forename: Fernando
authors.initials: F
authors.lastname: Saldarini
authors.forename: Alejandro
authors.initials: A
authors.lastname: Gómez
authors.forename: Pablo E
authors.initials: PE
authors.lastname: Gómez
authors.forename: Martin
authors.initials: M
authors.lastname: Deheza
authors.forename: Alan
authors.initials: A
authors.lastname: Zazu
authors.forename: Mónica
authors.initials: M
authors.lastname: Quinteros
authors.forename: Ariel
authors.initials: A
authors.lastname: Chena
authors.forename: Javier
authors.initials: J
authors.lastname: Osatnik
authors.forename: Damian
authors.initials: D
authors.lastname: Violi
authors.forename: Maria Eugenia
authors.initials: ME
authors.lastname: Gonzalez
authors.forename: Guillermo
authors.initials: G
authors.lastname: Chiappero
mesh_terms: D000328:Adult; D001118:Argentina / Q000453:epidemiology; D015331:Cohort Studies; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D053118:Influenza A Virus, H1N1 Subtype / Q000302:isolation & purification*; D007251:Influenza, Human / Q000453:epidemiology* / Q000503:physiopathology* / Q000821:virology; D007362:Intensive Care Units; D008168:Lung / Q000503:physiopathology*; D008297:Male; D008875:Middle Aged; D009102:Multiple Organ Failure / Q000453:epidemiology* / Q000503:physiopathology; D011014:Pneumonia / Q000401:mortality / Q000503:physiopathology / Q000821:virology*; D011446:Prospective Studies; D060888:Real-Time Polymerase Chain Reaction; D012121:Respiration, Artificial; D012129:Respiratory Function Tests; D016019:Survival Analysis