Critically Ill Patients with H1N1 Pneumonia: Two Year Experience in a Tertiary Level Indian ICU

Purpose: To learn about the clinical profile, outcome and quality of life and factors influencing these, in critically ill patients with H1N1 pneumonia. Methods: Retrospective analysis of case files and phone interview of 88patients with confirmed H1N1 pneumonia. Results: Out of 88 patients, 51 were males. Mean age was 48.23 [± 13.03]. 39 [44.31%] were in the 31-50 years age group and 37 [42.04%] were in the 51-70 age group. Diabetes [n=16] and Hypertension [n=20] were the most common comorbidities. Majority of the patients presented with cough [n=87], breathlessness [n=85] and fever [n=84]. 43 patients had severe ARDS on admission. Mean APACHE II score was 9.6 [± 5.4] Mean SOFA scores 4.99 [± 2.6]. Mean Murray score was 2.37 [± 0.76]. 46 patients [52%] survived. Factors associated with mortality were APACHE score [p=0.00], SOFA score [p=0.00] Murray score, severe ARDS [p=0.00], requirement of vasopressor support [p=0.00] or renal replacement therapy [p=0.00] and incidence of VAP [p=0.039]. Diabetes had a protective effect [p=0.04], as had non-invasive ventilation [p=0.00]. Murray score [p=0.000, SOFA score [p=0.036], initiation of mechanical ventilation [p=0.003] and incidence of VAP [p=0.00] was associated with increased length of stay among the survivors. Conclusion: Higher lung specific severity scores, severe ARDS, secondary organ failure and VAP were associated with increased mortality. Among survivors, higher Murray and SOFA scores, mechanical ventilation and vasopressor use entailed a longer ICU stay.

Extracorporeal membrane oxygenation in Jehovah’s Witness patients: Case report, literature review, and summary of recommendations

Extracorporeal Membrane Oxygenation (ECMO) is commonly associated with a high blood transfusion requirement. Jehovah’s Witness patients present a particular challenge. The impossibility of transfusing blood cells and starting anticoagulation treatment are common contraindications for this supportive measure. Here we report the case of a Jehovah’s Witness patient with refractory hypoxemia due to influenza A H1N1 pneumonia who required venovenous ECMO for 11 days. We describe the use of a bloodless approach to reduce the waste of blood, avoiding anticoagulation, and improving red blood cell production. We then summarize the current literature on the use of ECMO in Jehovah’s Witness patients and, finally, we propose some recommendations for their management.

Atraumatic Splenic Rupture Associated with Influenza A (H1N1) Pneumonia: Case Report and Review of the Literature

Influenza virus infection may present with fever, chills, headache, myalgia, malaise, and respiratory symptoms, with a few cases developing into pneumonia, respiratory failure, and other organ damage. Very few cases of atraumatic splenic rupture associated with influenza infection have been reported. Atraumatic splenic rupture, while rare, is associated with high mortality. Here, we report the first case of atraumatic splenic rupture associated with influenza infection in the English literature and review the prior reported literature. The patient was diagnosed with influenza A (H1N1) pneumonia and subsequently developed hemorrhagic shock requiring emergency laparotomy and removal of the ruptured spleen.

Differential Diagnosis of COVID-19 Pneumonia From Influenza A (H1N1) Pneumonia Using a Model Based on Clinicoradiologic Features

Objectives: Both coronavirus disease 2019 (COVID-19) pneumonia and influenza A (H1N1) pneumonia are highly contagious diseases. We aimed to characterize initial computed tomography (CT) and clinical features and to develop a model for differentiating COVID-19 pneumonia from H1N1 pneumonia.Methods: In total, we enrolled 291 patients with COVID-19 pneumonia from January 20 to February 13, 2020, and 97 patients with H1N1 pneumonia from May 24, 2009, to January 29, 2010 from two hospitals. Patients were randomly grouped into a primary cohort and a validation cohort using a seven-to-three ratio, and their clinicoradiologic data on admission were compared. The clinicoradiologic features were optimized by the least absolute shrinkage and selection operator (LASSO) logistic regression analysis to generate a model for differential diagnosis. Receiver operating characteristic (ROC) curves were plotted for assessing the performance of the model in the primary and validation cohorts.Results: The COVID-19 pneumonia mainly presented a peripheral distribution pattern (262/291, 90.0%); in contrast, H1N1 pneumonia most commonly presented a peribronchovascular distribution pattern (52/97, 53.6%). In LASSO logistic regression, peripheral distribution patterns, older age, low-grade fever, and slightly elevated aspartate aminotransferase (AST) were associated with COVID-19 pneumonia, whereas, a peribronchovascular distribution pattern, centrilobular nodule or tree-in-bud sign, consolidation, bronchial wall thickening or bronchiectasis, younger age, hyperpyrexia, and a higher level of AST were associated with H1N1 pneumonia. For the primary and validation cohorts, the LASSO model containing above eight clinicoradiologic features yielded an area under curve (AUC) of 0.963 and 0.943, with sensitivity of 89.7 and 86.2%, specificity of 89.7 and 89.7%, and accuracy of 89.7 and 87.1%, respectively.Conclusions: Combination of distribution pattern and category of pulmonary opacity on chest CT with clinical features facilitates the differentiation of COVID-19 pneumonia from H1N1 pneumonia.

Six-Month Outcomes of Post-ARDS Pulmonary Fibrosis in Patients With H1N1 Pneumonia

Background: Influenza virus is a common pathogen causing community-acquired pneumonia. After H1N1 infection, some patients present with rapid disease progression and various respiratory complications, especially immunocompromised patients and pregnant women. However, most patients have a favorable prognosis. Influenza viruses infect respiratory epithelial cells, leading to diffuse alveolar damage (DAD), which could induce secondary bacterial or fungal infections that could lead to serious complications, such as acute respiratory failure, severe pneumonia, pneumothorax, mediastinal emphysema, acute respiratory distress syndrome (ARDS) and post-ARDS fibrosis.Objective: The short-term mortality rate of ARDS is decreasing, and understanding survivors’ posthospitalization outcomes is very important. Our aim was to evaluate the outcomes of 69 patients who survived H1N1 pneumonia with severe respiratory complications and abnormal CT findings and developed post-ARDS pulmonary fibrosis.Materials and methods: The 280 inpatients included in this trial had been diagnosed with H1N1 infection that was confirmed by pharyngeal sputum or swab tests. The data were collected from January 2018 to January 2020 in the First Affiliated Hospital of Zhengzhou University and the Sixth People's Hospital of Zhengzhou. Of these patients, 232 had CT findings indicating pulmonary fibrosis after H1N1 infection, and 69 survived and consented to participate in this study. 6°months after diagnosis, the 69 surviving patients were interviewed and underwent physical examinations, CT scans, 6°min walk tests, and quality-of-life evaluations (SF-36). We analyzed the baseline variables and six-month outcomes of post-ARDS pulmonary fibrosis in patients with H1N1 pneumonia.Results: Of the 69 surviving patients with post-ARDS pulmonary fibrosis, there were 24 females and 45 males, with a mean age of 53.7 ± 16.8°years; 18 patients (26%) had no underlying disease, and 14 (20%) patients had more than one underlying disease. The distance walked in 6°min increased from an average of 451.9°m at 3°months to 575.4°m at 6°months; the mean 36-Item Short Form Survey (SF-36) physical function score increased from an average of 75.3 at 3°months to 77.5 at 6°months; and the average CT score decreased from 31.3 at 3°months to 14.8 at 6°months. Treatment with systemic corticosteroids and the presence of an underlying disease were related to the CT score and the distance walked in 6°min.Conclusion: Among the survivors with pulmonary fibrosis after H1N1 influenza, the 6°min walk test and CT scores continued to be affected after 6°months. The 6°min walk distance and imaging findings improved during the first 6°months. The health-related QoL (HRQoL) scores of H1N1 pneumonia survivors were lower than those of sex- and age-matched controls.

Comparative Study of Hematological and Radiological Feature of Severe/Critically Ill Patients with COVID-19, Influenza A H7N9 and H1N1 Pneumonia

Objectives This study aimed to explore useful clinical indexes for management of severe/critically ill patients with COVID-19, Influenza A H7N9 and H1N1 pneumonia by comparing hematological and radiological characteristics between them. Methods Severe/critically ill patients with confirmed diagnosis of COVID-19, Influenza A H7N9 and H1N1 pneumonia were retrospectively enrolled. The demographic data, clinical manifestations, hematological parameters, and radiological characteristics of three groups were compared. The influenza A was divided into two groups with/without patient death.Results In this study, 16 cases of COVID-19, 10 cases of influenza A (H7N9), and 13 cases of influenza A (H1N1) who met severe/critically ill criteria were included. Compared with COVID-19, the Influenza A (H7N9 and H1N1) groups had relatively more chronic diseases (80% and 92.3% vs 25%, P＜0.05), higher APACHE Ⅱ scores (16.00 ± 8.63 and 15.08 ± 6.24, vs 5.50 ± 2.58, P＜0.05) and higher mortality rates (40% and 46.2% vs 0%, P＜0.05). The hematological finding indicated that Influenza A H7N9 and H1N1 patients had more significant lymphocytopenia (0.59 ± 0.31 × 109/L and 0.56 ± 0.35 × 109/L vs 0.97 ± 0.33 × 109/L, P < 0.05), elevated neutrophil to lymphocyte ratio (NLR; 14.67 ± 6.10 and 14.64 ± 10.36 vs 6.29 ± 3.72, P < 0.05) compared to COVID-19. Especially in influenza A patients, NLR was significant different between the patients with or without death. Compared with the H7N9 group, ground glass opacity (GGO) on chest CT was more common in the COVID-19 group (P = 0.028), while pleural effusion was relatively rare (P = 0.001).ConclusionCompared to COVID-19, patients with Influenza A (H7N9 and H1N1) had more underlying chronic diseases and higher mortality rates. The NLR can be used as a clinical parameter for the predication of risk stratification and outcome in COVID-19 and Influenza A pneumonia. Manifestations of pleural effusion or GGO in chest CT may be helpful for the identification of different viral pneumonia.