H1N1 Virus

H1N1 Resources

This page is a compilation and resource tool for respiratory therapists seeking information about the novel H1N1 virus.

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your experiences with H1N1, the patients you see and the modalities used. (See sample.)

In the last month we have had 4 confirmed cases of flu ages 18–34. All 4 patients presented with severe hypoxemia (PaO2/FIO2 < 80) and all required at least 15 of PEEP. Two required high frequency ventilation. 2 of 4 expired. All four were morbidly obese.

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Your Reports

Here are reports from the field as submitted by AARC members:

I want to pose a question to all RT’s: What are the isolation requirements where they are working? I have been to hospitals that only require a surgical mask, deeming H1N1 a “droplet” issue, and others requiring an N95 and eye protection. I have seen studies that show once the fluid droplet containing a virus evaporates, which can easily happen rapidly in a dry environment with lots of airflow, the viral particle can stay airborne on the currents for over 100 feet.

Brad Allen
Illinois

As a VA hospital, we have had fewer cases than in the greater community. To date we have had 6 confirmed cases; 4 out-patient, 1 in-patient and 1 52-year old in the ICU on a ventilator with ARDS for 12 days. No deaths so far.

Shelley Arjes
Minneapolis, MN

We have had one 21 year old healthy male who contracted the H1N1 on vacation, thought he was getting better but developed severe respiratory distress in an eight hour period. He was brought to our hospital in complete severe ARDS. He expired within a week despite using PCV with 18 cm H2O PEEP and inversing the I:E ratio. We have HFOV and nitric oxide, however our doctors would did not use it in this case. until he was to sick to recover. I would love to have some case studies involving HFOV and NO.

Shawn Morse
Pensacola, Florida

Four weeks ago we had every non-invasive device and most of our ventilators in use and almost every patient on our medical wards were in droplet precautions for Flu like symptoms. One of our patients was a 36 year old female that ended up with streptococcus meningitis she had an abscessed tooth when she got the flu that progressed to an ear infection and then to meningitis. She was on the vent for two weeks and then in the hospital for two more weeks.

Ki Rabe
Klamath Falls, OR

We have had five pediatric patients 5 years to 16 years that have required mechanical ventilation. Four have requred HFOV and nitric oxide therapy with one requiring ECMO. The one sent for ECMO passed away. The other four have been extubated and have gone home with some residual respiratory dysfunction.

Clifton Dennis, RRT, AE-C
Augusta, Georgia

Observed that most patients are morbidly obese. Question: has anyone thought about the levels of estrogen in H1N1 patients? (Editor's Note: Morbid obesity and pregnancy are both risk factors for H1N1)

Allen Hassler
Albuquerque, NM

We have had four patients with H1N1 who developed ARDS. One patient was 24 weeks pregnant. She was on the ventilator using Bilevel and her baby was delivered early. The baby was placed on HFO and INO, but expired. The mother went on to recover. A 78 year old women with COPD and H1N1 was also on Bilevel ventilation for treatment of hypoxemia. She survived but ended up receiving a tracheostomy. Two additional patients were both men in their 70/s who were ventilated using Bilevel and both ended up requiring tracheostomy as well. All patients have survived. For those that used the 3100B for the H1N1 / ARDS , can you share with me some of your process.

Jose Morales
Miami, FL

In June and July, we had 10 cases of suspected influenza A H1N1 infection with severe respiratory failure. Of these, 8 needed mechanical ventilation, with refractary hypoxemia (PaO2/FIO2<100), and received high PEEP levels, and in same cases recruitment maneuvers and prone position. Three were pregnant women, 4 morbidly obese, and 1 asthmatic. Three had tracheostomy (prolonged mechanical ventilation).

Marco Bezzi
Buenos Aires. Argentina

We have experienced 2 confirmed H1N1 experiences and one suspected case. All 3 patients were Hispanic and were obese. All have required pressure control ventilation with FIO2's consistently above 80%. One patient is currently on an FIO2 of 100% and has been on that FIO2 for greater than a week, PCO2s are normal to high 50's all patients have metabolic acidosis. Test for sputum did not seem to help in early diagnosis.

John Nikkel
San Mateo, CA

We have a pretty significant outbreak of H1N1 throughout the United Arab Emirates. At our facility in Al Ain, along the Omani border, we have had multiple cases admitted to our Adult and Pediatric ICU's. Most all of these cases have gone on to ARDS, and we have experienced little success with conventional ventilation, or even APRV. We have placed a number of these cases on HFOV due to the severity of the ARDS and frequent Air-Leak Syndromes. Most cases are requiring long ventilatory assistance and are being trached. Multi-organ failure is also a co-morbidity with these cases - especially in patients already compromised by underlying immuno-depression such as in cancer.

Steff Woodworth, RRT-NPS
Tawam Hospital, Al Ain, UAE

We have had a single patient with H1H1 flu. She was pregnant with severe hypoxemia. She received High Frequency Oscillation combined with Inhaled Nitric Oxide. She was on the ventilator for 43 days and survived. Today she looks as though she were never ill and is the mother of a beautiful baby boy.

Donna
Texas

We have had quite a few H1N1 patients present to the hospital (ages 18-45). 3 deaths in otherwise healthy young adults with no underlying medical problems. They are presenting with a severe ARDS picture. PCV being used, high levels of PEEP (>15cmH2O), 100% FiO2. We are currently using inhaled NO on an 18yo male with somewhat good results for hypoxemia. Still unable to wean FiO2 or PEEP.

John Pfeffer
Cincinnati, Ohio

We have just had a case with a 25-year-old presenting with shortness of breath and hypoxia. He is currently on 6 liters per minute of oxygen with a Pao2 of 67, Chest xray with left lower lobe infiltrate. We are still in the process of being able to screen patients coming in. I want to tell all the RTs to really keep your eyes out and protect yourself. (Editor's Note: Wear appropriate face mask protection, wash your hands, practice univeral precautions.) Make sure you are being heard if you suspect a patient with H1N1.

Angela Leyes
Portland, OR

This paper from Critical Care describes the clinical and epidemiologic characteristics of patients admitted to the ICU in Spain.

Anonymous
Spain

We have had two females in their 30s with critically low PaO2 and SpO2 on as much as 15 cm PEEP and 100%. Both are improving slowly but wonder about neurolical outcomes. Has anyone tried Inhaled NO to try and correct the profound hypoxemia?

Mark Brady
Topeka, Kansas

We have had 2 cases that presented. Both young obese males 30–40s. Both were intubated and placed on mechanical ventilation. With onset of ARDS per criteria, protective and open lung strategies were used. ARDS protocol used. VT 6ml/kg, permissive hypercapnea. Eventually APRV mode with initial settings of PH 35, TH 4s, PL 0, TL .8s. Worked very well for both. Eventually 1 pt weaned to CPAP. Had trouble weaning FiO2; we tried to wean Fio2 then CPAP. Patient was extubated to BiPap but decompensated and was reintubated and eventually trached. Other patient coded after three days post intubation and efforts were unsuccesful. In both cases, oxygenation was always main serious issue. Ventilation was controlled well as per ABGs even with permissive hypercapnea.

Greg Ruiz
Brownsville, Texas

We have three patients in our facility with the H1N1 virus. The all are experiencing low oxygen saturation. All 3 had infiltrates similar to pneumonia. They are presenting with flu-like symptoms. Xrays show common signs of pneumonia. They are all between the ages of 23–45, and all had a compromised immune system. One has a history of asthma. They are on ventilators and we have been using the ARDS protocol.

Suzana Williams
Port St. Lucie, Florida

Age range 29–39 y.o., One male, two females. Male with multiple sclerosis. Female (1) pregnant, female (2) post-op with history of open-heart surgery. All immediately placed on mechanical ventilation due to severe hypoxemia. They all stated they weren’t feeling good for a day or two then couldn't breathe.

Michelle Toon
Green Cove Springs, FL

We are seeing patients present to the ER with > 7days of symptoms with Respiratory Distress. Some are showing ABG results with low PaO2 and Normal SaO2. Anyone else seeing this? Any explanations?

Ken Smith
McAllen, Texas

One of our therapists is in her third trimester of pregnancy. She was getting ready to go into an H1N1 patient’s room, and our ID doctor told her not to go in; find someone else to see the patient. Later, another doctor asked her to go in and do an ABG. He then saw that she is pregnant, and told her to get someone else to go in. Nice to know our docs are looking out for us!

Kelly Welton
Torrance, CA