Posted by Intensive Care Unit, United Christian Hospital, on 16 July 2009 

A F/37 of good past health came to work in Hong Kong. On the next day after arrival, she noticed to have fever during routine body check. CXR was normal.
She was given antibiotics. As the patient complained of persistent runny nose, sore throat and diarrhoea, she attended AED 10 days afterwards.
 

 

Figure. CXR on D1 of hospital admission shows bilateral pulmonary consolidation

Clinically she had severe CAP with severe desaturation, and was therefore directly admitted to the ICU. She was put on non-invasive ventilatory support. WCC was normal; ABG showed type I failure. Tienam and azithromycin were started. NPA influenza A/B rapid test was negative, and it was sent for viral culture. Subsequently, she had to be intubated as the conditon deteriorated.

Figure. CXR on D2 

Initial throat and nasal swab RT PCR swine: -ve. Other microbiological tests including mycoplasma and legionella were negative.

D4: T/A M protein +, started on tamiflu and amantadine

Figure. CXR on D4


D5: 1st NPA specimen for RT-PCR swine H1 +ve: confirmed swine flu. Tamiflu dose was doubled to 150mg BD, amantadine was deleted. N-acetylcysteine and statin were added. 

D6: Could not tolerate nebulized relenza because of severe desaturation

D7: Extracoporeal membrane oxygenation (ECMO) was started in view of further worsening despite high ventilatory support (PCV FiO2 1.0, high Pinsp 35 + PEEP 25), although the CXR showed some improvement 

Figure: Extracoporeal membrane oxygenation (ECMO): The Terumo Capiox (TM)

There was no other vital organ failure, and she only needed inotropic support for a short period. SaO2 could be maintained, but she failed to wean down ventilatory support so far.

D9: Zinc supplement was added

Figure. CXR on D10

Diagnosis: Novel Swine-Origin Influenza A H1N1 Pneumonia

Please kindly comment on the management of this patient, and also on future ICU care of H1N1 cases.