Death by Swine Flu

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Inflamed, Flooded Lungs Trigger Death by Swine Flu, Study Says

http://www.bloomberg.com/apps/news?pid=20601081&sid=aPd3JODa5N08

Swine flu is most dangerous when it causes the lungs to become inflamed, flood with fluid and fail to function, doctors in Australia and New Zealand found.

While a majority of people infected with the virus have a mild illness, a small number develop life-threatening disease, intensive-care specialists Steven Webb and Ian Seppelt said. The doctors described the most common of three main complications from the pandemic strain as flu A-associated acute respiratory disease syndrome, or "flaards."

"Flaards -- sometimes with associated multiple organ failure -- is the most common syndrome and has the highest attributable mortality," Webb and Seppelt wrote in an editorial in the September issue of the medical journal Critical Care and Resuscitation.

The new H1N1 influenza strain has killed at least 3,917 people and spread to 191 countries and territories since its discovery in Mexico and the U.S. in April. Hospitals in the Northern Hemisphere are bracing for a surge in flu cases in coming weeks, spurred by colder weather that promotes its spread. In Australia, flu patients occupied a quarter of beds in intensive-care units last winter and 178 died.

Cases may be peaking in Hong Kong. Average daily attendance at the city's accident and emergency departments rose from 6,354 in the last week of August to 7,086 last week, according to a government statement on Sept. 25. The virus has killed at least 23 people in Hong Kong, including Alan Dick, principal of the Canadian International School, according to Natalia Leung, a department of health spokeswoman.

Intensive-care doctors in Australia and New Zealand are pooling data on more than 400 swine flu cases to describe disease patterns and treatment strategies, and inform the Northern Hemisphere countries about what to expect this winter.

'Canary in the Coal Mine'

"ICUs are the 'canary in the coal mine'," Webb and Seppelt wrote in the editorial. "It is only by documenting the severe cases requiring intensive care that it is possible to get an idea of the overall impact of this new disease."

In Victoria, Australia's second most-populous state, the pandemic virus sickened about 5 percent of the population, with 0.3 percent of infected patients being hospitalized, health officials said in a study yesterday in the Medical Journal of Australia. One in five people admitted to the hospital were transferred to ICU, mostly because of severe respiratory failure.

Eighty-five percent of critically ill patients survived after staying an average of nine days in ICU. Almost three- quarters of these patients required mechanical ventilation to breathe and 7 percent needed to have their blood pumped through an artificial lung in a procedure known as extracorporeal membrane oxygenation, or ECMO.

Lung Invader

In most cases, flu remains in the nose, throat and bronchi, where it causes a runny nose, sore throat and cough until the body's immune systems eliminates it, usually within a week.

The new H1N1 strain may be at least 1,000 times more adept than seasonal flu at infiltrating the lower branches of the airway, said Yoshihiro Kawaoka, a virologist at the University of Tokyo, who has studied the viruses in non-human primates.

In severe cases, influenza can damage the capillaries surrounding the tiny grape-like sacs, known as alveoli, where gas is exchanged through the blood. Damaged alveoli can bleed, causing pulmonary hemorrhage and blood clots.

Inflammatory chemicals are produced by the immune system to fight the infection and repair the damage. An over-exuberant response can worsen the effect by filling the lungs with fluid and cause permanent scarring that restricts the lungs.

Bacterial Pneumonia

Besides flaards, the other predominant disease patterns associated with the pandemic flu virus are community-acquired bacterial pneumonia and an exacerbation by the virus of airflow limitation, Webb and Seppelt said.

Life-threatening infection may be more common in people with underlying health conditions, including morbid obesity, type-2 diabetes, cancer, a weakened immune system and chronic lung disease, they said. Pregnant women and those who recently gave birth also appear at higher risk.

Still, "many patients with flaards are young and previously well," they said. In Australia, the median age of people dying from seasonal flu is 83. With the novel H1N1 virus, it is 51 years, the health department said in a report last week.

(hat tip Avian Flu Diary)

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Specializes in School Nursing.

I wonder...now that they know this, is there a way to break the inflammatory cycle and prevent a "routine" H1N1 case from developing ARDS? RTC anti-inflammatories? I dunno, but I wish they would come up with some kind of home-care that is effective in preventing this complication, because it seems pretty random on who gets a mild 2-3 day illness and who ends up dead. Add to that the fact that clinics, EDs and PCPs in my area are swamped and basically refusing patients with only mild symptoms and no chronic conditions, and you have cases like the 8th grader who died this week.

I sent a 1st grader home yesterday with flu like symptoms. He has severe asthma and has already been hospitalized once this year and once last year for pneumonia. His mom took his straight to the ED at the children's hospital and waited until 1AM, when she finally gave up and went home. His PCP is squeezing him in today. I am glad he made it through the night. I am scared for my kiddos and staff at this point. We have 10% of the student population absent, most of which have flu like illness.

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Specializes in NICU, PICU, PCVICU and peds oncology.

My son has cold symptoms today. He has no fever, but has a runny nose. He has pre-existing health issues so I'm really not looking forward to winter. Never mind the N95 mask thing at work, I'm worried about my boy.

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Specializes in Too many to list.

I meant to get back to you about those masks, janfrn. The IOM came out with guidance recently that said the N95 should be fit tested, as you may have heard.

I would say to that, good guidance, but the study it was based on in Beijing, China clearly said that it did not seem to matter whether or not the masks were fit tested or not, just as long as it was an N95, they were 75% more efficacious than the surgical mask. You could listen to the actual testimony of Dr. Raina McIntyre at the IOM open hearings on this if you have the time as it is archived. It stayed in my mind because of you.

I only bring this up because you mentioned in a prior post your concern about the poor fit. It is better to have a good fit, but because of that study, I am not as personally concerned for myself though I am very careful with these patients when they are actively coughing. Actually, I worry more about people that do not know that they are infected, are not masked, but are coughing, like the folks on the airplanes that I traveled on last week to the CIDRAP Conference.

We are all gaining lots of experience in PPE right now, even on my psych unit as these patients begin to show s/s after they are admitted to our floor. We have to put on our gear in the nurse's station, and troop down the hall in full PPE to the patient's room.

We are so not prepared to deal with this on this type of unit...

I am sorry that your little one is sick right now. I hope that he recovers quickly.

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Specializes in Too many to list.

I wonder...now that they know this, is there a way to break the inflammatory cycle and prevent a "routine" H1N1 case from developing ARDS? RTC anti-inflammatories?

I think that starting anti-inflammatories would be a very good idea for a certain subset of kids known to have had to use them in the past. Parents should be having a discussion with the docs, and maybe with the school nurse about this now in advance of the kids getting sick. Being pro-active, and having a plan is smart given how busy these docs are going to be very soon.

I say this only because I am an asthmatic, and have had to use the prednisone dose packs myself. I know when I need it. A sick colleague put herself on prednisone recently. She was a probable swine flu case (exposed to cousin on Tamiflu), and very ill when she called off work. I saw how sick she was when she left work, and I do believe that starting the prednisone for her was a very wise idea. She is an immune suppressed asthmatic with several other health problems as well. She did, of course, contact her doc about what she was doing as well.

As for the otherwise perfectly healthy kids that start getting very sick, I am stumped there. How do we protect them? It is not happening from hand washing. The science simply does not support handwashing as a method of preventing swine flu. This was a point hammered home at the CIDRAP Conference. Handwashing is important for other reasons, but it will not prevent kids from getting swine flu at school.

I cannot help but admit that some of these fatal cases particularly in children have really shaken me...The very last point that Dr. Osterholm made at the CIDRAP Conference was that many would not take this pandemic seriously until the numbers of dead children became too many to be ignored. As I read some of the comments on some of these threads here at allnurses, I have to agree. Until the personal tragedy of these families actually hits them in the face, many will trivialize what is happening.

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I saw very sad thing on TV news yesterday. A grief stricken man talking about his dead 14 year old daughter. Child had no health problems. It was 4 days from onset of infection to death. They apparently were getting ready to put her on ECMO when she arrested. HE said, "my little girl was radiant". Then he cried. Just rips your heart out.

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Specializes in Too many to list.

Researcher Identifies New Target To Prevent Fatal Flu Lung Complication

http://www.redorbit.com/news/health/1762025/researcher_identifies_new_target_to_prevent_fatal_flu_lung_complication/

Research led by Dr. Jay Kolls, Professor and Chairman of Genetics at LSU Health Sciences Center New Orleans, has identified a therapeutic target for acute lung injury resulting in acute respiratory distress syndrome, a highly fatal complication of influenza infection. The research, which will be published in The Journal of Immunology in October, is currently available in the Next in the JI section online at http://0-www.jimmunol.org.innopac.lsuhsc.edu/cgi/reprint/jimmunol.0900995v1.

Interleukin-17 (IL-17), an immune system cell involved in proinflammatory response, is a potent regulator of neutrophils (white blood cells). Following infection, IL-17 uses a signaling receptor called IL-17RA to direct large numbers of neutrophils to the infection. Neutrophils play a key role in the development of acute lung injury because they rapidly infiltrate the lung and are an important source of cytokines (immunomodulating agents), a byproduct of which is swelling, fluid in the lungs, and low levels of oxygen in the blood.

The research team wanted to determine whether blocking IL-17RA signaling would protect against acute lung injury following influenza infection. Using an influenza model in control and knockout mice (genetically engineered without IL-17RA), they worked to identify a pathway to control the function of IL-17RA and the migration and action of neutrophils. They found decreased levels of illness and death among the IL-17RA knockout mice, despite a higher viral load. The researchers found that the knockout mice had fewer neutrophils in the lung, thus lower levels of inflammation and less lung injury. Comparing their results to studies of IL-17RA knockout mice in other models of viral infection, the researchers conclude that therapeutic regulation of IL-17 signaling may be beneficial not only in acute lung injury, but also in treating viral infections of other organs.

"Each year, more than 200,000 people are hospitalized with flu-related complications in the United States," notes Dr. Kolls. "A number of those who have died from H1N1 flu this year have had lung damage different than we typically see with seasonal flu. These cases have been marked by deep lung infections with diffuse damage to the alveoli - the structures that deliver oxygen to the blood. Advancing our findings has the potential to benefit both."

The research was supported by a grant from the National Heart, Lung, and Blood Institute of the National Institutes of Health.

(hat tip flutrackers/shiloh)

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Specializes in NICU, PICU, PCVICU and peds oncology.

Thanks for the further info on mask fittings, Indigo. I chuckled at your comment about my little one... who is 26, severely handicapped and developmentally delayed. He's also a transplant recipient. So I have big concerns for him. He attends a day program for severely handicapped/medically fragile adults and many of them have been sick in the recent past. The facility has a pandemic plan in place and will send clients home if the on-site nurse feels their symptoms are suggestive, so I'm thankful for that. I'm sure tempted at this point to put him on low-dose prednisone but he has such terrible side effects from it that it would be a last resort.

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Specializes in Too many to list.
Thanks for the further info on mask fittings, Indigo. I chuckled at your comment about my little one... who is 26, severely handicapped and developmentally delayed. He's also a transplant recipient. So I have big concerns for him. He attends a day program for severely handicapped/medically fragile adults and many of them have been sick in the recent past. The facility has a pandemic plan in place and will send clients home if the on-site nurse feels their symptoms are suggestive, so I'm thankful for that. I'm sure tempted at this point to put him on low-dose prednisone but he has such terrible side effects from it that it would be a last resort.

Not a little kid, but still your baby.

What does his doc say about using the low dose prednisone with his heatlh challenges? Not my area of expertise at all...

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Specializes in NICU, PICU, PCVICU and peds oncology.

I'd have to run it by her. He was on prednisone for a LONG time after his last rejection episode (thankfully nearly 20 years ago now) and gained 25 pounds. His BP was already high and only went higher still. But if it keeps him from ending up in ICU, then I think it might be worth it.

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