World Journal of Emergency Medicine ›› 2018, Vol. 9 ›› Issue (2): 118-124.doi: 10.5847/wjem.j.1920-8642.2018.02.006
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Hui Xie, Zhi-gang Zhou, Wei Jin, Cheng-bin Yuan, Jiang Du, Jian Lu, Rui-lan Wang(
)
Received:2017-05-08
Online:2018-06-15
Published:2018-06-15
Contact:
Rui-lan Wang
E-mail:wangyusun@hotmail.com
Hui Xie, Zhi-gang Zhou, Wei Jin, Cheng-bin Yuan, Jiang Du, Jian Lu, Rui-lan Wang. Ventilator management for acute respiratory distress syndrome associated with avian influenza A (H7N9) virus infection: A case series[J]. World Journal of Emergency Medicine, 2018, 9(2): 118-124.
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Table 1
Clinical characteristics of 8 patients infected with H7N9 virus
| Parameters | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 |
|---|---|---|---|---|---|---|---|---|
| Age (year) | 61 | 35 | 54 | 34 | 72 | 62 | 58 | 83 |
| Sex | Female | Male | Male | Male | Male | Female | Male | Female |
| Underlying conditions | Hypertension | / | / | / | Hypertension | / | Cerebellar hemorrhage, cirrhosis | Hypertension, diabetes, atrial fibrillation |
| APACHE II | 19.25±6.34 | 8.25±2.06 | 11.00±3.37 | 8.50±3.00 | 8.25±2.63 | 9.00±2.58 | 8.50±1.91 | 24.67±2.31 |
| SOFA | 12.00±2.82 | 6.25±0.96 | 6.75±0.96 | 6.75±1.50 | 5.25±1.71 | 6.00±1.15 | 6.50±1.29 | 13.67±0.58 |
| Complications | ||||||||
| Acute renal damage | Yes | No | No | No | No | No | No | No |
| Rhabdomyolysis | Yes | Yes | Yes | Yes | Yes | No | No | Yes |
| Encephalopathy | Yes | No | No | No | No | No | No | No |
| Secondary infections | No | Yes | Yes | Yes | No | No | Yes | Yes |
| Stphylococcus epidermidis | Staphylococcus haemolyticus, pseudomonas aeruginosa | Staphylococcus aureus | Staphylococcus aureus | Candida albicans, Candida tropicalis | ||||
| Duration of MV (days) | 20 | 20 | 25 | 13 | 7 | 13 | 11 | 9 |
| Prone position of MV (days) | 2 | / | / | 2 | / | / | / | / |
| Recruitment maneuvers | Yes | Yes | Yes | Yes | No | No | No | No |
| Continuous renal replacement therapy (CRRT) | Yes | No | No | No | No | No | No | No (abandoned) |
| Antibiotic therapy | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Antiviral agent | Oseltamivir | Oseltamivir | Oseltamivir | Oseltamivir | Oseltamivir | Oseltamivir | Oseltamivir | Oseltamivir |
| Glucocorticoid therapy | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Intravenous immune globulin therapy | Yes | Yes | Yes | No | No | Yes | Yes | Yes |
| Anticoagulation | LMW Heparins | LMW Heparins | LMW Heparins | LMW Heparins | LMW Heparins | LMW Heparins | / | LMW Heparins |
| Length of stay in ICU (days) | 20 | 30 | 25 | 20 | 15 | 15 | 41 | 11 |
| Length of stay in hospital (days) | 20 | 40 | 25 | 27 | 25 | 27 | 41 | 11 |
| Outcome | Died | Survived | Died | Survived | Survived | Survived | Survived | Died |
Table 2
CT findings in 8 patients infected with H7N9 virus, n (%)
| CT findings | Patients (n=8) |
|---|---|
| Architectural distortion | 8 (100) |
| Traction bronchiolectasis | 6 (75) |
| Traction bronchiectasis | 6 (75) |
| Intralobular septal thickening | 4 (50) |
| Interlobular septal thickening | 7 (87) |
| Honeycombing | 1 (12.5) |
| Ground-glass attenuation | 8 (100) |
| Air-space consolidation | 8 (100) |
Figure 1.
Finding in a 35-year-old man who survived (patient 2). A: first CT; B: six months after discharge from hospital.
Figure 2.
Finding in a 54-year-old man who did not survive (patient 3). CT shows diffuse interstitial exudation and areas of ground-glass attenuation associated with traction bronchiolectasis (arrows), bronchiectasisand architectural distortion. This patient died of pneumothorax after long-term MV.
Table 3
Extent of each CT finding in 8 patients infected with H7N9 virus
| Parameters | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | Mean±SD |
|---|---|---|---|---|---|---|---|---|---|
| The Murray's score at the first CT examination | 3.67 | 3.25 | 2.75 | 2.75 | 3.25 | 3.33 | 2.5 | 2.5 | 2.97±1.03 |
| The CT score at the first CT examination | 260.9 | 240.4 | 294.7 | 207.6 | 240.4 | 196.3 | 255.7 | 285.4 | 247.68±34.28 |
| Spared area (%) | 26.0 | 17.0 | 33.5 | 55.3 | 35.2 | 60.0 | 24.5 | 25.6 | 34.64±15.32 |
| Ground-glass attenuation (%) | 22.4 | 32.6 | 6.5 | 10.2 | 10.5 | 10.5 | 18.6 | 24 | 16.91±8.98 |
| Air-space consolidation (%) | 31.3 | 46.9 | 13.5 | 17.2 | 42.4 | 16.1 | 40 | 6.4 | 26.73±15.31 |
| Ground-glass attenuation + traction bronchiolectasis or bronchiectasis (%) | 5.3 | 0 | 24.8 | 6.2 | 2.5 | 0 | 10.5 | 30.4 | 9.96±11.52 |
| Air-space consolidation + traction bronchiolectasis or bronchiectasis (%) | 15.0 | 3.5 | 21.7 | 11.1 | 9.4 | 13.4 | 6.4 | 10.6 | 11.39±5.54 |
| Honeycombing (%) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 3 | 0.375±1.06 |
Figure 3.
Illustration of PEEP induced lung recruitment detected by bedside ultrasound in patient 2. A: The images of upper part of anterior region of left chest wall before and after RM. Left: Transversal view of a lung region with alveolar syndrome. Multiple well-defined B lines (B1 lines) arising from the pleural line are present. Right: After RM, the same lung region appears normally aerated. The pleural line can be seen. B: The images of upper part of anterior region of right chest wall before and after RM. Left: Coalescent B lines (B2 lines) arising from the pleural lineare present. Right: After RM, the same lung region appears normally aerated. The pleural line can be seen with two isolated B lines. These artifacts correspond to ground-glass areas on chest computed tomography. C: The images of lower part of lateral region of right chest wall before and after RM. Left: Transversal view of consolidated right lobe. Lung consolidation appears as a tissue structure can be seen. Right: After RM, the same lung region appears normally aerated. The pleural line can be seen with an isolated B line. These artifacts correspond to air-space consolidation areas on chest computed tomography.
Table 4
Extent of each CT finding in 8 patients infected with H7N9 virus
| Parameters | 1 | 2 | 3 | 4 |
|---|---|---|---|---|
| Ultrasound reaeration score | +7 | +10 | +11 | +6 |
| PEEP before RM (cmH2O) | 16 | 30 | 10 | 14 |
| FiO2 before RM (%) | 100 | 100 | 100 | 100 |
| PaO2/FiO2 ratio | ||||
| Before RM | 71 | 114 | 50 | 110 |
| After RM (20 minutes) | 93 | 220 | 191 | 125 |
| PaO2/FiO2 increase (%) | 30.99 | 92.98 | 282 | 13.64 |
| Lung recruitment measured with the PV curve (mL) | 468 | 706 | 830 | 338 |
Figure 4.
The PaO2/FiO2 ratio, PaCO2, PEEP, FiO2 values of the 61-year-old female patient (No. 1) during the prone positioning. This patient died of multiple organ failure (MOF) after refractory hypoxemia.
Figure 5.
The PaO2/FiO2 ratio, PaCO2, PEEP, FiO2 values of the 34-year-old male patient (No. 4) during the prone positioning.
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