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Use of Rescue Therapies During the H1N1 Pandemic: A Systematic Review Exploring Global Differences in the Management of Severe Acute Respiratory Distress Syndrome FREE TO VIEW

Shruti Gadre, MD; Abhijit Duggal, MD
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Cleveland Clinic Foundation, Cleveland, OH

Chest. 2015;148(4_MeetingAbstracts):178A. doi:10.1378/chest.2274372
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SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM

PURPOSE: The 2009-2010 Influenza A (H1N1) outbreak was declared the first pandemic of this century after early reports of high morbidity and mortality. The H1N1 pandemic was the first instance of a pandemic that was globally reported over different geographical and socioeconomic strata. There are significant differences in the utilization of resources for Acute Respiratory Distress Syndrome (ARDS) management in different geographical settings. Our goal was to better understand global differences in the management of severe ARDS with a focus on the utilization of non-conventional modalities.

METHODS: We performed a systematic review of all studies published between 3/2009 and 6/2013 describing patients with ARDS during the 2009-2010 Influenza A (H1N1) outbreak.

RESULTS: We identified 121 studies from 41 countries that described ARDS in the setting of H1N1 influenza A. Only 39 (32.23%) studies from 20 countries reported exclusively on adult patients with ARDS. The mean age ranged from 31.2- 48.3 years. The mean APACHE II score ranged from 11.4- 66. The mean PaO2 to FiO2 ratio ranged from 52.9-196 mmHg. Studies from Europe and North America utilized rescue interventions like prone position ventilation (13-32% patients), inhaled vasodilators (13-27% patients) and ECMO (11-86% patients) much more than in countries with limited critical care capacity. At a global level, the inhaled vasodilators (n=231, 16.92%), prone position ventilation (n=206, 15.09%) and extra corporeal membrane oxygenation (ECMO) (n=461, 33.77%) were the most common rescue interventions for severe ARDS. Globally, the use of neuromuscular blockade (n=7, 0.51%), airway pressure release ventilation (APRV) (n=11, 0.8%) and high frequency oscillatory ventilation (HFOV) (n=14, 1.02%) was infrequent. The short-term mortality for patients in developed countries was 23-43% compared to 20-77% in developing countries.

CONCLUSIONS: The 2009 pandemic resulted in a sudden increase in the incidence of severe respiratory failure due to a reversible infectious etiology in a relatively young population. In developed countries, prone position ventilation and inhaled vasodilators were used often. ECMO was a commonly used rescue strategy with favorable short-term mortality. In developing countries, rescue treatments for refractory hypoxemia were infrequently used and a higher short-term mortality was noted.

CLINICAL IMPLICATIONS: The systematic review describes the utilization of rescue strategies for ARDS, which could direct therapy in the event of a future pandemic.

DISCLOSURE: The following authors have nothing to disclose: Shruti Gadre, Abhijit Duggal

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