h1n1 ards case presentation

A Case of Acute Hypoxemic

Respiratory Failure

DR. VITRAG SHAH

FIRST YEAR FNB RESIDENT,

DEPARTMENT OF CCEM,

SGRH, DELHI

History

• 32 year old male

• Farmer by occupation

• Resident of Gwalior

• No past comorbidities

• Non-smoker, Non-Alcoholic

• Symptoms :

• Fever with chills

• Cough with scanty expectoration for 5 days

• Breathlessness mMRC II—III for 3 days

• No other significant history

History

• Initially admitted at Gwalior on 29/09/15

• Routine blood tests : Normal

• Chest x-ray : B/L lower zone infiltrates (Lt>Rt)

• Managed with IV antibiotics, oxygen & other supportive

treatment

• Then brought to SGRH for further management &

admitted to Respiratory HDU on 02/10/15.

• Initially maintained SpO₂ 90-92% on 100% O₂ mask

• On 03/10/15 in view of worsening breathlessness and

desaturation on 100% mask, patient was shifted to ICU

Initial Chest X-Ray & CT Thorax

(Gwalior)

Physical Examination on ICU admission

• Patient was conscious, oriented

• Respiratory distress present, using accessory muscles

• Temperature : 37.6°c (Axillary)

• Pulse : 104/min, regular

• RR : 32/min, thoracoabdominal

• BP : 130/70 mmhg

• SpO₂ : 88% on 100% Oxygen Mask

• No pallor, clubbing, cyanosis, edema, lymphadenopathy

Systemic Examination on ICU admission

Respiratory system :

• Inspection – bilateral hemithorax movement equal

• Palpation – bilateral hemithorax expansion equal

• Percussion – no abnormality seen

• Auscultation – Bronchial breath sounds & bilateral fine

inspiratory creps heard over bilateral infraaxillary and

infrascapular region

Other System Examination

Cardiovascular – S1, S2 heard-normal and no murmurs

Gastroenterology – soft, bowel sounds heard, no free fluid or

organomegaly seen, no guarding/rigidity

Neurological – Higher function – normal, no focal

neurological deficit

ROUTINE BLOOD INVESTIGATIONS

ABGA on ICU admission (on 100% O2

Mask)

pH 7.45 PO₂ 49.8 PCO2 42 HCO3 28.9

Lactate 1.18

BUN / Creatinine 31.85 / 0.95

Na/K 134/3.66

Total/direct bilirubin 0.92/0.37

Prot/Alb 5.79/2.62

SGOT/PT 100/46

PT/aPTT WNL

Procalcitonin 1.5

Hb/TLC/PLT 14.6/10.2/193

Rest Investigations

• RBS : 118, ECG : Incomplete RBBB

• H1N1 RT PCR was also sent on the day of admission

and report was awaited.

• Malarial antigen, PS for MP, Scrub typhus IgM,

Leptospirosis IgM, Dengue NS1 antigen & IgM-IgG were

sent

• Blood & urine culture were sent. Cough was non-

productive, so sputum gram stain-culture were not sent.

Chest X-Ray on Day-1 ICU Admission

What are the differential

diagnosis in this patient?

Differential Diagnosis • Bilateral pneumonia with ARDS (Viral / Bacterial)

• Tropical illness (Dengue/Malaria/Scrub Typhus/Leptospirosis)

• Cardiac abnormalities- valvular dysfunctions, cardiomyopathy

and congestive cardiac failure

• Connective tissue disorders

• Septic source from other organs

How will you manage

this patient?

Management plan on Day-1 ICU admission

• NIV (CPAP-PSV) ,Plan for SOS ET Intubation, relatives

were counseled for same

• IV Antibiotics (Meropenam & Teicoplanin)

• Cap. Doxycycline (For atypical coverage & scrub typhus)

• Tab.Oseltamivir (For H1N1 Influenza)

• SOS Inj.Paracetamol (Antipyretic) , Other supportive

treatment & IV Fluids

Course in ICU

• Malarial antigen, PS for MP, Scrub typhus IgM,

Leptospirosis IgM, Dengue NS1 antigen & IgM-IgG were

negative.

• Initial Blood & urine culture were negative.

• H1N1 RT PCR came positive.

• 2D Echo on Day-1 ICU admission – Normal , No PAH

• USG Abdomen – Normal

Course in ICU

• ICU Day 1&2 (03/10/15 - 04/10/15) :

• Managed on NIV (CPAP-PSV), was maintaining

SpO2 around 93-94%

• ABGA on ICU Day-2 ICU(04/10/15) :

• pH 7.45 PO₂ 82 PCO₂ 39 HCO3 26.8 Lactate 1.91

• ICU Day 3 (05/10/15) :

• I/V/O decreasing SpO₂ and increasing respiratory

distress, intubated & taken on mechanical ventilator

Chest X-Ray after ET Intubation

How will you ventilate

this patient?

• What is Lung Protective Ventilation?

• What is open lung ventilation?

• How to Titrate PEEP?

• Fluid management

• Evidence

Initial Ventilatory Settings

• Ventilated as per lung protective ventilation strategy

• Height - 175 cm , IBW - 70.5kg

Mode : CMV

FiO₂ : 100% 85%

PEEP : 12

RR : 24

TV : 430

• ABGA after 6 hours of mechanical ventilation :

• pH 7.37 PCO₂ 44 PO₂ 75 HCO₃ 25.7 Lactate 1.46

How will you manage

further?

• Proning

• Recruitment maneuvers

Course in ICU (ICU Day 3 onward)

• Still PO2/FiO2 < 100, so proning done for 26 hours. After

1st cycle of proning, there was significant improvement in

oxygenation.

• ABGA (on CMV, 40% FiO2):

• pH 7.37 PCO2 52 PO2 97.7 HCO3 29.8 Lactate 1.03

• Total 5 cycles of proning ranging from 16-26 hours were

done from 05/10/15 to 10/10/15

• Patient has very high sedation requirement. To prevent

ventilatory dyssynchrony, patient was on atracurium +

Midazolam+Fentanyl infusion with regular sedation &

relaxant free interval in between.

Course in ICU (ICU Day 7 onward)

• CXR showed worsening with increasing TLC

• ET c/s – Acinetobacter

• Antibiotics were modified to Cefipime, Tigecycline and

Colistin.

• Serum Galactomannan – negative

• 10/10/15 onwards, patient was not maintaining adequate

saturation above 90% on 100% FiO2 & 12 PEEP & not even

while proning and after recruitment manuvouers.

How will you proceed

further?

• How will you manage refractory

hypoxemia?

• Role of Extracorporeal membrane

oxygenation (ECMO)

• VV vs VA ECMO

• Indications & Contraindication

• Evidence

Further plan of action

• ABGA on 11/10/15:

• pH 7.36 PO2 55.7 PCO2 70 HCO3 39 Lactate 2.35

• Till now, patient was hemodynamically stable, sensorium

was intact, had no other organ dysfunction & was passing

adequate urine output.

• Consensus was arrived after detailed discussion with

chest physician, among ICU team & with family to put

patient on ECMO. Patient was kept on VV ECMO on

11/10/15 with Right IJ & Right Femoral cannulation.

• Multiple sessions of bronchoscopies were done for lavage

as well as sampling.

Chest X-Ray (Before starting ECMO)

Date pH PCO2 HCO3 Lactate PO2 FiO2 PEEP

3/10

On 100% O2Mask 7.45 42 28.9 1.18 49.8 100%

4/10

On NIV 7.45 39 26.8 1.91 82 80% 8

5/10

Before Intubation – ON NIV 7.49 33 24.9 1.38 70 100% 8

5/10/15

After Intubation 7.37 44 25.7 1.46 75 85%

12

6/10

After 1st cycle of proning 7.37 52 29.8 1.03 97.7 40% 12

11/10

Before ECMO Initiation 7.36 70 39 2.35 55.7 100% 12

PO2 & FiO2 before ECMO Initiation

0%10%20%30%40%50%60%70%80%90%100%

0.00

50.00

100.00

150.00

200.00

250.00

300.00

PO2

FiO2

PO2/FiO2 ratio before ECMO Initiation

0.00

50.00

100.00

150.00

200.00

250.00

300.00

PO2/FiO2

PO2/FiO2

• How to Initiate ECMO?

• Monitoring during ECMO

ECMO Initiation

• FiO2 : 100%

• Flow : 4.5 lit/min

• Sweep Gas : 3.5 lit/min

• Delta Pressure : 35

• Ventilator settings during ECMO :

• Mode : PCV

• FiO2 : 30%

• Rate : 12

• Pi : 26

• PEEP : 12

ECMO Monitoring Protocol

• 1. Ventilatory settings : Low FiO2 (25-30%), Rate

(12/min) Pi (24-26) ; PEEP (10-12) to keep alveoli

open

• 2. Blood gas targets : PO2 > 50, sPO2 >88% PCO2

40-45, pH 7.35-7.45

• 3. Investigations : CBC, ABGA, Electrolytes 8 hourly

for 2 days and then twice daily, ACT 4 hourly, PT,aPTT

once a day, Fibrinogen once and then every 3-4 day

• 4.Fluid management : To maintain flow and prepump

• 5. Adequate urine output and monitor color of urine

ECMO Monitoring Protocol

• 6.Transfusion Targets: Hb >9 , Platelet : >30,000 if not

bleeding and >75,000 if bleeding

• 7. Sedation as per requirement

• 8. Heparin infusion 20unit/kg/hr to target ACT around 180

• 9. No lipid based drugs (Propofol, liposomal amphotericin)

• 10. Adequate enteral nutrition

• 11. Genral nursing care while maintaing flow and

saturation

Date ECMO Settings Ventilator Setings Generated

Volume-

Avg

(Compliance)

ABGA

Flow Sweep

Gas

∆P FiO2 FiO2 RR PEEP Pi PO2 PCO2

11/10 4.5 3.5 35 100 30 12 12 26 250 86 51

12/10 4 3.5 35 100 30 12 12 26 250 75 48

13/10 4 5 28 100 30 12 12 26 200 78 45

14/10 3.5 5 28 100 30 12 12 26 250 78 40

15/10 3.5 4.5 26 100 30 12 12 26 270 76 38

16/10 3.5 4.5 26 100 30 12 11 26 220 72 36

17/10 3 4 26 100 30 12 10 26 250 84 39

18/10 3 4 24 100 30 12 10 26 220 88 38

19/10 3 3.5 24 60 30 12 10 26 250 84 42

20/10 3.4 3.5 28 100 30 12 10 26 250 82 44

21/10 3.4 3.5 26 60 30 12 10 26 280 81 35

22/10 3.2 2 28 21 40 24 8 26 300 90 42

23/10 3.6 1.5 28 40 45 26 7 26 320 88 44

24/10 3 0 28 0 45 26 6 28 350 82 48

25/10 3 0 28 0 45 28 6 28 380 79 47

Chest X-Ray – 5 days after ECMO

ECMO & Ventilator FiO2 trend during

ECMO

0

20

40

60

80

100

120

11

-Oct

12

-Oct

13-O

ct

14-O

ct

15-O

ct

16

-Oct

17

-Oct

18

-Oct

19

-Oct

20

-Oct

21

-Oct

22-O

ct

23-O

ct

24

-Oct

25

-Oct

ECMO FiO2

Ventilator FiO 2

Flow & Sweep Gas trend during ECMO

0

1

2

3

4

5

6

7

11

-Oct

12

-Oct

13

-Oct

14

-Oct

15

-Oct

16

-Oct

17

-Oct

18

-Oct

19

-Oct

20

-Oct

21

-Oct

22-O

ct

23-O

ct

24-O

ct

25-O

ct

Flow

Sweep Gas

Lung Compliance trend during ECMO

0

100

200

300

400

500

600

11-O

ct

12-O

ct

13-O

ct

14-O

ct

15-O

ct

16-O

ct

17-O

ct

18-O

ct

19-O

ct

20-O

ct

21-O

ct

22-O

ct

23

-Oct

24-O

ct

25-O

ct

Generated Volume

Generated Volume

ECMO Weaning : How & When ?

ECMO weaning

• There was no significant radiological improvement, but

Lung compliance was improved after 10 days.

• From 21/10/15, ECMO weaning was started.

• On 25/10/15, finally ECHO was discontinued.

Course after ECMO removal

• Central line & Foley’s catheter were changed on

26/10/15

• Percutaneous tracheostomy was done on 26/10/15

• After tracheostomy, sedation requirement was

significantly decreased. Patient was neurologically

sound.

• Patient was maintaing sPO2 >90% for 3 days after

ECMO removal with FiO2 50-60% and PEEP 8, initially

on PCV and then on CMV.

Date pH PCO2 HCO3 Lactate PO2 FiO2 PEEP

11/10

Before ECMO Initiation 7.36 70 39 2.35 55.7 100% 12

11/10

After ECMO Initiation 7.42 35 23 1.01 81 100% 12

25/10

Before ECMO removal 7.38 47 27 1.12 79 45% 6

26/10

1 day after ECMO Removal 7.33 57 29 1.23 86 60% 8

27/10


28/10


30/10

5 day after ECMO Removal 7.25 90 39 2.42 48.1 100% 8

31/10

6 day after ECMO Removal 7.27 96 44 2.74 37.4 100% 8

PO2 & FiO2 trend after ECMO Removal

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0

50

100

150

200

250

300

25-Oct 26-Oct 27-Oct 28-Oct 29-Oct 30-Oct 31-Oct

PO2

FiO2

Course after ECMO removal

• 2D ECHO (26/10/15) : WNL except PASP 74mmhg.

• iNO at 10-15 ppm was started on 26/10/15.

• Repeat 2D ECHO on 28/10/15 : PASP 45mmhg

• On 29/10/15, patient had increasing FiO2 requirement,

continuous fever, went into shock, vasopressors were

started & antibiotics were modified.

What is the Role on

inhaled NO?

Further Course in ICU

• Patient’s condition deteriorated inspite of all above

measures, patient developed refractory hypoxia & shock

on 30/10/15 and expired on 31/10/15.

Course in Hospital - Summary

2/10

• Admitted in Respi. HDU, ABG s/o Acute Hypoxemic Respiratory Failure, initially maintained sPO2 >90% on 100% O2 Mask

3/10

• Respiratory distress increased, not maintaing sPO2 >90% on 100% Mask

• Shifted to ICU, Managed with NIV (CPAP-PSV)

5/10

• Intubated in view of increasing distress & desaturation

• Taken on mechanical ventilator

5/10

•After 6 hours of mechcanial ventilation, PO2/FiO2 <100% despite recruitment manuvouer, so proning done for 26 hours

•PO2/FiO2 improved to >200 after 1st cycle of proning

5/10-10/10

•Total 5 cycles of proning done ranging from 16-26 hours from 5/10 to 10/10

• PO2/FiO2 dropped <100 after 4 cycle of proning, Plan to start ECMO discussed with Family after 5th cycle of proning

11/10-19/10

•ECMO initiated with minimum ventilatory support and 12 PEEP to keep alveoli open, Multiple sessions of broncoscopies done

•Lung complainance improved and ECMO weaning tried from 19/10

19/10-25/10

• Lung Complaince gradually improved from 21/10 and ECMO weaning progressed

• Finally ECMO removed on 25/10

26/10-28/10

•Central line & foley’s cather changed & tracheostomy done on 26/10; iNO started on 26/10 at 10-15 ppm i/v/o PASP 74mmhg

•Patient maintained sPO2 till 28/10, PASP went down upto 45

29/10-31/10

• From 29/10, patient has gone into secondory sepsis with shock, & refractory hypoxia

• Inspite of all above efforts, patient expired on 31/10/15 due to refractory shock and hypoxia.

Important trials related to ARDS

• ARMA trial

• FACCT Trial

• Meta-analysis on N-M Blockers (Cisatracurium)

• Meta-analysis on role of steroid

• EXPRESS, LOVS, ALVEOLI trial & Metaanalysis

• OSCAR & OSCILLATE trial

• PROSEVA trial & previous meta-analysis on proning

• Meta-analysis on recruitment maneuvers

Questions…….?

Thank you

•THANK YOU

h1n1 ards case presentation

Health & Medicine