on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on...
Transcript of on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on...
![Page 1: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/1.jpg)
Viral Threat on Respiratory Failure
Younsuck Koh, MD, PhD, FCCM
Department of Pulmonary and Critical Care Medicine
Asan Medical Center
University of Ulsan College of Medicine
Seoul, Korea
![Page 2: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/2.jpg)
No Conflict of Interest related to this topic
![Page 3: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/3.jpg)
A Major Cause of Unknown RF with MV
512 mechanically ventilated pts in 14 studies. Virus was most common cause of infection (42/84; CMV, Influenza, HSV, Adenovrius) Wong AK & Walkey AJ. Ann Am Thorac Soc 2015;12:1226-30
![Page 4: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/4.jpg)
Respiratory Viruses in ICUs
Requiring ECMO
• The emergence of different clinical manifestation
![Page 5: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/5.jpg)
Shieh W-J, et al, Am J Pathol 2010
Virus solely causes LRTI
![Page 6: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/6.jpg)
2009 Pandemic Influenza A (H1N1): Pathology and
Pathogenesis of 100 Fatal cases in the United States
• DAD; most significant & consistent finding
- viral antigens : predominantly in the lung parenchyme
- a high amount of viral Ag observed in close association with DAD
• Also showed viral Ag in trachea, bronchi, or bronchioles
▶ target both upper and lower respiratory tract tissue
Shieh W-J, et al, Am J Pathol 2010
![Page 7: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/7.jpg)
Viral causes seem to be popular
in bilateral lung infiltrates.
Results in inappropriate Abs use, if not considered
![Page 8: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/8.jpg)
• 198 (CAP 64, HCAP 134) in AMC • Bronchoscopic bronchoalveolar lavage: 58.1% (115/198)
8
![Page 9: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/9.jpg)
CAP = community-acquired pneumonia; HCAP = healthcare-associated pneumonia
Choi SH et al. Am J Respir Crit Care Med. 2012;186:325-32
Similar detection rate bwt CAP & HCAP
In severe pn requiring ICU care (AMC experience)
Identified organism Total (n = 198) CAP (n = 64) HCAP (n = 134) P value
None 65 (32.8) 16 (25.0) 49 (36.6) 0.11
Bacteria 71 (35.9) 22 (34.4) 49 (36.6) 0.87
Virus 72 (36.4) 26 (40.6) 46 (34.3) 0.43
Rhinovirus 17 (8.6) 4 (6.3) 13 (9.7) 0.59
Parainfluenza virus 15 (7.6) 3 (4.7) 12 (9.0) 0.39
hMPV 13 (6.6) 5 (7.8) 8 (6.0) 0.76
Influenza virus 12 (6.1) 6 (9.4) 6 (4.5) 0.21
RSV 10 (5.1) 7 (10.9) 3 (2.2) 0.01
CMV 8 (4.0) 0 8 (6.0) 0.056
CoV OC43 4 (2.0) 3 (4.7) 1 (0.7) 0.10
Adenovirus 1 (0.5) 1 (1.6) 0 0.32
Enterovirus 1 (0.5) 0 1 (0.7) 1.00
![Page 10: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/10.jpg)
25.5% 26.5%
33.3%
0%
5%
10%
15%
20%
25%
30%
35%
Bacteria Virus Bacteria + virus
Choi SH et al. Am J Respir Crit Care Med. 2012;186:325-32
P = 0.82
Similar MR
In severe pn requiring ICU care (AMC experience)
![Page 11: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/11.jpg)
11
![Page 12: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/12.jpg)
Clinical Significance of
Rhinovirus in Viral Pn.
Rhinovirus
- The predominant cause of the common cold
- The most frequent virus to exacerbate COP
- HRV-C seems to be associated with more severe RF in
children
![Page 13: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/13.jpg)
• M/73, Farmer • 40 PY ex-smoker • BAL: rhinovirus PCR+ • Expired
Rhinovirus
13
![Page 14: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/14.jpg)
• F/35 • 27 weeks pregnant woman • NP PCR+ • Survived
Rhinovirus
14
![Page 15: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/15.jpg)
Rhinovirus infection (+) Rhinovirus infection (-) COPD with Rhinovirus(+)
Mallina P, et al. Am J Respir Crit Care Med 2012: 186; 1117-1124
![Page 16: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/16.jpg)
Rhinovirus
Kraft CS, et al. JCM. 2012;50:1061-3
Severity of Human Rhinovirus Infection in Immunocompromised
Adults Is Similar to That of 2009 H1N1 Influenza
![Page 17: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/17.jpg)
Rhinovirus vs. Influenza virus
Factor Rhinovirus (n=27)
Influenza virus (n=51)
P value
Immunocompromised state
81.5% 33.3% < 0.001
Viral co-infection 29.6% 11.8% 0.07
Bacterial co-infection 18.5% 37.3% 0.09
Shock at admission 29.6% 54.9% 0.03
28-day mortality 29.6% 35.3% 0.61
In-hospital mortality 55.6% 51.0% 0.70
• Mar 2010 ~ Feb 2014 in AMC
17
![Page 18: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/18.jpg)
18
Perennial distribution
![Page 19: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/19.jpg)
Non-immunocompromised vs. Immunocompromised
Factor Non-IC (n=25)
IC (n=32)
P value
Mean age 71.9 yr 56.5 yr < 0.001
Hematologic malignancy 0 59.4% < 0.001
COPD 20.0% 0 0.01
CAP 44.0% 0 < 0.001
HCAP 36.0% 37.5% 0.91
HAP 20.0% 62.5% < 0.001
Coinfection 40.0% 43.8% 0.78
28-day mortality 8.0% 50.0% 0.001
In-hospital mortality 21.7% 68.8% 0.001
• Mar 2010 ~ Oct 2013 in AMC
Parainfluenza virus
19
![Page 20: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/20.jpg)
MSSA with Parainfluenza
M/62 Fever and Cough s/p Kidney Transplanted
![Page 21: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/21.jpg)
F/30 1st pregnancy with 30 weeks gestation Influenza type A, at ER and 1 & half days later
Influenza A
![Page 22: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/22.jpg)
PCR–confirmed respiratory syncytial virus infections (n = 123) in Hong Kong - Respiratory insufficiency (52.8%), requirement for assisted ventilation (16.3%), and ICU admission/death at 60 days (12.2%/13.8%). - Nearly all (98.4%) hospitalized RSV patients had received initial antibiotics and 35.8% received systemic corticosteroid treatment.
RSV
22
Lee N, et al. JID 2015;21:1237-40
![Page 23: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/23.jpg)
Zoonotic Viral Threat on Resp. Failure
- Hantaviruses by rodents - Dengue (the Flavirididae family) by Mosquitoes - Ebolar virus (Filoviridae family) by a monkey - Coronavirues: SARS by a bat (?), MERS by camel
![Page 24: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/24.jpg)
![Page 25: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/25.jpg)
7 days
7 days
N=14
N=34
40 yr
35 yr
June 7th, 2015
MERS Epidemic in Korea
![Page 26: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/26.jpg)
Clinical Manifestations of Viral Pneumonia
• Prodromal sx: Rhinorrhea
• Absence of purulent sputum
• Diffuse infiltration
• Bilaterality
• Ground-glass opacity
• Centrilobular nodules
• Interstitial pneumonitis
26
![Page 27: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/27.jpg)
Co-infection is not rare
2ndary bacterial infection followed by viral infection
- 2009 H1N1: 4-24%
Concomitant virus-bacterial infection
- 14-15 % in reported 2 CAP studies
- rhino/S. pn, influenza A/S. pn, influenza/S. aureus
Concomitant viruses infection
- two viruses identified; 9 among 63 pts (14%) in our study*
*Choi SH et al. Am J Respir Crit Care Med. 2012;186:325-32
![Page 28: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/28.jpg)
Pneumonia
Bacterial/Fungal Viral Mixed
Epidemics, seasonality
Age
Sx & signs
Labs
CRP/WBC/CXR pattern
Culture
Procalcitonin
How to diagnose viral pn?
![Page 29: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/29.jpg)
Choi SH et al. Am J Respir Crit Care Med. 2012;186:325-32
Seasonality
![Page 30: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/30.jpg)
Lung infiltrate with RF
Pneumonia
Unilateral Bilateral
Usual Approach with CXR infiltrates with RF in ICU
![Page 31: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/31.jpg)
Bilateral lung infiltrate with Pn.
Usual Approach with Bilateral Infiltrate
Noninfectious
Toxic
Edema, Hemorrhage
Immunologic Others
![Page 32: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/32.jpg)
Bilateral lung infiltrate with Pn.
CAP/HCAP Opportunistic Severity
Usual Approach with Bilateral Infiltrate
CMV Influenza
Noninfectious
![Page 33: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/33.jpg)
Pneumonia
Bacterial/Fungal Viral Mixed
Epidemics, seasonal
Age
Sx & signs
Labs
CRP/WBC/CXR pattern
Culture
Procalcitonin
RT-PCR (BAL, nasopharyngel specimen)
Recent Advance in Molecular Diagnostic Technology
![Page 34: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/34.jpg)
Needs BAL?
• Only + in BAL specimen: about 15% among 94 + cases in AMC data.
34
*N: nasopharyngeal specimen, B: BAL specimen
concordance
![Page 35: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/35.jpg)
PREDICTORS FOR THE DIAGNOSIS OF BACTERIAL
PNEUMONIA compared with viral pn in matched cases
Choi SH et al. J Clin Microbiol 2015; 53:1310-6
![Page 36: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/36.jpg)
• Obligate airborne - TB
• Preferential or obligate airborne - measles, smallpox
• Opportunistic airborne -SARS-CoV, MERS-CoV?
“…the aerosol becomes so dilute as it travels away from the source that most secondary infections occur in the immediate vicinity of the index patient…a dilute aerosol mimics that expected with large-droplet or surface contact…it should be also not be dismissed out of hand.”
Roy CJ, et al. NEJM 2004;350:1710-2
Prevention
![Page 37: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/37.jpg)
KCDC
Lessons, you may already know: Appropriate use of personal protective equipment (Gown-Mask-Goggles-Gloves)
From CDC
![Page 38: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/38.jpg)
• Neuraminidase inhibitors: oseltamivir, zanamivir
• M2 ion channel blockers: amantadine or rimantadine
Antivirals for Treatment of Influenza
A Systematic Review and Meta-analysis of
Observational Studies
J Hsu, et al. Ann Intern Med. 2012;156:512-524.
Treatments
![Page 39: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/39.jpg)
Role of Steroid in Viral Pn.
![Page 40: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/40.jpg)
without steroid
with steroid
Kim SH, et al. Am J Respir Crit Care Med 2011 ;183:1207-14
Steroid therapy seems to be harmful in H1N1 virus pneumonia
![Page 41: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/41.jpg)
• 36 fatal children analysis
• 10 of 23 pts with culture results (43%) detected bacterial infection
• 5 S. aureus
• 3 pneumococcus
• 1 S. pyogenes, 1 S. constellatus
“Empiric antibacterial therapy, when indicated, should be directed at
likely…”
Empirical Antibiotics Use
![Page 42: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/42.jpg)
DK Oh, et al. J Crit Care 2013
![Page 43: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/43.jpg)
PRONE POSITIONING
![Page 44: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/44.jpg)
Referral to an Extracorporeal Membrane Oxygenation
Center and Mortality Among Patients With Severe
2009 Influenza A (H1N1). Noah et al. JAMA 2011 36(15):1659
Non-ECMO-referred Pts (85 hospitals)
ECMO-referred Pts (UK ECMO centers)
H1N1-related ARDS
VS.
by matching patients
![Page 45: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/45.jpg)
Conclusion
• Significant?
Truly, significant problem.
![Page 46: on Respiratory Failure - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic...Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical](https://reader036.fdocuments.net/reader036/viewer/2022070802/5f02d42f7e708231d406373d/html5/thumbnails/46.jpg)
Conclusion
• The emergence of new subtype viruses enhanced
intensivists’ awareness about viral pn.
• Viral cause is not rare in severe RF with pn even in
HCAP.
• Molecular diagnostic methods improved our
understanding about viral pn.
• Needs of a Global Collaboration in case of global
viral epidemics
• Further studies are needed to address questions.