key: cord-0005731-zf2xel3t
authors: Djibré, Michel; Berkane, Nadia; Salengro, Anne; Ferrand, Edouard; Denis, Michel; Chalumeau-Lemoine, Ludivine; Parrot, Antoine; Mayaud, Charles; Fartoukh, Muriel
title: Non-invasive management of acute respiratory distress syndrome related to Influenza A (H1N1) virus pneumonia in a pregnant woman
date: 2009-10-10
journal: Intensive Care Med
DOI: 10.1007/s00134-009-1684-0
sha: 39e8b03d48e62ccb3b48f544cacc06466f9a32d0
doc_id: 5731
cord_uid: zf2xel3t

nan

A 38-year-old pregnant woman was admitted at 31 weeks' gestation to the intensive care unit on 4 August 2009 for fever, chills, cough, vomiting and weakness of 1-week duration. The core temperature was 39.8°C, the respiratory rate 40 cycles/min, the oxygen saturation 92% on 10 l/min oxygen, the heart rate 135 beats/min and the arterial blood pressure 100/ 50 mmHg. Physical examination revealed a bloody expectoration and bilateral crackles. A chest X-ray showed extensive bilateral opacities. Partial pressure of oxygen (PaO 2 ) was 116 mmHg and carbon dioxide (PaCO 2 ) 32 mmHg on 10 l/min oxygen. Influenza A pneumonia was suspected, and oseltamivir (75 mg tid) was administered on 5 August in association with cefotaxim, spiramycin and linezolid. A nasopharyngeal swab specimen was positive for Influenza A (H1N1) virus, using realtime reverse transcription-polymerase chain reaction (rRT-PCR). Sputum and Streptococcus pneumoniae and Legionella pneumophila urinary antigen tests were negative. Severe acute respiratory distress syndrome (ARDS) rapidly developed, and noninvasive positive pressure ventilation (NIPPV) was administered continuously during the next 72 h through a facial mask, with a FiO 2 of 1, a 14 cmH 2 O maximum positive airway pressure and a 5 cmH 2 O positive expiratory pressure to maintain the pulse oximetry C94%. Arterial oxygenation improved slowly with PaO 2 / FiO 2 ratio ranging from 98 to 184. There was no left heart dysfunction on echocardiogram. Fetal monitoring was satisfactory. After 3 days, NIPPV was administered intermittently. A repeated nasopharyngeal swab specimen was negative. Oseltamivir and antibiotics were stopped. On 15 August, the shortness of breath worsened, and intermittent NIPPV was administered again. A CT scan demonstrated bilateral ground-glass opacities (Fig. 1) . A fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) was performed. Bronchial mucosa was normal; BAL was macroscopically haemorrhagic with 170,000 cells per ml (neutrophils 77%, lymphocytes 11%, macrophages 10%, eosinophils 7%), a very low residual positivity for Influenza A (rRT-PCR) and no bacteria. Broadspectrum antibiotics and oseltamivir were again administered together with intravenous methylprednisolone (2 mg/kg/day) on 17 August. As the clinical status did not improve, a multidetector CT angiography was performed showing a right upper lobe pulmonary embolism and fibrosis (Fig. 2) . Finally, a cesarean delivery was performed, under spinal and peridural analgesia and high-flow oxygen. The infant was born in good health, with no influenza infection. The mother's clinical status improved slowly thereafter.

A mortality rate reaching 60% has been reported in patients requiring mechanical ventilation (MV) for H1N1-related ARDS [1] . Six deaths in pregnant women with ARDS were recently reported to the US Centers for Disease Control and Prevention, five of whom had undergone a caesarean delivery [2] . Although NIPPV may be associated with a reduction of endotracheal intubation and mortality rates in ARDS [3] , it has not been evaluated during pregnancy. Neither the optimal time for delivery nor the modality is clearly defined in the absence of obstetrical indications [4] , although cesarean delivery appears more appropriate in case of CORRESPONDENCE respiratory failure. This observation highlights the multidisciplinary therapeutic approach to management ARDS during pregnancy and suggests that NIPPV may be useful in selected women with isolated acute respiratory failure. The role of steroids for H1N1-related ARDS remains to be determined [5] . N 

Pneumonia and respiratory failure from swine-origin influenza A (H1N1) in Mexico

Novel Influenza A (H1N1) Pregnancy Working Group

A multiple-center survey on the use in clinical practice of noninvasive ventilation as a first-line intervention for acute respiratory distress syndrome

Acute respiratory distress syndrome in pregnancy

H1N1 pneumonitis treated with intravenous zanamivir

Fartoukh Service de Pneumologie et Réanimation, Hôpital Tenon

Fartoukh e-mail: muriel.fartoukh@tnn.aphp.fr