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Intensive care management of life‐threatening avian influenza A (H5N1)

A large proportion of patients with avian influenza A (H5N1) develop life‐threatening manifestations, often including ARDS, acute renal failure and multiple organ failure that requires aggressive intensive care management. The pace of development of respiratory failure is often rapid and can occur in previously healthy hosts, mandating close observation and timely intervention of infected individuals. Use of standard, contact, droplet and airborne isolation precautions is recommended to protect healthcare workers. Key components of ARDS management encompass appropriate mechanical ventilation including limiting tidal volume to ≤6 mL/kg of predicted body weight, maintaining transpulmonary pressures ≤30 cm H2O, and utilizing positive end–expiratory pressure to limit alveolar deflation and to improve oxygenation. Additional strategies include conservative fluid management and using nutrition supplemented with antioxidants. Use of corticosteroids is controversial for both early and late ARDS and although often used for avian influenza, beneficial effects on outcomes have not been demonstrated for corticosteroids. Prone positioning can improve oxygenation temporarily and might be useful as rescue therapy for severe hypoxemia. Administration of inhaled nitric oxide and high frequency oscillatory ventilation can improve oxygenation but have not been demonstrated to improve survival in ARDS—their role in avian influenza is uncertain and availability limited. Management of multiple organ failure may include vasopressor support for septic shock and renal replacement therapy for acute renal failure.