Clinical Management

Guidelines for

SWINE FLU ( H1N1)

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Dr. Vinod NikhraM.D., ICCN, PGCHM, FIMSA,

Fellow Royal Society of Medicine

Hindu Rao Hospital, DelhiCivic Centre 05.02.2015

Our Set Up at HRH

Sample Collection Facility

Swine Flu Ward

Swine Flu Ward at Hindu Rao Hospital

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Guidelines for Sample Collection

• Sample Type: Throat Swab or Nasal Swab

• Collection: You will need PPE kit, N95 mask, Viral media, Swab stick

• Transportation of Specimens

Sample for Real time-PCR (polymerase chain reaction) for H1N1 should taken:

1. If the patient has a severe or progressive disease in both high risk and other groups with warning signs

2. There is cluster of cases

3. High risk individuals with ILI

Guidelines on Categorization of

Influenza A - H1N1 Cases for Testing and Treatment

• Category A:Mild fever plus cough/ sore throat. A mild illness.Do not require anti-viaral medication, i.e., Oseltamivir (Fluvir or Tamiflu). Noneed of Testing for H1N1. No need of hospital admission. Should be confined athome and asked to observe precautions.• Category B:(i) Cat. B1: Moderate S/Ss. Treatment strategy same like Cat. A. No testing for

H1N1 is required.(ii) Cat. B2: Those with high risk; They should be treated with Oseltamivir.• Category C:S/S of a severe disease. Breathlessness, chest pain, altered consciousness, fall inBP, blood tinged sputum, peripheral cyanosis. In children with ILI havingsomnolence, high and persistent febrile state, not accepting feeds, shortness ofbreath, convulsions.The Cat. C patients require immediate hospitalization and treatment.

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High Risk Groups for Complications of H1N1

•Pregnant women

• Infant and Children below 5 years

• Elderly >65 years

•Patients with COPD/chronic resp disease, CAD, Chronic neurological disease which impairs breathing or clearance of secretions, CRF, DM, haemoglobin-pathies, or immunocompromised (on steroids and such drugs, cancers, HIV).

Care of a

Suspected or Confirmed Case of H1N1

• As per the National Guidelines, a confirmed H1N1 case has to be treated:

At Home, or

In the Hospital Setting

Depending on:

Clinical presentation and presence of complications

For this, the Respiratory Disease Activity is to be monitored.

Special emphasis if the patient belongs to high risk group

Guidelines for the Patient Care at Home

• Dos:

1. Wear mask

2. Wash hands frequently

3. Observe cough etiquettes

4. Stay at home and avoid going into the community

5. Take the prescribed treatment

6. Self monitor health and report to hospital in case S/S worsen.

Guidelines for the Patient Care at Home ..2

• Don’ts:1. Smoke2. Close contact with others3. Touching of eyes, nose or mouth• Alerts:1. Persistent fever2. Difficulty in breathing3. Blood tinged sputum4. Alteration of sensorium5. Exacerbation of S/S of associated comorbidities6. In case of children: irritability, not accepting orally, vomiting, fast

breathing, seizures, etc.

Management of H1N1 Patients admitted in Hospital

Treatment decisions involve:1. Complications of influenza

2. Worsening of pre-existing illness

3. High risk groups

4. Tools to assess Resp. status:

• X Ray Chest

• CURB65 A scoring tool for deciding the action to be taken

0-1: Treat as an outpatient2-3: Consider a short stay in hospital or monitor carefully as an outpatient4-5: Requires hospitalization with consideration for respiratory support.

• CRB65 The CRB-65 tool has been simplified by taking SBP,

and omitting DBP.Thus, risk class 1 for those with score 0,Risk class 2 for those with Score 1-2Risk class 3 for those with 3-4.Patients in risk class 1 would be ideal candidates for ambulatory treatment in the absence of any severecomorbidity.

CURB-65

Signs Points

Confusion 1

BUN>7 mmol/l 1

Respiratory rate>=30 1

SBP<90mmHg, DBP=<60mmHg

1

Age>=65 1

CALCULATE TOTAL SCORE --

Warning Signs for Severe Disease

• Dyspnoea

• ALI (Acute lung injury) – Pneumonia

• Hypoxia (pO2 <60mmHg, SaO2 <90%)

• Hypercapnia

• Persistent fever

• Hypotension

• Acidosis

• Altered mental status

• Septic shock

Predictors of Severe Disease

•Clinical and radiological signs of LRTI

• Exacerbation of underlying disease

• Shock and multi-organ involvement

•CNS complications

•Higher CURB65 / CRB65 score

• Signs of secondary bacterial infection

• Signs of respiratory compromise / poor oxygenation

Treatment of Indoor H1N1 Patient

•ABC: Care about Airway, Breathing and Circulation

• Supplemental Oxygen and Respiratory support including mechanical ventilation

•Antipyretics (avoid aspirin), Bronchodilators, Decongestants (avoid steroids), Treat Complications like shock, bacterial infection

•Nutritional supplementation and rehydration

• Stress ulcer prophylaxis

•Other supportive treatment.

Anti-Viral Treatment

• Anti-viral treatment should be started in ILI in high risk group and in case of Severe and progressive illness

• Oseltamivir (a neuraminidase) is the primary drug. Adv.: oral administration and a higher lung availability.

• Dose schedule:

Adult: 75 mg twice daily for 5 days

Children: <15 Kg – 30 mg twice daily

15-23 Kg – 45 mg twice daily

23 to less than 40 Kg – 60 mg twice daily

40 Kg or more – 75 mg twice daily

Infants: <3m – 12mg BD; 3-5m – 20mg BD; 6-11 m – 25 mg BD

Anti-viral Tt: Side Effects and Toxicity

OSELTAMIVIR:

• Nausea and vomiting

• Allergic reaction, skin rash, facial swelling

• Hepatitis

• Various neuropsychiatric adverse effects

ZANAMIVIR: Given by inhalation. For the treatment in those of 7 years or older. Not recommended for individuals with underlying respiratory disease. SIDE EFFECTS: headaches, diarrhea, nausea, cough, vomiting, disturbance in temperature regulation, and dizziness. NOT AVAILABLE.

DRUGS TO BE AVOIDED: Steroids and Aspirin.

Respiratory Support

Non-invasive Ventilation (NIV):

NIV is a modality that supports breathing without the need for intubationor surgical airway. It is a popular method of adult respiratory support in theemergency and indoor wards and the intensive care unit (ICU), and isparticularly helpful in the care of paediatric patients.

It avoids the adverse effects of invasive ventilation, and has the addedadvantage of patient comfort. It delivers ventilator support without theplacement of an artificial airway. Useful in milder cases where Pt. isconscious

NIV can be (i) Negative pressure ventilation (NPV) or (ii) Non-invasivepositive pressure ventilation (NIPPV). NIPPV includes continuous positiveairway pressure (CPAP) and bilevel positive airway pressure (BiPAP).

NIV will benefit patients with PaO2/FiO2 > 200 and those with APACHE II <6.

APACHE II (Acute Physiology and Chronic Health Evaluation II) is a severity-of-disease classification system, designed to measure the severity of disease for adult patients admitted in ICU. It is applied within 24 hours of admission of a patient to ICU: an integer score from 0 to 71 is computed based on several measurements; higher scores correspond to more severe disease and a higher risk of death.

Weaning from NIV is associated with a reduced mortality and lower incidence of ventilator-associated pneumonia.

Respiratory Support ..2

Respiratory Support ..3

Invasive Mechanical Ventilation: It will ensure adequate oxygen therapy, tidal volume 5-7 ml/kg PBWPEEP to achieve adequate oxygenation. Invasive ventilation is a method to mechanically assist or replace spontaneous breathing. It involves an endotracheal tube or a tracheostomy tube. Respiration is assisted by a ventilator or an Ambu bag.

The mechanical ventilation can be Positive Pressure Ventilation (where air is pushed into the trachea) or Negative Pressure Ventilation (where air is sucked into the lungs).

Mechanical ventilation is indicated when the spontaneous ventilation is inadequate.

Ventilatory Treatment of each patient need to be individualised.