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      Application of extracorporeal membrane oxygenation in patients with severe acute respiratory distress syndrome induced by avian influenza A (H7N9) viral pneumonia: national data from the Chinese multicentre collaboration

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          Translated abstract

          Background

          Evidence concerning the efficacy and safety of extracorporeal membrane oxygenation (ECMO) in patients with influenza A (H7N9) has been was limited to case reports. Our study is aimed to investigate the current application, efficacy and safety of ECMO in for severe H7N9 pneumonia-associated acute respiratory distress syndrome (ARDS) in the Chinese population.

          Methods

          A multicentre retrospective cohort study was conducted at 20 hospitals that admitted patients with avian influenza A (H7N9) viral pneumonia patients’ admission from 9 provinces in China between October 1, 2016, and March 1, 2017. Data from the National Health and Family Planning Commission of China, including general conditions, outcomes and ECMO management, were analysed. Then, successfully weaned and unsuccessfully weaned groups were compared.

          Results

          A total of 35 patients, aged 57 ± 1 years, were analysed; 65.7% of patients were male with 63% mortality. All patients underwent invasive positive pressure ventilation (IPPV), and rescue ventilation strategies were implemented for 23 cases (65.7%) with an average IPPV duration of 5 ± 1 d, PaO 2/FiO 2 of 78 ± 23 mmHg, tidal volume (VT) of 439 ± 61 ml and plateau pressure (P plat) of 29 ± 8 cmH 2O pre-ECMO. After 48 h on ECMO, PaO 2 improved from 56 ± 21 mmHg to 90 ± 24 mmHg and PaCO 2 declined from 52 ± 24 mmHg to 38 ± 24 mmHg. Haemorrhage, ventilator-associated pneumonia (VAP) and barotrauma occurred in 45.7%, 60% and 8.6% of patients, respectively. Compared with successfully weaned patients ( n = 14), the 21 unsuccessfully weaned patients had a longer duration of IPPV pre-ECMO (6 ± 4 d vs. 2 ± 1 d, P < 0.01) as well as a higher P plat (25 ± 5 cmH 2O vs. 21 ± 3 cmH 2O, P < 0.05) and VT (343 ± 96 ml vs. 246 ± 93 ml, P < 0.05) after 48 h on ECMO support. Furthermore, the unsuccessfully weaned group had a higher mortality (100% vs. 7.1%, P < 0.01) with more haemorrhage (77.3% vs. 28.6%, P < 0.01).

          Conclusions

          ECMO is effective at improving oxygenation and ventilation of patients with avian influenza A (H7N9) induced severe ARDS. Early initiation of ECMO with appropriate IPPV settings and anticoagulation strategies are necessary to reduce complications.

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          Most cited references21

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          Human Infection with a Novel Avian-Origin Influenza A (H7N9) Virus

          New England Journal of Medicine, 368(20), 1888-1897
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            Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome.

            The novel influenza A(H1N1) pandemic affected Australia and New Zealand during the 2009 southern hemisphere winter. It caused an epidemic of critical illness and some patients developed severe acute respiratory distress syndrome (ARDS) and were treated with extracorporeal membrane oxygenation (ECMO). To describe the characteristics of all patients with 2009 influenza A(H1N1)-associated ARDS treated with ECMO and to report incidence, resource utilization, and patient outcomes. An observational study of all patients (n = 68) with 2009 influenza A(H1N1)-associated ARDS treated with ECMO in 15 intensive care units (ICUs) in Australia and New Zealand between June 1 and August 31, 2009. Incidence, clinical features, degree of pulmonary dysfunction, technical characteristics, duration of ECMO, complications, and survival. Sixty-eight patients with severe influenza-associated ARDS were treated with ECMO, of whom 61 had either confirmed 2009 influenza A(H1N1) (n = 53) or influenza A not subtyped (n = 8), representing an incidence rate of 2.6 ECMO cases per million population. An additional 133 patients with influenza A received mechanical ventilation but no ECMO in the same ICUs. The 68 patients who received ECMO had a median (interquartile range [IQR]) age of 34.4 (26.6-43.1) years and 34 patients (50%) were men. Before ECMO, patients had severe respiratory failure despite advanced mechanical ventilatory support with a median (IQR) Pao(2)/fraction of inspired oxygen (Fio(2)) ratio of 56 (48-63), positive end-expiratory pressure of 18 (15-20) cm H(2)O, and an acute lung injury score of 3.8 (3.5-4.0). The median (IQR) duration of ECMO support was 10 (7-15) days. At the time of reporting, 48 of the 68 patients (71%; 95% confidence interval [CI], 60%-82%) had survived to ICU discharge, of whom 32 had survived to hospital discharge and 16 remained as hospital inpatients. Fourteen patients (21%; 95% CI, 11%-30%) had died and 6 remained in the ICU, 2 of whom were still receiving ECMO. During June to August 2009 in Australia and New Zealand, the ICUs at regional referral centers provided mechanical ventilation for many patients with 2009 influenza A(H1N1)-associated respiratory failure, one-third of whom received ECMO. These ECMO-treated patients were often young adults with severe hypoxemia and had a 21% mortality rate at the end of the study period.
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              Clinical findings in 111 cases of influenza A (H7N9) virus infection.

              During the spring of 2013, a novel avian-origin influenza A (H7N9) virus emerged and spread among humans in China. Data were lacking on the clinical characteristics of the infections caused by this virus. Using medical charts, we collected data on 111 patients with laboratory-confirmed avian-origin influenza A (H7N9) infection through May 10, 2013. Of the 111 patients we studied, 76.6% were admitted to an intensive care unit (ICU), and 27.0% died. The median age was 61 years, and 42.3% were 65 years of age or older; 31.5% were female. A total of 61.3% of the patients had at least one underlying medical condition. Fever and cough were the most common presenting symptoms. On admission, 108 patients (97.3%) had findings consistent with pneumonia. Bilateral ground-glass opacities and consolidation were the typical radiologic findings. Lymphocytopenia was observed in 88.3% of patients, and thrombocytopenia in 73.0%. Treatment with antiviral drugs was initiated in 108 patients (97.3%) at a median of 7 days after the onset of illness. The median times from the onset of illness and from the initiation of antiviral therapy to a negative viral test result on real-time reverse-transcriptase-polymerase-chain-reaction assay were 11 days (interquartile range, 9 to 16) and 6 days (interquartile range, 4 to 7), respectively. Multivariate analysis revealed that the presence of a coexisting medical condition was the only independent risk factor for the acute respiratory distress syndrome (ARDS) (odds ratio, 3.42; 95% confidence interval, 1.21 to 9.70; P=0.02). During the evaluation period, the novel H7N9 virus caused severe illness, including pneumonia and ARDS, with high rates of ICU admission and death. (Funded by the National Natural Science Foundation of China and others.).
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                Author and article information

                Contributors
                xuehuaalice@126.com
                zhangweiliuxin@163.com
                yiyiyang2004@163.com
                1346801465@qq.com
                lwh683@126.com
                2644257577@qq.com
                zxnt@163.com
                icuwu@163.com
                shangjia666@126.com
                cailihua0912@163.com
                liulong988@sina.com
                m15890122166@163.com
                wwyymm_love@163.com
                +86 13911318339 , caobin1999@gmail.com
                +86 13911785957 , drzhanqy@163.com
                cyh-birm@263.net
                Journal
                BMC Infect Dis
                BMC Infect. Dis
                BMC Infectious Diseases
                BioMed Central (London )
                1471-2334
                8 January 2018
                8 January 2018
                2018
                : 18
                : 23
                Affiliations
                [1 ]ISNI 0000 0004 1771 3349, GRID grid.415954.8, Department of Pulmonary and Critical Care Medicine, , Centre for Respiratory Diseases, China-Japan Friendship Hospital, ; No. 2 Yinghua East Road, Chaoyang District, Beijing, 100029 People’s Republic of China
                [2 ]ISNI 0000 0004 1758 4073, GRID grid.412604.5, The First Affiliated Hospital of Nanchang University, ; Nanchang, Jiangxi Province People’s Republic of China
                [3 ]ISNI 0000 0004 1761 0489, GRID grid.263826.b, Department of Critical Care Medicine, Zhongda Hospital, , Southeast University, ; Nanjing, Jiangsu Province People’s Republic of China
                [4 ]Department of Intensive Care Unit, Wuhan Medical Treatment Center Hospital, Wuhan, Hubei Province People’s Republic of China
                [5 ]GRID grid.452929.1, Department of Intensive Care Unit, , The First Affiliated Hospital of Wannan Medical College, Yijishan Hospital, ; Wuhu, Anhui Province People’s Republic of China
                [6 ]GRID grid.479690.5, Department of Intensive Care Unit, , Taizhou People’s Hospital, ; Taizhou, Jiangsu Province People’s Republic of China
                [7 ]GRID grid.440642.0, Department of Intensive Care Unit, , Affiliated Hospital of Nantong University, ; Nantong, Jiangsu Province People’s Republic of China
                [8 ]GRID grid.440227.7, Department of Intensive Care Unit, , Suzhou Municipal Hospital, ; Suzhou, Jiangsu Province People’s Republic of China
                [9 ]GRID grid.414011.1, Department of Infectious Diseases, , Henan Provincial People’s Hospital, ; Zhengzhou, Henan Province People’s Republic of China
                [10 ]GRID grid.440180.9, Department of Intensive Care Unit, , Dongguan People’s Hospital, ; Dongguan, Guangdong Province People’s Republic of China
                [11 ]GRID grid.452273.5, Department of Intensive Care Unit, , The First People’s Hospital of Kunshan, ; Kunshan, Jiangsu Province People’s Republic of China
                Article
                2903
                10.1186/s12879-017-2903-x
                5759204
                29310581
                c6944dea-b9e6-4c5e-9342-bfb00dfee0ec
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 23 August 2017
                : 10 December 2017
                Funding
                Funded by: the National Key Research and Development Programme—Major Chronic Non-communicable Diseases’ Prevention and Control
                Award ID: QML 2016YFC1304300
                Award Recipient :
                Funded by: the National Science Fund for Distinguished Young Scholars
                Award ID: 81425001/H0104
                Award Recipient :
                Funded by: the National Natural Science Foundation of China
                Award ID: 81271840/ H1904 and 81030032/H19
                Award Recipient :
                Funded by: the National Program for the Prevention and Control of Human Infections by Avian-Origin H7N9 Influenza A Virus
                Award ID: KJYJ-2013-01-05
                Award Recipient :
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2018

                Infectious disease & Microbiology
                extracorporeal membrane oxygenation (ecmo),avian influenza a (h7n9),acute respiratory distress syndrome (ards),complications,mortality

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