Prone position ventilation, recruitment maneuver and intravenous zanamivir in severe refractory hypoxemia caused by influenza A (H1N1)

The influenza A (H1N1) resurgence was identified in April of 2009 in North America, 35 years after its initial description. Since then, cases of influenza A (H1N1) have been reported on all continents, with the clinical presentation ranging from mild symptoms (runny nose, fever, cough, and myalgia) to acute respiratory distress syndrome (ARDS). Approximately 75% of patients with influenza A (H1N1) admitted to an intensive care unit (ICU) required invasive mechanical ventilation, one-third of whom progressed to refractory hypoxemia and needed rescue ventilation techniques, including alveolar recruitment maneuvers, ventilation in the prone position, high-frequency ventilation, extracorporeal membrane oxygenation, or inhaled nitric oxide. In addition to the ventilatory support, treatment for respiratory failure due to influenza A (H1N1) includes antiviral agents, which should be initiated at the time of clinical suspicion, preferably within 48 hours of the onset of symptoms. We describe herein the case of a patient with ARDS secondary to influenza A (H1N1) on whom recruitment maneuvers and ventilation in the prone position were used for the treatment of refractory hypoxemia, along with corticosteroids, oseltamivir, and intravenous zanamivir.