Medical Therapy

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The Fluwiki is meant to develop and share information about coping with a public health problem, prevalent community illness from circulating influenza A virus. The medical-related and management articles here are not meant as a substitute for professional care, nor is there any claim the information provided is sufficiently accurate or useful to make clinical decisions. Even when accurate, it takes professional judgment and specific information to know when it applies to a particular individual. This means, as a legal matter, no one who provides information here takes responsibility for the results or consequences of using it for the practice of medicine. The old adage in medicine holds: “A doctor who treats himself has a fool for a patient and a fool for a doctor.” If you suspect you have a problem, see your health care provider.

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Key Facts

• Key Flu Facts from the CDC

“Some of the complications caused by the flu include bacterial pneumonia, dehydration, and worsening of chronic medical conditions, such as congestive heart failure, asthma, or diabetes. Children and adults may develop sinus problems and ear infections.”

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Emergency Signs

Here are some “emergency warning signs” that require urgent medical attention.

In children, emergency warning signs that need urgent medical attention include:

  • Fast breathing or trouble breathing
  • Bluish skin color
  • Not drinking enough fluids
  • Not waking up or not interacting
  • Being so irritable that the child does not want to be held
  • Flu-like symptoms improve but then return with fever and worse cough
  • Fever with a rash

In adults, emergency warning signs that need urgent medical attention include:

  • Difficulty breathing or shortness of breath
  • Pain or pressure in the chest or abdomen
  • Sudden dizziness
  • Confusion
  • Severe or persistent vomiting

For detailed description of H5N1 cases, see clinical features from WHO
See also: Avian Influenza A (H5N1) Infection in Humans The Writing Committee of the World Health Organization (WHO) Consultation on Human Influenza A/H5. New England Journal of Medicine. Sept 29, 2005

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Symptomatic Relief

OTC

  • Antipyretics (fever reducers)
    • acetaminophen (tylenol) Very effective at reducing fever and pain, but has no effect on the underlying disease process. Great care needs to be taken because larger doses can damage the liver. Especially, the maximum doses indicated in the directions must be very strictly observed.
    • ibuprofen is also very effective at reducing fever and pain, but care needs to be taken because at larger doses, or over an extended period, it can cause gastric ulcers. Maximum doses indicated in the directions must be strictly observed.
    • alternating ibuprofen and acetaminophen is one possible approach for lowering a serious fever without exceeding the dosage guidelines of either ibuprofen or acetaminophen. http://pediatrics.about.com/cs/weeklyquestion/a/012302_ask.htm
    • aspirin is also effective, but must be strictly be avoided in children because it poses an unacceptable risk of a serious and often fatal malady, Reyes Syndrome http://www.reyessyndrome.org/what.htm ; http://www.reyessyndrome.org/aspirin.htm Further, aspirin poses a greater risk of gastric ulcers than ibuprofen.
  • Home remedies
    There are numerous home remedies available, but here are a few principles about treatment.
    • Home remedies do not cure disease, rather make the illness bearable.
    • Avoid alcohol. It is dehydrating and can reduce the quality of sleep. (An exception is an alcohol bath to reduce fever. This is usually rubbing alcohol, however, which should never be ingested as it is poisonous.)
    • From ARDS research, it appears fish oil and borage seed oil taken together improve the outcome in ARDS by altering the balance of cell-membrane fats which the body modifies for use in cytokine signalling, One interesting aspect of this research is that it apparently has lead Abbott Pharmaceuticals to offer a medical meal-replacement formula containing these oils for use in patients suffering from ARDS and related conditions. The original research using these oils to supplement other kinds of enteric feeding improved the mortality rate from ARDS from 40% to 28%. These data should be interpreted cautiously.

How important is hydration? The last time I had a real ILI, I sipped a lot of Gatorade (fortunately I could keep it down). After a couple of days of fever spiking/breaking cycles (about four hours per cycle), I was OK. I don’t remember feeling run down for more than a day or so. Anecdotal evidence, but in the end, it’s the body that has to do the work of fighting infections & we should give it as much ammo as it can use.

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Antivirals

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Secondary Infections

Bacterial pneumonia

S. aureus is most commonly involved although S. pneumoniae and H. influenzae may be found. link, link

Antibiotics for pneumonia are typically highly effective. In 1918, the Spanish Flu (also Avian based) was associated with a high incidence of bacterial pneumonia. As there were no antibiotics available at the time, it is hard to estimate what the affect of antibiotics will be in developed countries on net mortality. In undeveloped countries, mortality rates will likely be higher. An important issuse regarding antibiotic use will be 1)access to a healthcare prescriber, 2)determining when to properly use antibiotics and 3) being able to get the desired antibiotic. 4)Will it make a difference or not?

If your doctor is overwhelmed with patients or is ill or does not have the proper staff then it will be hard to get in. Even now, patients commonly have extended waits till they can be seen. In a true pandemic, the system will not have the capacity to see everyone who wants to be seen. It may also be difficult to know when you should try to go in to be seen.

If you are not sure if you have a routine cold or the flu, do you want to go to the office where trully there will be more people with the true flu? Will you get something worse than you started out with? I believe it will be very important for healthcare providers to have a clear understanding of the average clinical course of avian influenza is like to help differentiate what is flu related and what is bacterial. If it is too difficult to tell if there is a bacterial infection on top of the influenza then you may well “get antibiotics just in case.”

The next issue is getting the proper antibiotics. Most pharmacies stock a few hundred tablets of each commonly used antibiotics and then depend on just in time shipping to get their stocks refilled. If the system is having trouble getting supplied from staffing difficulties in any level from production to shipping to stocking then it may prove difficult to get the proper antibiotics.

Finally, it is hard to know at this point if treatment for secondary bacterial infections will change overall mortality rates in a true pandemic. At this point we have too little experience to know. If the viral infection is overwhelming then treating the bacterial side makes little difference. Hopefully, they will make a difference. At any rate, they will be helpful for all the thousands of people who get a regular bacterial pneumonia.

The best advice would be for doctors offices and pharmacies to stock up a bit, particularly if there is an outbreak anywhere in the world, then load up while the supply system is working proplerly. There are antibiotics in the National Emergency Supply system but distribution issues need to be worked out in advance. Hospitals, pharmacies, and health departments across the country need to know how to access emergency supplies.’‘’

Prevention of Secondary Infections

While fulminant viral infection,particularly in young adults remains the nightmare scenario, secondary bacterial infection will take a heavy toll, especially among the elderly, infants and children, and the chronically ill. Primary prevention of these infections is imperative, and primary medical providers everywhere should aggressively target these populations with the available vaccines to these devastating infections. Some bacteria that cause pneumonia are ubiquitous in the nose and mouth; reducing contact with others will not make you ‘bacterial pneumonia-proof’.

  • Pneumococcal Polyvalent Vaccine aka pneumovax.

Pneumococcal polyvalent vaccine is a vaccine to 23 of the most common and virulent strains of Streptococcus pneumoniae (pneumococcus).

Pneumococcus remains one of the most dangerous bacteria causing primary and secondary pneumonias in all age groups. The vaccine is thought to be about 60% effective in preventing invasive disease.

It currently is given as a one time injection, with one booster for certain high-risk groups.

The current recommendations of the ACIP.

Note that younger children (< 6 years) already are immunized against some strains of pneumococcus through the use of standard childhood vaccines (Pneumococcal conjugate vaccines or PCVs). The Pneumococcal polyvalent vaccine is not efficacious in young children whereas the PCV is.

  • HIB vaccine

Haemophilus influenzae (HiB) is a bacteria that, before the advent of vaccines in the early ‘90s, was responsible for many severe secondary and primary infections in people of all ages, but in particular infants and young children, causing about 12,000 cases of meningitis yearly, as well as pneumonias, sinus infections, ear infections and sore throats. After HiB vaccine became standard for infants and children, the incidence of invasive disease from HiB has decreased markedly in pediatric patients world-wide.

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Oxygen Therapy

Supplemental Oxygen (O2) is prescribed when the body is unable to meet its metabolic requirements through normal ventilation of room air. How this is diagnosed is beyond the scope of this entry, but is an interplay of clinical observation and laboratory testing.

O2 is prescribed by both volume (dosage) and delivery system: low volume systems include nasal cannulas (NC), shields, and masks. They can deliver usually up to 6 liters per minute (NC,)--which works out to about roughly 38–40% of O2-- or up to 10–15 l/min (mask). Because of mixing in of atmospheric air, the masks and shields never deliver quite 100%, but they can get close. (I dispute this ‘close’ in the case of NC, will find the figures for you—Lisa the GP)

Their drawbacks are that they are drying to the nasal mucosa,and eyes, particularly at the higher liter flows, the masks pinch and can cause skin breakdown, and most importantly that they are a passive system, dependent on the lungs ability to breathe in the air and make the gas exchanges.

The next layer of respiratory support above purely passive oxygen delivery is BiPAP or CPAP. In these devices, some level of air pressure above atmospheric air pressure is kept in the airways to help hold them open—variable in the case of BiPAP, and constant in the case of CPAP. While this does not force air into or out of the lungs, it can help keep inflamed airways (in the case of infection) or floppy airways (in the case of sleep apnea and in emphesaema) open when they would otherwise swell (or flop) shut. This allows air to move in and out of areas of the lung that would otherwise be poorly ventilated. While suboptimal for patients whose illness justifies a respirator, BiPAP and CPAP with supplemental oxygen are sometimes used to help stabilize a patient when a mechanical ventilator is not available; during a pandemic these devices may give patients a little more time to wait while the search for a ventilator goes on.

If the lungs cannot keep the body oxygenated with these methods,the next step is usually mechnical ventilation (‘vent’). A breathing tube is inserted through the mouth into the trachea (intubation), and O2 is supplied directly to the lungs, taking over the work of breathing, This reduces the energy needed to breathe, allows O2 to get to the alveoli more efficently, and can give the body the time it needs to recover. Its drawbacks are that it can allow the chest muscles to weaken though disuse, can give bacteria an inroad into the lungs, and muxt be carefully monitored to avoid metabolic inbalances developing. Patients on ventilators are typically in critical care or intensive care units or ICUs (see below). Because long term use of the tube can cause pressure ulcers in the throat, patients who are on a ‘vent’ for prolonged periods (generally > 2 weeks but varies by institution) may get a tracheostomy, which is a hole cut directly into the trachea for ventilation access. In most cases when a patient has recovered this hole can be repaired, leaving a scar.

Though we think of oxygen as a good thing, it should be noted that in its pure form Oxygen is so strong an oxidizing agent as to be somewhat ‘corrosive’ to tissue, and it can actually cause lung damage if pure oxygen is delivered by ‘vent’ for more than a few hours (other modes inherently dilute it enough that this effect is not a problem). For this reason most institutions will try to wean back the oxygen concentration from 100% within the first 24 hours of placing a patient on mechanical ventilation. Some institutions advocate adding a few ppm of NO (nitric? oxide, not nitrous) to the oxygen, which alters blood flow in the lungs and usually allows a lower concentration of oxygen to be used while maintaining the same level of measured blood oxygen. However there are some toxicities associated with NO use as well, particularly in cases of ARDS, so this remains somewhat controversial. Finding the right balance is an art.

One problem common to all oxygen delivery systems is that they are easily dislodged, which is of particular concern because people who are oxygen deprived tend to get delirious; because the oxygen systems are uncomfortable it is not unusual that patients will keep taking them off, and they may require restraint to prevent this. Restraints pose an additional layer of difficulty and risk in managing patients receiving oxygen therapy.

Lastly, oxygen safety—higher oxygen concentrations cause other materials to burn more quickly and to ignite at lower temperatures than they ordinarily would, and so heat sources near any oxygen supply or outlet should be avoided. This effect is so severe that on a warm day, liquid oxygen dripped onto asphalt can cause the asphalt to burst into flame, and people who work with patients on oxygen and subsequently go outside to smoke have been known to ignite their own oxygen-enriched clothing.

O2 is a vital medication, and an uninterrupted supply? of it will be vital in a influenza pandemic.

Oxygen Therapy in the Home or Extended Care Facility American Assoc for Respiratory Care Clinical Guideline

Oxygen Conserving Devices Patient Instructions Apria Healthcare

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Higher requirement medical care

  • Home care
  • Emergency Departments and Emergency Rooms
    • the ability to absorb a surge in patients is limited - see CDC Press Release. ERs are famously adaptable, however. Add solutions here, including when to seek care (see description of personnel and operation of ERs here).
  • Hospitalization
    • “The impact of over two million hospitalized patients would test and possibly overwhelm the surge capacity of hospitals nationwide. For instance, according to the American Hospital Association, in 2003 there are only 965,256 staffed hospital beds in registered hospitals.” From A Killer Flu? - see Other Resources. Hospitals will develop their own plans to cope. See State and Local Plans in your area.
  • Critical care
    • Critical care beds, like hospital beds, will be limited. Intensive care will most likely be needed for respiratory failure due to pneumonia, or ARDS 2º to cytokine storm.
    • Critical care draft triage protocals have been suggested for critical care resources, ventilators and respiratory personnel.
      • effect on adult ICUs
        • potential lack of beds
          • recovery rooms could expand ICU beds by cutting back elective surgery (infection control an issue)
        • potential lack of ventilators
          In the United States, for example, there are 105,000 mechanical ventilators, 75,000 to 80,000 of which are in use at any given time for everyday medical care. During a routine influenza season, the number of ventilators being used shoots up to 100,000. In an influenza pandemic, the United States may need as many as several hundred thousand additional ventilators. Osterholm reference
        • Respiratory Therapy Working Group - Draft
        • potential personnel shortage
      • effect on NICUs
        • potential personnel shortage
        • risk of nosocomial (introduced by staff) infection

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Influenza and Pregnancy

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Page last modified on April 03, 2007, at 07:26 PM by DemFromCT