Jaber S, Conseil M, Coisel Y, Jung B, Chanques G
Unité de réanimation et de transplantation, service d'anesthésie-réanimation B, hôpital Saint-Eloi, CHU de Montpellier, 80 avenue Augustin-Fliche, Montpellier cedex 5, France.
Ann Fr Anesth Reanim. 2010 Feb;29(2):117-25. doi: 10.1016/j.annfar.2009.12.026. Epub 2010 Feb 8.
Novel influenza A (H1N1) at the origin of the 2009 pandemic flu developed mainly in subjects of less than 65 years contrary to the seasonal influenza, which usually developed in elderly patients of more than 65 years. Elderly subjects are partly protected by old meetings with close stocks. Influenza A(H1N1) can arise in serious forms within 60 to 80% of cases a fulminant acute respiratory distress syndrome (ARDS) "malignant and fulminant influenza" in subjects without any comorbidity, which makes the gravity and the fear of this influenza. The fact that this influenza A (H1N1) can develop in healthy young patients and evolve in few hours to a severe ARDS with a refractory hypoxemia gave to the foreground the possible interest of the recourse to extracorporeal oxygenation (ECMO) in some selected severe ARDS (5-10%). The first publications of patients admitted in intensive care unit (ICU) for severe influenza A (H1N1) often associated to an ARDS reported a mortality rate from 15 to 40%. This mortality variability may be explained in part by different studied populations, ARDS characteristics and human and material resources in the ICUs between the countries. Indeed, the highest mortality rates (30-40%) have been reported by in Mexico which were affected the first by pandemic flu and which were not prepared. A bacterial pneumonia was associated to H1N1 influenza in approximately 30% of the cases as at admission in ICU or following the days of the admission justifying an early antibiotherapy associated to the antiviral treatment by oseltamivir (Tamiflu). Obesity, pregnancy and respiratory diseases (asthma, COPD) seem to be associated to the development of a severe viral pneumonia due to influenza A (H1N1) often with ARDS. Older age, high APACHE II and SOFA scores and a delay of initiation of the antiviral treatment by oseltamivir are associated to higher morbidity and mortality. Other analyses of the results obtained from the first published papers included more patients and future studies would permitted to better define the role of therapeutics such as steroids and ECMO.
2009年大流行性流感起源的新型甲型H1N1流感主要在65岁以下人群中发病，这与季节性流感不同，季节性流感通常在65岁以上的老年患者中发病。老年人群体部分受到过去接触密切毒株的保护。甲型H1N1流感在60%至80%的病例中可能以严重形式出现，即暴发性急性呼吸窘迫综合征（ARDS），也就是“恶性暴发性流感”，在没有任何合并症的患者中出现，这使得这种流感的严重性和令人恐惧之处。这种甲型H1N1流感能够在健康的年轻患者中发病，并在数小时内发展为伴有难治性低氧血症的严重ARDS，这使得在某些选定的严重ARDS（5% - 10%）病例中采用体外膜肺氧合（ECMO）成为可能受到关注的方法。首批关于因严重甲型H1N1流感入住重症监护病房（ICU）且常伴有ARDS的患者的出版物报道，死亡率在15%至40%之间。这种死亡率的差异部分可能是由于不同的研究人群、ARDS的特征以及各国ICU中的人力和物力资源不同。事实上，墨西哥报告的死亡率最高（30% - 40%），该国首先受到大流行性流感的影响且没有做好准备。在入住ICU时或入住后的几天里，约30%的病例中细菌性肺炎与H1N1流感相关，这证明在使用奥司他韦（达菲）进行抗病毒治疗的同时应尽早使用抗生素治疗。肥胖、怀孕和呼吸系统疾病（哮喘、慢性阻塞性肺疾病）似乎与甲型H1N1流感导致的严重病毒性肺炎的发展相关，且常伴有ARDS。年龄较大、急性生理与慢性健康状况评分系统（APACHE II）和序贯器官衰竭评估（SOFA）评分较高以及奥司他韦抗病毒治疗开始延迟与更高的发病率和死亡率相关。对首批发表论文所得结果的其他分析纳入了更多患者，未来的研究将有助于更好地确定类固醇和ECMO等治疗方法的作用。
