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JAMA. Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome
Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome, October 12, 2009, The Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators 0 (2009): 2009.1535 (Abstract, edited)
Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome
The Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators*
JAMA. 2009;302(17): (doi:10.1001/jama.2009.1535).
Context
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).
Objectives
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.
Design, Setting, and Patients
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.
Main Outcome Measures
Incidence, clinical features, degree of pulmonary dysfunction, technical characteristics, duration of ECMO, complications, and survival.
Results
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) PaO2/fraction of inspired oxygen (FIO2) ratio of 56 (48-63), positive end-expiratory pressure of 18 (15-20) cm H2O, 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.
Conclusions
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 young adults with severe hypoxemia had a 21% mortality rate at the end of the study period.
*Authors/Management and Writing Committee:
Andrew Davies, MBBS, FRACP, FJFICM (chair), Australian and New Zealand Intensive Care Research Center, Monash University, and Alfred Hospital, Melbourne, Australia; Daryl Jones, MD, BSc(Hons), FRACP, FJFICM, Australian and New Zealand Intensive Care Research Center, Monash University, and Austin Hospital, Melbourne, Australia; Michael Bailey, PhD, MSc(statistics), BSc(Hons), Australian and New Zealand Intensive Care Research Center, Monash University, Melbourne, Australia; John Beca, MBChB, FRACP, FJFICM, Auckland City Hospital, Auckland, New Zealand; Rinaldo Bellomo, MD, FRACP, FJFICM, Australian and New Zealand Intensive Care Research Center, Monash University, and Austin Hospital, Melbourne, Australia; Nikki Blackwell, BSc, FRCP, FRACP, DTMH, FAChPM, FJFICM, Prince Charles Hospital, Brisbane, Australia; Paul Forrest, MBChB, FANZCA, Royal Prince Alfred Hospital, Sydney, Australia; David Gattas, MBBS, MMed(ClinEpi), FRACP, FJFICM, Royal Prince Alfred Hospital, Sydney, Australia; Emily Granger, FRACS, St Vincent's Hospital, Sydney, Australia; Robert Herkes, MBBS, FRACP, FJFICM, Royal Prince Alfred Hospital, Sydney, Australia; Andrew Jackson, MBBS, FANZCA, St Vincent's Hospital, Sydney, Australia; Shay McGuinness, MBChB, FRCA, FANZCA, Auckland City Hospital, Auckland, New Zealand; Priya Nair, MD, FJFICM, St Vincent's Hospital, Sydney, Australia; Vincent Pellegrino, MBBS, FRACP, FJFICM, Alfred Hospital, Melbourne, Australia; Ville Pettil?, MD, PhD, Australian and New Zealand Intensive Care Research Center, Monash University, Melbourne, Australia; Brian Plunkett, MBChB, Royal Prince Alfred Hospital, Sydney, Australia; Roger Pye, FRACP, FJFICM, FANZCA, St Vincent's Hospital, Sydney, Australia; Paul Torzillo, MBBS, FRACP, FJFICM, Royal Prince Alfred Hospital, Sydney, Australia; Steve Webb, MPH, PhD, FRACP, FJFICM, Royal Perth Hospital, and School of Population Health and School of Medicine and Pharmacology, University of Western Australia, Perth, Australia; Michael Wilson, BScMed, FRACS, Royal Prince Alfred Hospital, Sydney, Australia; Marc Ziegenfuss, MBBCh, BSc, Dip(PEC), FRCS, FJFICM, Prince Charles Hospital, Brisbane, Australia.
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<cite cite="http://jama.ama-assn.org/cgi/content/abstract/2009.1535v1?etoc">JAMA -- Abstract: Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome, October 12, 2009, The Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators 0 (2009): 2009.1535</cite>
The Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators*
JAMA. 2009;302(17): (doi:10.1001/jama.2009.1535).
Context
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).
Objectives
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.
Design, Setting, and Patients
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.
Main Outcome Measures
Incidence, clinical features, degree of pulmonary dysfunction, technical characteristics, duration of ECMO, complications, and survival.
Results
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) PaO2/fraction of inspired oxygen (FIO2) ratio of 56 (48-63), positive end-expiratory pressure of 18 (15-20) cm H2O, 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.
Conclusions
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 young adults with severe hypoxemia had a 21% mortality rate at the end of the study period.
*Authors/Management and Writing Committee:
Andrew Davies, MBBS, FRACP, FJFICM (chair), Australian and New Zealand Intensive Care Research Center, Monash University, and Alfred Hospital, Melbourne, Australia; Daryl Jones, MD, BSc(Hons), FRACP, FJFICM, Australian and New Zealand Intensive Care Research Center, Monash University, and Austin Hospital, Melbourne, Australia; Michael Bailey, PhD, MSc(statistics), BSc(Hons), Australian and New Zealand Intensive Care Research Center, Monash University, Melbourne, Australia; John Beca, MBChB, FRACP, FJFICM, Auckland City Hospital, Auckland, New Zealand; Rinaldo Bellomo, MD, FRACP, FJFICM, Australian and New Zealand Intensive Care Research Center, Monash University, and Austin Hospital, Melbourne, Australia; Nikki Blackwell, BSc, FRCP, FRACP, DTMH, FAChPM, FJFICM, Prince Charles Hospital, Brisbane, Australia; Paul Forrest, MBChB, FANZCA, Royal Prince Alfred Hospital, Sydney, Australia; David Gattas, MBBS, MMed(ClinEpi), FRACP, FJFICM, Royal Prince Alfred Hospital, Sydney, Australia; Emily Granger, FRACS, St Vincent's Hospital, Sydney, Australia; Robert Herkes, MBBS, FRACP, FJFICM, Royal Prince Alfred Hospital, Sydney, Australia; Andrew Jackson, MBBS, FANZCA, St Vincent's Hospital, Sydney, Australia; Shay McGuinness, MBChB, FRCA, FANZCA, Auckland City Hospital, Auckland, New Zealand; Priya Nair, MD, FJFICM, St Vincent's Hospital, Sydney, Australia; Vincent Pellegrino, MBBS, FRACP, FJFICM, Alfred Hospital, Melbourne, Australia; Ville Pettil?, MD, PhD, Australian and New Zealand Intensive Care Research Center, Monash University, Melbourne, Australia; Brian Plunkett, MBChB, Royal Prince Alfred Hospital, Sydney, Australia; Roger Pye, FRACP, FJFICM, FANZCA, St Vincent's Hospital, Sydney, Australia; Paul Torzillo, MBBS, FRACP, FJFICM, Royal Prince Alfred Hospital, Sydney, Australia; Steve Webb, MPH, PhD, FRACP, FJFICM, Royal Perth Hospital, and School of Population Health and School of Medicine and Pharmacology, University of Western Australia, Perth, Australia; Michael Wilson, BScMed, FRACS, Royal Prince Alfred Hospital, Sydney, Australia; Marc Ziegenfuss, MBBCh, BSc, Dip(PEC), FRCS, FJFICM, Prince Charles Hospital, Brisbane, Australia.
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doi:10.1001/jama.2009.1535). 
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3 symptoms of sore throat,<sup> </sup>cough, myalgia or arthralgia, respiratory distress, vomiting<sup> </sup>or diarrhea, and core temperature >38?C). We also assessed<sup> </sup>whether they fulfilled criteria for community-acquired pneumonia<sup>
<sup>2</sup> tests for equal<sup> </sup>proportion or Fisher exact tests when numbers were small. Continuous<sup> </sup>variables were compared using Wilcoxon rank sum tests. All reported<sup> </sup>P values are 2-sided and were not adjusted for multiple comparisons.<sup> </sup>P<.05 was considered statistically significant. Analysis<sup> </sup>was performed using SAS version 9.1 (SAS Institute Inc, Cary,<sup> </sup>North Carolina).<sup> </sup>
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