Fighting off swine fluApril 9, 2019
Elbualy Mohamed Ali, a Kenyan national, was visiting New Delhi to support a close relative who was undergoing treatment for a cancerous condition. Much to his dismay, during his stay as a caregiver, Ali quite suddenly developed high fever, severe breathlessness and persistent cough. A concerned Kenyan acquaintance of Ali referred him to Dr Sudha Kansal, a senior consultant in the Department of Respiratory Medicine, Critical Care and Sleep Medicine at the Indraprastha Apollo Hospital in New Delhi.
During preliminary examination, Dr Kansal thought that Ali’s condition was due to community-acquired pneumonia with respiratory failure and suspected obstructive sleep apnoea. In addition, Ali was also a known hypertensive and a type II diabetic. Primary investigative chest X-ray indicated bilateral chest opacities and confirmed a chest infection. To further determine the causative agent, blood culture, sputum culture, complete blood counts and kidney and liver function tests were carried out. Simultaneously, Ali was placed on a non-invasive ventilator to facilitate his breathing and started on injection azithromycin and ceftriaxone.
Though a diagnosis of community-acquired pneumonia was relatively apparent because of the sudden onset of fever and quickly deteriorating respiratory symptoms, atypical pneumonia, possibly due to a viral or mycoplasma etiology was also considered. Much to everybody’s surprise, the throat swab RT-PCR turned out to be positive for swine flu. This diagnosis required immediate action. Within 18 hours of being admitted, Ali was started on the anti-viral tablet, oseltamivir, a well-known antiviral agent used to treat influenza type A virus, including swine flu.
In spite of the prompt diagnosis and quick treatment, Ali’s condition started deteriorating and his oxygenation level was not improving with the noninvasive ventilator. Since these were concerning signs, he was intubated and subsequently moved to prone ventilation support due to severe hypoxia. However, this was not effective either and his blood oxygenation levels remained low. His condition continued to worsen, and a decision was taken to move him back to a supine position, and Veno-venous Extracorporeal Membrane Oxygenation (ECMO) support was initiated. As the name suggests, ECMO is an extracorporeal technique that allows the exchange of blood gases to occur outside the body through a specially designed equipment. It is used in children and adults with cardiac and respiratory failure when blood carbon dioxide levels need to be reduced and blood oxygenation needs to be normalized after failing mechanical ventilation, while allowing the lungs to rest to recover from the injury caused due to infection, trauma etc.
The ECMO support comes with its own set of challenges. For patients on ECMO, it is necessary that the blood flows at an appropriate rate for the exchange of gases to occur. Patients are put on anticoagulants such as heparin to prevent clotting of the circuit, which requires close monitoring of blood clotting time. Due to the use of heparin, there is always the impending danger of internal bleeding which can sometimes be fatal, especially if it occurs in the brain. It has been observed that about 20-30% of patients on ECMO may have internal bleeding due to heparin.
While Ali’s activated clotting time was being closely monitored, he developed significant gastrointestinal bleeding. His heparin levels were therefore re-titrated and blood products were transfused to prevent further bleeding. As he also had multiple episodes of generalized seizures while on ECMO, Ali was immediately started on antiepileptic drugs. Seizures might have been precipitated by conditions such as metabolic encephalopathy as no focal deficit, suggesting a brain bleed, was noticed. A brain CT scan would have been ideal to determine bleeding in the brain; however, this could not be done as the patient could not be moved to CT scan department due to ongoing ECMO. Ali was kept on minimum sedation so that he could be closely monitored, and his neurological status could be continuously assessed.
Ali’s condition slowly recovered after being on ECMO support for 8 days. He was then weaned off the ECMO over two days and maintained on ventilator support. However, by now, Ali had developed critical illness myo-neuropathy and was very weak. A tracheostomy was needed to assist his breathing and slowly the ventilator support was stopped after 3 days. After this, he gradually recovered. Intensive chest physiotherapy and limb therapy were started. Wheelchair mobilisation was done. He had to undergo considerable physiotherapy to regain his strength before he could be discharged.
It was a difficult journey for both the patient and the medical team, especially since Ali’s condition deteriorated so rapidly, with the ventilator being ineffectual and him developing multiple generalized seizures and GI bleeding. However, Ali was one of the lucky severe swine flu infected patients who survived and eventually regained his strength to normalcy. Dr Kansal would like to specially thank Dr Rajesh Chawla, Dr Mukesh Goel, the entire ICU team, and the perfusionist for their tireless efforts in bringing Ali back to health.
Dr Kansal mentions that in the past season, they had 20 swine flu patients who required ventilator support, 5 of who had to be given ECMO, and of these, only 2 survived. She stresses that “swine flu can be one of the most severe ARDS, that must be diagnosed early on. If the patient does not start improving with mechanical ventilation, ECMO therapy should be considered”. While ECMO can be expensive, early treatment is imperative, although there is no guarantee that it will work for everyone.