Physicians should be more critical in the use of steroids in patients who have acute respiratory distress syndrome (ARDS) and influenza. Studies have shown: critically ill patients with influenza pneumonia have significantly lower survival if they receive corticosteroids.
The focus of the evaluation by Professor Dr. Michael Dreher, Aachen, was on critically and severely ill patients who are not hospitalized in normal wards but end up in intensive care. These are patients in whom even the experienced pulmonologist often cannot understand why this or that patient in particular has such a severe course.
When looking at the epidemiology and pathogenesis of viral sepsis, it often turns out that the lungs are affected. Reasons for this are the epithelial cells being affected, but also because cytokine storm occurs or because the epithelial-endothelial barrier is affected. In addition, doctors often see myocarditis and encephalopathies. Prof. Dreher highlighted three aspects and examined how severe courses are described and characterized based on these in the literature.
ARDS and steroids
“We should be more critical in the use of steroids in patients who have acute respiratory distress syndrome (ARDS) and influenza,” Prof. Dreher indicated. Quite a number of papers in recent years have addressed the issue of steroids and influenza in the critically ill patients, comparing, for example, patients treated with corticosteroids with those not treated with corticosteroids [1]. The key difference here is that patients are significantly more likely to be treated with corticosteroids when there is an underlying pneumologic condition. “It’s that natural reflex: The patient has COPD and comes in with an acute exacerbation of their disease, so they get a steroid shot first.” The study showed that those who received steroids were more likely to require ventilation and more likely to need a rescue oxygenation strategy, such as ECMO or high-flow oxygen ventilation (HFOV). Of course, one can argue that these patients are more severely ill and have pulmonary comorbidity because of which they are more likely to receive steroids. However, according to the expert’s criticism, this argument is always difficult to work out, at least in retrospective analyses. “And when we look at the data for in-hospital mortality, we see that the APACHE II score is a predictor, but so is corticosteroids.” Another 2018 analysis supports this: According to this analysis, the probability of survival in the critically ill patient with influenza pneumonia was significantly lower in patients who received corticosteroids [2].
However, a related review also restricts the results: Although the authors of this review also confirm that there is an association between corticosteroids and increased mortality, this should not be generalized. On the other hand, however, there is no evidence, at least at present, that steroids should be applied to critically ill patients with influenza [3].
Cardiac events
In the days following influenza, the rate of myocardial infarction increases. There are several reasons for this; the cytokine storm is one, and macrophage activation in the coronaries is another. But in terms of the critically ill patient in the ICU, it is more common to see myocarditis and patients who not only have fulminant ARDS but independently have cardiac dysfunction, some of which is so severe that you have to treat these patients with VA-ECMO. There is very little data in the literature on this point. A Case Report [4], which did a literary review at the same time, was published in January 2019. A case is described here of a patient with influenza B infection. In the past, influenza A was primarily thought to cause cardiac myocarditis. Here, however, we were dealing with a patient with cardiogenic shock who had no other cause except influenza B infection. Another study [5] has also shown: Influenza myocarditis is a rare but reversible form of cardiogenic shock that can be treated with VA-ECMO as salvage therapy. That’s why it’s something to keep in mind when you get a patient during the influenza season who is suspected of having myocarditis or has circulatory failure, which can also be a cause.
ARDS and invasive aspergillosis.
“Five years ago, I thought invasive aspergillosis was extremely rare and that only maximally immunosuppressed patients would get that,” Prof. Dreher explained. Typical therefore for patients e.g. with stem cell transplantation, HIV or transition to AIDS or other oncological diseases. “In recent years, however, we’ve learned that our critically ill patients, especially those with influenza, very often also have invasive aspergillosis.”
The risk for invasive aspergillosis has been shown to be increased in patients with influenza if the ill have elevated leukocytes, if there are CT-graphic infiltrates suggestive of fungal infection, and, again, if the patients were receiving steroids upon entry to the ICU. The expert strongly recommended making use of the rapid test options when a patient comes in with suspected influenza, and withdrawing steroids if necessary or at least critically questioning whether they are really necessaryThe largest study available on this topic is a retrospective analysis over several years of Dutch intensive care units [6]. There, they looked at the influenza cohort and compared patients with influenza who had invasive aspergillosis vs. patients with influenza without invasive aspergillosis:
- 75% ventilation needed
- 12% one ECMO
- 19% of patients with influenza had invasive aspergillosis
- 32% of immunocompromised patients with influenza had invasive aspergillosis
- Risk (in this retrospective cohort study) is independent of influenza season and subtype
- 90-day mortality in invasive aspergillosis was 51%, significantly higher compared with 28% in influenza without invasive aspergillosis
According to Prof. Dreher, the results also reflect his own experience, highlighting the 19% proportion of patients with invasive aspergillosis. “One in five, that’s quite remarkable. And these are not the most critically ill patients.” When he looks at ICU patients in his own hospital who are ventilated and/or need ECMO due to influenza, the expert said, the rate of invasive aspergillosis is certainly higher than that 19%.
Source: Symposium “Influenza 2019” at the 60th Congress of the German Society of Pneumology and Respiratory Medicine in Munich (D).
Literature:
- Delaney, et al: Critical Care 2016; 20: 75.
- Moreno, et al: Intensive Care Med 2018; 44: 1470-1482.
- Lansbury, et al: Cochrane Database of Systematic Reviews 2019; Issue 2. Art.
- Huang, et al: Clin Respir J. 2019 Jan 20; doi: 10.1111/crj.12995.
- Van de Veerdonk, et al: Am J Respir Crit Care Med; April 2017.
- Schauwvlieghe, et al: Lancet Respir Med. 2018; 6(10): 782-792.
InFo PNEUMOLOGY & ALLERGOLOGY 2019; 1(1): 30-31 (published 6/6/19, ahead of print).