A lecture by Dr Vinod Nikhra at Conference on Swine Flu, organised by Health Department, South Delhi Municipal Corporation at Civic Centre, Delhi on 05 February 2015.

1. Clinical Management
Guidelines for
SWINE FLU ( H1N1)
.
Dr. Vinod Nikhra
M.D., ICCN, PGCHM, FIMSA,
Fellow Royal Society of Medicine
Hindu Rao Hospital, Delhi
Civic Centre 05.02.2015

2. Our Set Up at HRH
Sample Collection Facility
Swine Flu Ward

3. Swine Flu Ward at Hindu Rao Hospital
.

4. Guidelines for Sample Collection
• Sample Type: Throat Swab or Nasal Swab
• Collection: You will need PPE kit, N95 mask, Viral media, Swab stick
• Transportation of Specimens
Sample for Real time-PCR (polymerase chain reaction) for H1N1
should taken:
1. If the patient has a severe or progressive disease in both high risk
and other groups with warning signs
2. There is cluster of cases
3. High risk individuals with ILI

5. Guidelines on Categorization of
Influenza A - H1N1 Cases for Testing and Treatment
• Category A:
Mild fever plus cough/ sore throat. A mild illness.
Do not require anti-viaral medication, i.e., Oseltamivir (Fluvir or Tamiflu). No
need of Testing for H1N1. No need of hospital admission. Should be confined at
home and asked to observe precautions.
• Category B:
(i) Cat. B1: Moderate S/Ss. Treatment strategy same like Cat. A. No testing for
H1N1 is required.
(ii) Cat. B2: Those with high risk; They should be treated with Oseltamivir.
• Category C:
S/S of a severe disease. Breathlessness, chest pain, altered consciousness, fall in
BP, blood tinged sputum, peripheral cyanosis. In children with ILI having
somnolence, high and persistent febrile state, not accepting feeds, shortness of
breath, convulsions.
The Cat. C patients require immediate hospitalization and treatment.

6. .
.
.

7. High Risk Groups for Complications of H1N1
• Pregnant women
• Infant and Children below 5 years
• Elderly >65 years
• Patients with COPD/chronic resp disease, CAD,
Chronic neurological disease which impairs breathing
or clearance of secretions, CRF, DM, haemoglobin-
pathies, or immunocompromised (on steroids and
such drugs, cancers, HIV).

8. Care of a
Suspected or Confirmed Case of H1N1
• As per the National Guidelines, a confirmed H1N1 case has
to be treated:
At Home, or
In the Hospital Setting
Depending on:
Clinical presentation and presence of complications
For this, the Respiratory Disease Activity is to be
monitored.
Special emphasis if the patient belongs to high risk group

9. Guidelines for the Patient Care at Home
• Dos:
1. Wear mask
2. Wash hands frequently
3. Observe cough etiquettes
4. Stay at home and avoid going into the community
5. Take the prescribed treatment
6. Self monitor health and report to hospital in case S/S
worsen.

10. Guidelines for the Patient Care at Home ..2
• Don’ts:
1. Smoke
2. Close contact with others
3. Touching of eyes, nose or mouth
• Alerts:
1. Persistent fever
2. Difficulty in breathing
3. Blood tinged sputum
4. Alteration of sensorium
5. Exacerbation of S/S of associated comorbidities
6. In case of children: irritability, not accepting orally, vomiting, fast
breathing, seizures, etc.

11. Management of H1N1 Patients admitted in Hospital
Treatment decisions involve:
1. Complications of influenza
2. Worsening of pre-existing illness
3. High risk groups
4. Tools to assess Resp. status:
• X Ray Chest
• CURB65 A scoring tool for deciding the action to be taken
0-1: Treat as an outpatient
2-3: Consider a short stay in hospital or monitor carefully as an outpatient
4-5: Requires hospitalization with consideration for respiratory support.
• CRB65 The CRB-65 tool has been simplified by taking SBP,
and omitting DBP.
Thus, risk class 1 for those with score 0,
Risk class 2 for those with Score 1-2
Risk class 3 for those with 3-4.
Patients in risk class 1 would be ideal candidates for ambulatory treatment in the absence of any severe
comorbidity.
CURB-65
Signs Points
Confusion 1
BUN>7 mmol/l 1
Respiratory rate>=30 1
SBP<90mmHg,
DBP=<60mmHg
1
Age>=65 1
CALCULATE TOTAL SCORE --

12. Warning Signs for Severe Disease
• Dyspnoea
• ALI (Acute lung injury) – Pneumonia
• Hypoxia (pO2 <60mmHg, SaO2 <90%)
• Hypercapnia
• Persistent fever
• Hypotension
• Acidosis
• Altered mental status
• Septic shock

13. Predictors of Severe Disease
• Clinical and radiological signs of LRTI
• Exacerbation of underlying disease
• Shock and multi-organ involvement
• CNS complications
• Higher CURB65 / CRB65 score
• Signs of secondary bacterial infection
• Signs of respiratory compromise / poor oxygenation

14. Treatment of Indoor H1N1 Patient
• ABC: Care about Airway, Breathing and Circulation
• Supplemental Oxygen and Respiratory support
including mechanical ventilation
• Antipyretics (avoid aspirin), Bronchodilators,
Decongestants (avoid steroids), Treat Complications
like shock, bacterial infection
• Nutritional supplementation and rehydration
• Stress ulcer prophylaxis
• Other supportive treatment.

15. Anti-Viral Treatment
• Anti-viral treatment should be started in ILI in high risk group
and in case of Severe and progressive illness
• Oseltamivir (a neuraminidase) is the primary drug. Adv.: oral
administration and a higher lung availability.
• Dose schedule:
Adult: 75 mg twice daily for 5 days
Children: <15 Kg – 30 mg twice daily
15-23 Kg – 45 mg twice daily
23 to less than 40 Kg – 60 mg twice daily
40 Kg or more – 75 mg twice daily
Infants: <3m – 12mg BD; 3-5m – 20mg BD; 6-11 m – 25 mg BD

16. Anti-viral Tt: Side Effects and Toxicity
OSELTAMIVIR:
• Nausea and vomiting
• Allergic reaction, skin rash, facial swelling
• Hepatitis
• Various neuropsychiatric adverse effects
ZANAMIVIR:
Given by inhalation. For the treatment in those of 7 years or older. Not
recommended for individuals with underlying respiratory disease. SIDE
EFFECTS: headaches, diarrhea, nausea, cough, vomiting, disturbance in
temperature regulation, and dizziness. NOT AVAILABLE.
DRUGS TO BE AVOIDED: Steroids and Aspirin.

17. Respiratory Support
Non-invasive Ventilation (NIV):
NIV is a modality that supports breathing without the need for intubation
or surgical airway. It is a popular method of adult respiratory support in the
emergency and indoor wards and the intensive care unit (ICU), and is
particularly helpful in the care of paediatric patients.
It avoids the adverse effects of invasive ventilation, and has the added
advantage of patient comfort. It delivers ventilator support without the
placement of an artificial airway. Useful in milder cases where Pt. is
conscious
NIV can be (i) Negative pressure ventilation (NPV) or (ii) Non-invasive
positive pressure ventilation (NIPPV). NIPPV includes continuous positive
airway pressure (CPAP) and bilevel positive airway pressure (BiPAP).

18. NIV will benefit patients with PaO2/FiO2 > 200 and those with
APACHE II <6.
APACHE II (Acute Physiology and Chronic Health Evaluation II) is a
severity-of-disease classification system, designed to measure the
severity of disease for adult patients admitted in ICU. It is applied
within 24 hours of admission of a patient to ICU: an integer score
from 0 to 71 is computed based on several measurements; higher
scores correspond to more severe disease and a higher risk of death.
Weaning from NIV is associated with a reduced mortality and lower
incidence of ventilator-associated pneumonia.
Respiratory Support ..2

19. Respiratory Support ..3
Invasive Mechanical Ventilation:
It will ensure adequate oxygen therapy, tidal volume 5-7 ml/kg
PBWPEEP to achieve adequate oxygenation. Invasive ventilation
is a method to mechanically assist or replace spontaneous
breathing. It involves an endotracheal tube or a tracheostomy
tube. Respiration is assisted by a ventilator or an Ambu bag.
The mechanical ventilation can be Positive Pressure Ventilation
(where air is pushed into the trachea) or Negative Pressure
Ventilation (where air is sucked into the lungs).
Mechanical ventilation is indicated when the spontaneous
ventilation is inadequate.
Ventilatory Treatment of each patient need to be individualised.