Surfactant Replacement Therapy in Influenza A H1N1

To the Editors: A 22-month-old boy was admitted to the Clinic for Infective Diseases, University Clinical Center, Tuzla (Bosnia and Herzegovina), because of fever, cough, loss of appetite, and vomiting. An influenza virus type A H1N1 infection quick test (QuickVue, Influenza A+B—QuickVue Influenza A+B—bioMérieux) had a positive result, and 48 hours later infection with Influenza type A H1N1 was confirmed by polymerase chain reaction (multiplex real-time PCR, firma Roche Diagnostics, Laval, Quebec, Canada) at the University Clinical Center, Sarajevo. A chest radiograph showed bilateral pneumonia. During the first 4 days, he had attacks of hypoxemia, which finally became irremediable on oxygen therapy via nasal cannula. The boy was afebrile, unconscious, periodically agitated, cyanotic, dehydrated, pale, tachycardic and tachydyspnoic with clear signs of cardial decompensation, and worsening of the chest radiograph. He was transferred to the pediatric intensive care unit (PICU, Clinic for Pediatric Disease, University Clinic Center in Tuzla) for mechanical support. After 4 hours of mechanical ventilation with low lung compliance, it was decided to give bovine surfactant (Survanta, Abbott Laboratories) endotracheally. After 10 minutes, there was a significant improvement in lung compliance, oxygen saturation, and normalization of the heart rate. Therapy with surfactant was repeated every 8 hours. After 48 hours, auscultatory examination and chest radiograph of the boy were considerably improved. The role of surfactant in treating respiratory failure is doubtful in children, except in the newborn, even though surfactant can improve oxygenation and significantly decrease mortality in infants, children, and adolescents with acute lung injury and respiratory distress syndrome.1 That kind of therapy has been found ineffective in adults.2 Some investigations have shown that pulmonary surfactant proteins SP-A and SP-D can act as opsonins and neutralize influenza virus.3 In treatment of this child, we used medication that consisted of only surfactant proteins SP-B and SP-C. The medication led to significant improvement in lung function and the general condition, which was probably the result of lower alveolar surface tension and better lung compliance, but it is not possible to exclude a neutralizing effect of surfactant on influenza virus type A H1N1 by opsonization. Fahrija Skokić, MD, PhD Clinic of Pediatrics Igor Hudić, MD, PhD Clinic of Gynecology and Obstetrics Nešad Hotić, MD, PhD Belkisa Cǒlić, MD, PhD Clinic of Pediatrics Mirsada Prašo, MD, PhD Clinic of Anesthesiology and Reanimation Dubravka Bačaj, MD, PhD Clinic of Pediatrics University Clinical Center Tuzla, Bosnia and Herzegovina

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