The critically ill avian influenza A (H5N1) patient*

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Abstract
This review examines perspectives of human infection with avian influenza A H5N1 (AI H5N1), specifically focusing on the presentation, diagnosis, and management of those critically ill with AI H5N1. PubMed (1966–2006), PubMed “related articles,” publications and Web sites of the World Health Organization and the Centers for Disease Control and Prevention, personal files, abstract proceedings, and reference lists. We reviewed English-language publications pertaining to clinical presentation, diagnosis, and management of AI H5N1 and infection control expressly relating to the intensive care setting. The majority of reported patients with AI H5N1 are critically ill and require intensive care management. These patients progress rapidly to severe acute respiratory distress syndrome. Multiorgan failure occurs in a large proportion. Because of the nonspecific clinical, laboratory, and radiologic features, it is critical to seek a history of exposure to poultry or wild birds in suspected cases. Reverse transcription polymerase chain reaction performed on nasopharyngeal aspirate is the most reliable method for the laboratory diagnosis of AI H5N1. Treatment includes starting neuraminidase inhibitor oseltamivir as early as possible in addition to the standard supportive management. Aerosol generating procedures should be minimized to avoid nosocomial transmission. Strict infection control procedures are paramount to staff safety, although human-to-human transmission is rare as of this time. Many patients with AI H5N1 are critically ill either at presentation or shortly thereafter. Intensivists and intensive care units are therefore at the front line for this new cause of severe lung injury. Practitioners must be familiar with the nonspecific presentation of AI H5N1 and its diagnostic and therapeutic options. Although treating the infected patient with AI H5N1 is a priority, safeguarding healthcare workers and other patients must be considered of equal priority.