High Dose N-acetylcysteine and ECMO for severe novel H1N1 pneumonia

High Dose N-Acetylcysteine And ECMO TherapyFor the Treatment of Severe Novel H1N1 Pneumonia : 

High Dose N-Acetylcysteine And ECMO TherapyFor the Treatment of Severe Novel H1N1 Pneumonia Dr. Jeffrey Kam Fai Hong Dr. Kang Yiu Lai Dr. George W. Y. Ng Intensive Care Unit Queen Elizabeth Hospital

Admission : 

Admission On 15 August 2010, we admitted a 50 year old obese (Body Mass Index 34.2) gentleman with past history of hypertension and diabetes mellitus for the treatment of severe novel H1N1 pneumonia complicated with multiple organ failure. He was a nonsmoker. He had shock, acute renal failure and severe adult respiratory distress syndrome that satisfies ECMO recruitment criteria. He had viral myocarditis. His left ventricular ejection fraction was 40% while he was on inotropic agent.

Treatment : 

Treatment He was on haemofiltration for acute renal failure since admission to avoid fluid overload. We gave the patient oseltamivir, antibiotics (vancomycin, tazobactam plus piperacillin, and minocycline), physiological dose of steroid and high-dose N-acetylcysteine at 75 mg/kg continuous intravenous infusion daily.

ECMO : 

ECMO His Murray score was 3.75. He had refractory type II respiratory failure despite pressure controlled ventilation with 100% oxygen, PEEP of 18-cm H2O, muscle relaxant and inhaled nitric oxide at 40 p.p.m. We started him on veno-venous ECMO and lung protective ventilatory strategy on 16 September 2010. He was put on pressure controlled ventilation with respiratory rate of 10 per minute, PEEP 10 cmH2O, pressure above PEEP 10 cmH2O and 30% inspiratory oxygen. Nitric oxide was rapidly weaned off within a few hours of ECMO support. Daily bronchoscopy was performed for clearing of sputum.

Progress : 

Progress The patient had a rapid decrease in CRP concentration with corresponding improvement in adult respiratory distress syndrome after high-dose NAC therapy and ECMO therapy. He was weaned off ECMO on 18 August 2009. Screening for bacterial co-infection was initially negative on admission. He later developed nosocomial infection which was successfully treated with antibiotic. He was extubated on 25 August 2010 and discharged from hospital on 18 September, 2010. His myocardial function and renal function returned to normal on discharge.

Discussion : 

Discussion Influenza virus induces reactive oxygen species that activate NFκB to produce cytokines. NFκB activation is a prerequisite for influenza virus infection. NAC, through its anti-oxidant effect, attenuates influenza-induced activation of NFκB and proinflammatory cytokines production. High-dose NAC, at 100 mg/kg continuous intravenous infusion daily, suppressed novel H1N1 influenza virus induced cytokine storm. CRP is produced under the direct influence of IL6 and may serve as a biomarker of IL6 level and influenza-induced cytokine activities. (1) Lai KY, Ng WY, Chan PKO, et al. High-dose N-acetylcysteine therapy for novel H1N1 influenza pneumonia. Ann Intern Med 2010; 152: 687-8.

Discussion : 

Discussion ECMO was successfully used as salvage therapy in severe ARDS during novel H1N1 pandemic. The average duration of ECMO support in severe H1N1 in previous reports varied from 6 to 15 days.2,3 Our patient suffered from multiple organs failure and severe ARDS that satisfy ECMO recruitment criteria.4 He was successfully weaned off ECMO in 3 days and there is a close correlation of his clinical improvement to the reduction in CRP level. (2) Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators, Davies A, Jones D, et al. Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome. JAMA. 2009;302:1888-95. (3) Freed DH, Henzler D, White CW, et al. Extracorporeal lung support for patients who had severe respiratory failure secondary to influenza A (H1N1) 2009 infection in Canada. Can J Anaesth. 2010;57:240-7. (4) Peek GJ, Mugford M, Tiruvoipati R, et al. CESAR trial collaboration. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet. 2009;374:1351-63.

Discussion : 

Discussion The early institution of ECMO and lung protective ventilatory strategy, by preventing oxygen toxicity and barotrauma to the lung, may contribute to the improvement of our patient. N-acetylcyteine, via its rapid control of cytokine storm, may account for successful early weaning of ECMO in our patient. Therefore the rapid cytokine suppressing action of high-dose N-acetylycysteine may have a complimentary role to ECMO and oseltamivir in the treatment of severe novel H1N1 pneumonia. The shortening of duration of ECMO therapy may reduce its inherent risk to the patient and optimize the utilization of scare ICU resource in pandemic situation.

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The Story Begins in 1997

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Cellular transcriptional profiling in influenza A virus-infected lung epithelial cells: The role of the nonstructural NS1 protein in the evasion of the host innate defense and its potential contribution to pandemic influenza. Geiss GK, Salvatore M, Tumpey TM, Carter VS, Wang X, Basler CF, Taubenberger JK, Bumgarner RE, Palese P, Katze MG, García-Sastre A.Proc. Natl. Acad. Sci. USA 2002 Aug 6;99(16):10736-41. Epub 2002 Jul 29 The makings of a killer Peter Palese, Christopher F. Basler & Adolfo García-Sastre Nature Medicine 8, 927 - 928 (2002) Yuen KY, Chan PKS, Peiris M, Tsang DNC, Que TL, Shortridge KF, Cheung PT, To WK, Ho ETF, Sung R, Cheng AFB, and members of the H5N1 study group. Clinical features and rapid viral diagnosis of human disease associated with avian influenza A H5N1 virus. Lancet 1998; 351(9101):467-471. Attenuation of influenza-like symptomatology and improvement of cell-mediated immunity with long-term N-acetylcysteine treatment S De Flora, C Grassi, and L Carati Eur Respir J 1997; 10:1535-1541 Pandemic with potential to knock out 2/3 of the world population Treatment that can save the world

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H1 Gene Introduced

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U shape Mortality Rate of Seasonal Influenza Vs W shaped Mortality Rate of H1N1 High mortality contributed by NS1 Gene

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The makings of a killer Peter Palese, Christopher F. Basler & Adolfo García-Sastre Nature Medicine  8, 927 - 928 (2002)

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The Hong Kong NS1 protein is characterized by the presence of a glutamic acid at position 92. The mere change of this glutamic acid to an aspartic acid, as found in the NS1 of most influenza virus strains, disarmed the virus.

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60% mortality Rate High Mortality Contributed by Suprapotent H5N1 NS1 gene

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High mortality contributed by H5N1 NS1 Gene Cumulative H5N1 Mortality Rate up to 8/2/2010

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NS1 Gene of H5N1 as Sword of Damocles Against Human Race Implication of NS1 Gene of H5N1

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W.H.O. has raised pandemic alert from phase 5 to phase 6 on 11/6/2009

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Viral Load in H1N1 ( From David Hui PWH) NPA is unreliable in confirming diagnosis if patient present late.

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55 22 Pneumococcus 10 Staphylococcus 7 S. Pyogenes 6 HiB 1 In an analysis of lung tissue specimens from 77 confirmed fatal US cases of 2009 H1N1, in which deaths occurred from May 1 to August 20, 2009, bacterial coinfections were present in 22 (29%) cases. Of the 22 cases with bacterial coinfection, 10 were caused by S pneumoniae, 7 by S aureus, 6 by S pyogenes, 2 by S mitis, and 1 by Haemophilus influenzae. In 4 cases, there were multiple pathogens. Median age was 31 years (range, 2 months – 56 years), and half were men. CDC MMWR September 29 2009 Half are vaccine preventable H1N1 death

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In the Denver metropolitan area with active bacterial core surveillance (ABC) program, invasive pneumococcal disease has tripled from an average of 20 to 58 in October 2009. Most of that increase has been in adults under the age of 60. Dr. Anne Schuchat, director of the Centers for Disease Control and Prevention's National Center for Immunization and Respiratory Diseases Nov. 25 2009 20 58

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? Protected by Pneumococal and Haemophilus influenza B Immunization Program with major reduction in mortality 1918 Influenza U.S.A. CDC Volume 12, Number 1, January 2006 1918 Influenza: the Mother of All Pandemics Jeffery K. Taubenberger* and David M. Morens Very similar Mortality Rate

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W-shaped mortality contributed by NS1 gene

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Critically ill patients with 2009 influenza A(H1N1) infection in Canada. Kumar A JAMA. 302(17):1872-9, 2009 Nov 4. Same W-shaped mortality contributed by NS1 gene

Critically ill patients with 2009 influenza A(H1N1) infection in Canada. Kumar A JAMA. 302(17):1872-9, 2009 Nov 4. : 

Critically ill patients with 2009 influenza A(H1N1) infection in Canada. Kumar A JAMA. 302(17):1872-9, 2009 Nov 4. The spring outbreak of 2009 influenza A(H1N1) infection in Canada affected primarily young, female, and aboriginal patients without major comorbidities, and conferred a 28-day mortality of 14.3% among critically ill patients. The mean (SD) age was 32.3 (21.4) years; 113 patients were female (67.3%), 50 were children (29.8%). The most common comorbidities among critically ill patients were lung disease, obesity, hypertension, and a history of smoking or diabetes, each occurring in 30% to 40% of patients. 1/3 patients required vasopressor support on day 1 following ICU admission. 1/3 patients required advanced ventilatory support and rescue therapies for profound hypoxemic respiratory failure, including high levels of inspired oxygen and PEEP, pressure control, and airway pressure release ventilation, high-frequency oscillatory ventilation, prone positioning ventilation, neuromuscular blockade, inhaled nitric oxide, and extracorporeal membrane oxygenation.

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Extracorporeal Membrane Oxygenation for Nonneonatal Acute Respiratory Failure: The Massachusetts General Hospital Experience From 1990 to 2008 Nehra, Deepika MD Arch Surg Volume 144(5), May 2009, p 427–432 Overall survival 53%

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Burden of ECMO in Australia For the first 2000 patient hospitalized patients for H1N1, 350 required ICU admission and 21 required ECMO. That means that 3.5% patient required ICU admission and 1% of hospitalized patient or 6% of ICU patient required ECMO support. Initial 2000 hospitalized case of H1N1 2009 in Australia 17.5 % 6%

H1N1 patients may be have prolonged virus shedding as opposed to seasonal influenzaThe 49th annual Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) in San Francisco : 

H1N1 patients may be have prolonged virus shedding as opposed to seasonal influenzaThe 49th annual Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) in San Francisco Gaston De Serres from Laval University in Quebec and his team, found that eight of 43 patients, or 19%, were still shedding H1N1 virus eight days after they became ill. They found that a week after flu onset, between 45% and 75% of cases still showed evidence of the virus on RT-PCR and that about a third were still shedding replicating virus based on culture findings. David Lye of Tan Tock Seng Hospital in Singaporeassessed the duration of viral shedding in 70 patients treated with oseltamivir (Tamiflu). In Lye's study of 70 patients, 80% of the treated patients were still shedding virus after five days of illness, 47% after seven days and 8% after 10 days. People who didn't get Tamiflu were infectious longer.

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Mortality Rate Per Confirmed novel H1N1 Infection 10/4/2010 http://www.flucount.org/

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http://www.flucount.org/ (10/4/2010)

Role of High Dose N-Acetylcysteine Anti-oxidant therapy in SuppressingCytokine Storm of H1N1 Pneumonia : 

Role of High Dose N-Acetylcysteine Anti-oxidant therapy in SuppressingCytokine Storm of H1N1 Pneumonia DR. Lai Kang Yiu Intensive Care Unit Queen Elizabeth Hospital

Theory Behind High Dose N-acetylcysteine Therapy for H1N1 Pneumonia : 

Theory Behind High Dose N-acetylcysteine Therapy for H1N1 Pneumonia H1N1 Pneumonia kills by cytokine storm and co-infection NFκβ hold a pivotal role in cytokine activation in influenza infection We can selectively block NFκβ and hence its cytokine activity without affecting the B cell and T cell immunity of influenza virus infection. The activation of NFκβ is induced by reactive oxygen species during influenza infection N-acetylcysteine in doses used for the treatment of acetaminophen (Paracetamol) poisoning can achieve high enough anti-oxidant activity to block reactive oxygen species induced by influenza infection. (hypothesis) "Attenuation of influenza-like symptomatology and improvement of cell-mediated immunity with long-term N-acetylcysteine treatment". S. De Flora, C. Grassi, L. Carati (1997).Eur Respir J: 1535–1541 Falk Nimmerjahn Journal of General Virology (2004), 85, 2347–2356 Active NF-kB signalling is a prerequisite for influenza virus infection Role of oxidants in influenza virus-induced gene expression Katharine Knobil et al Am J Physiol Lung Cell Mol Physiol vol 274: issue 1, L134-L142, 1998 van Klaveren, RJ, Demedts, M, Nemery, B Cellular glutathione turnover in vitro, with emphasis on type II pneumocytes. Eur Respir J 1997;10,1392-1400 Wendl, A, Cikryt, P The level and half life of glutathione in human plasma. FEBS Lett 1980;120,209-211 Effect of N-acetyl cysteine on the concentrations of thiols in plasma, bronchoalveolar lavage fluid, and lung tissue. M M Bridgeman. Thorax 1994;49:670-675 Expression of influenza virus hemagglutinin activates transcription factor NF-kappa B HL Pahl and PA Baeuerle J. Virol., Mar 1995, 1480-1484, Vol 69, No. 3

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Cutting Edge: Influenza A Virus Activates TLR3-Dependent Inflammatory and RIG-I-Dependent Antiviral Responses in Human Lung Epithelial Cells Ronan Le Goffic The Journal of Immunology, 2007, 178: 3368-3372. Cytokine storm can be blocked without affecting anti-viral activity.

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Cytokine Storm TNF-alpha, IL-1beta, IL-6, and IL-8. Expression of influenza virus hemagglutinin activates transcription factor NF-kappa B HL Pahl and PA Baeuerle J. Virol., Mar 1995, 1480-1484, Vol 69, No. 3 The cytokines storm of influenza virus is through the activation of NF-ķB by reactive oxygen species

Nuclear Factor κβ : 

Nuclear Factor κβ Role in cytokine storm in influenza infection Activated by reactive oxygen species by ER overlaod Inhibition by N-acetylcysteine, an anti-oxidant Dr. Lai Kang Yiu Intensive Care Unit Queen Elizabeth Hospital

NFκB : 

NFκB NFκβ is a ubiquitous rapid response transcription factor that regulates the expression of proinflammatory cytokines, chemokines and cell adhesion molecules involved in ROS generation. NFκβusually resides in the cytoplasm bound to inhibitor of NFκβ(I κβ). The entry of NFκβ from the cytosol to the nucleus is regulated by IκB, whose induction and binding to NFκβ prevents the translocation of NFκβ into the nucleus. The anti-inflammatory effect of glucocorticoids and aspirin act through the induction of an increase in IκB production. NFκβ activation requires removal and degradation of I κβafter phosphorylation of I κβ by a complex of inhibitor B kinases ((I κK) Active NF-kB signalling is a prerequisite for influenza virus infection and activation of NF-kB is by the production of reactive oxygen species via reticulum endothelium overload. Anti-oxidant Vitamin E, Vitamin C, Zinc and N-acetylcysteine have been shown to exert its action on suppressing production of NFκβin ameliorating influenza symptomatology Only High Dose N-acetylcysteine has been shown to improve survival in lethal mice study. Nuclear factor k B: a pivotal role in the systemic inflammatory response syndrome and new target for therapy J.W. Christman L.H. Lancaster T.S. BlackwellIntensive Care Med (1998) 24: 1131±1138 α -Tocopherol enrichment of monocytes decreases agonist-induced adhesion to human endothelial cells. Islam KN, Devaraj S, Jialal I. 1998 Circulation. 98:2255–2261 Redox Regulation of Nuclear Factor Kappa B: Therapeutic Potential for Attenuating Inflammatory John W. Christman, Timothy S. Blackwell1, and Bernhard H.J. Juurlink ResponsesBrain Pathology 10: 153-162(2000)

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Haemagglutinin Activation of NF-kappa B is caused by the accumulation of proteins in the endoplasmic recticulum membrane, a condition we have called ER overload. Both the release of Ca2+ from the ER and the subsequent production of reactive oxygen intermediates are required for ER-overload-mediated NF-kappa B activation. The ER-overload response: activation of NF-kappa B. Pahl HL. Baeuerle PA. Trends in Biochemical Sciences. 22(2):63-7, 1997 Feb. Signal Transduction From the Endoplasmic Reticulum to the Cell Nucleus Heike L. Pahl Physiological Reviews, Vol. 79, No. 3, July 1999, pp. 683-701 Role of NAC

Common Anti-oxidant of the Body : 

Common Anti-oxidant of the Body Regeneration

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Nucleus Dehydroascorbic acid Ascorbic acid Reactive Oxygen Species Both enzyme inhibited by dehydroascorbic acid but not by ascorbic acid Role of dehydroascorbic acid in inhibition of NFķβ activation NFκB Vitamin C is a kinase inhibitor: Dehydroascorbic acid inhibits I {kappa} B {alpha} kinase {beta}. Carcamo JM, Pedraza A, Borquez-Ojeda O et al. Mol Cell Biol 2004; 24(15):6645-6652.

The Effectiveness of Vitamin C in Preventing and Relieving the Symptoms of Virus-Induced Respiratory InfectionsGorton, J.C. & Jarvis, K. J Manipul Physiol Ther 1999; 22: 530-3 : 

The Effectiveness of Vitamin C in Preventing and Relieving the Symptoms of Virus-Induced Respiratory InfectionsGorton, J.C. & Jarvis, K. J Manipul Physiol Ther 1999; 22: 530-3 Evaluated megadoses of vitamin C (1000mg po tid) in preventing and relieving cold and flu symptoms in subjects aged 18-32. The control group was composed of 463 students while the test study group was composed of 252 students. Vitamin C was also given to the test group after they developed flu symptoms. Results: Vitamin C administered before or after the appearance of the flu relieved symptoms in 85% of test cases compared to controls.

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Nucleus Zn is able to inhibit NF- ķβ activation by blocking the phosphorylation and degradation of the inhibitory proteins IkBs and its multisubunit IkB kinases, essential reactions required for the activation of NFķβ. Role of Zinc in inhibition of NFķβ activation Thiol-reactive metal compounds inhibit NF-[kappa][beta] activation by blocking [IOTA][kappa][beta] kinase. Jeon KI, Jeong JY, Jue DM. J. Immunol. 2000; 164: 5981–9. Inhibitors of NF-KB Activity: Tools for Treatment of Human Ailments Vinay Tergaonkar, Qiutang Li and Inder M. Vennm NFκβ

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Effect of long-term dietary antioxidant supplementation on influenza virus infection Sung Nim Han, Mohsen Meydani, Dayong Wu, Bradley S Bender, et al. The Journals of Gerontology. Oxford: Oct 2000. Vol. 55A, Iss. 10; p. B496 (8 pages) Vitamin E supplementation decreases lung virus titers in mice infected with influenza. Hayek MG. Taylor SF. Bender BS. Han SN. Meydani M. Smith DE. Eghtesada S. Meydani SN. Journal of Infectious Diseases. 176(1):273-6, 1997 Jul.

The Treatment of Pneumonias in Influenza Using AntioxidantsNagibina, M.V. et. al. Terapeuticheskii Arkhiv 1996; 68: 33-35 (Russian) : 

The Treatment of Pneumonias in Influenza Using AntioxidantsNagibina, M.V. et. al. Terapeuticheskii Arkhiv 1996; 68: 33-35 (Russian) Lipid peroxidation occurs in patients with influenza complicated by pneumonia. Parameters of oxidative stress are greatest in the acute phase and in seriously ill patients. Administration of antioxidants, including vitamin E, decreases oxidative stress and is associated with an improved clinical response.

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"Attenuation of influenza-like symptomatology and improvement of cell-mediated immunity with long-term N-acetylcysteine treatment". S. De Flora, C. Grassi, L. Carati (1997).Eur Respir J: 1535–1541

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"Attenuation of influenza-like symptomatology and improvement of cell-mediated immunity with long-term N-acetylcysteine treatment". S. De Flora, C. Grassi, L. Carati (1997).Eur Respir J: 1535–1541

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"Attenuation of influenza-like symptomatology and improvement of cell-mediated immunity with long-term N-acetylcysteine treatment". S. De Flora, C. Grassi, L. Carati (1997).Eur Respir J: 1535–1541

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"Attenuation of influenza-like symptomatology and improvement of cell-mediated immunity with long-term N-acetylcysteine treatment". S. De Flora, C. Grassi, L. Carati (1997).Eur Respir J: 1535–1541

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"Attenuation of influenza-like symptomatology and improvement of cell-mediated immunity with long-term N-acetylcysteine treatment". S. De Flora, C. Grassi, L. Carati (1997).Eur Respir J: 1535–1541 N-acetylcysteine 600mg b.d.

Protective effect of n-acetylcysteine in a model of influenza infection in mice.[Ungheri D, Pisani C, Sanson G, Bertani A, Schioppacassi G, Delgado R, Sironi M, Ghezzi P Int J Immunopathol Pharmacol. 2000 Sep;13(3):123-128.] : 

Protective effect of n-acetylcysteine in a model of influenza infection in mice.[Ungheri D, Pisani C, Sanson G, Bertani A, Schioppacassi G, Delgado R, Sironi M, Ghezzi P Int J Immunopathol Pharmacol. 2000 Sep;13(3):123-128.] Reactive oxygen intermediates (ROI) and cytokines, particularly tumor necrosis factor (TNF) have been implicated in the pathogenesis of influenza. Using a murine model of influenza, we have studied the levels of TNF, interleukin 6 (IL-6) and of superoxide-generating xanthine oxidase (XO). Mice infected intranasally with influenza virus APR/8 had high levels of XO, TNF and IL-6 in the broncoalveolar lavage, as early as 3 d after infection. XO was elevated also in serum and lung tissue. Administration of the antioxidant N-acetylcysteine (NAC,1 g/kg per day, orally) significantly decreased the mortality in infected mice, indicating a role for RO1 in the lethality associated with influenza infection.

N-acetylcysteine synergizes with oseltamivir in protecting mice from lethal influenza infectionGarozzo A. Tempera G. Ungheri D. Timpanaro R. Castro A. International Journal of Immunopathology & Pharmacology. 20(2):349-54, 2007 Apr-Jun. : 

N-acetylcysteine synergizes with oseltamivir in protecting mice from lethal influenza infectionGarozzo A. Tempera G. Ungheri D. Timpanaro R. Castro A. International Journal of Immunopathology & Pharmacology. 20(2):349-54, 2007 Apr-Jun. In a murine model of lethal influenza infection, NAC was given as a single daily dose of 1000 mg/kg starting from 4 h before infection and until day 4 after infection; Oseltamivir was given twice daily at dose of 1 mg/kg/die for 5 days, starting from 4 h before infection. 21 day survival rate: NAC alone: 20% Oseltamivir alone: 60% Oseltamivir and NAC combination: 100% Since NAC does not show any antiviral action, the present findings suggest that antioxidant therapy increase survival by an improvement in host defense mechanisms, and/or by a direct antioxidant effect against oxidative stress associated with viral infection.

Synergistic combination of N-acetylcysteine and ribavirin to protect from lethal influenza viral infection in a mouse modelGhezzi P. Ungheri D. International Journal of Immunopathology & Pharmacology. 17(1):99-102, 2004 Jan-Apr. : 

Synergistic combination of N-acetylcysteine and ribavirin to protect from lethal influenza viral infection in a mouse modelGhezzi P. Ungheri D. International Journal of Immunopathology & Pharmacology. 17(1):99-102, 2004 Jan-Apr. Mice (12 per group) infected intranasally with a lethal dose of influenza A virus APR/8. NAC was given as a single daily dose of 1000 mg/kg starting from 4 h after infection and until day 4 after infection, in association with ribavirin (100 mg/kg, i.p.). 14-day survival: Without Rx: 17% NAC alone: 25% Ribavirin alone:58% Ribavirin and NAC: 92% This suggest that antioxidant therapy can increase survival by either improving the defenses against virus or by protecting from the pathogenesis of lung inflammation.

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High Dose NAC has been shown to control cytokine storm in a patient with novel H1N1 pneumonia Lai KY, Ng WY, Chan PKO, et al. High-dose N-acetylcysteine therapy for novel H1N1 influenza pneumonia. Ann Intern Med 2010; 152: 687-8.

Theory Behind High Dose N-acetylcysteine Therapy for H1N1 Pneumonia : 

Theory Behind High Dose N-acetylcysteine Therapy for H1N1 Pneumonia When there is bacterial co-infection, the mortality rate of influenza pneumonia increased 10x because of bacterial viral synergy Influenza open up neuraminidase site for attachment of bacteria Bacteria amplify viral proliferation by providing protease for cleavage activation of haemagglutinin. Neuraminidase inhibitor and high dose N-acetylcysteine is synergistic because Neuraminidase can reduce escape of virus and the subsequent exposure of neuraminidase site High dose N-acetycysteine prevent inactivation of anti-protease by reactive oxygen species in epithelial lining fluid and the subsequent cleavage activation of haemoglutinin by bacterial protease. The synergistic action of Tamiflu and high dose N-acetylcysteine in reducing mortality is shown in lethal mice model. Protective effect of n-acetylcysteine in a model of influenza infection in mice Ungheri D, Pisani C, Sanson G, Bertani A, Schioppacassi G, Delgado R, Sironi M, Ghezzi P Int J Immunopathol Pharmacol 2000 Sep-Dec;13(3):123-128. N-acetylcysteine synergizes with oseltamivir in protecting mice from lethal influenza infection Garozzo A, Tempera G, Ungheri D, Timpanaro R, Castro A Int J Immunopathol Pharmacol. 2007 Apr-Jun;20(2):349-54 Synergistic combination of N-acetylcysteine and ribavirin to protect from lethal influenza viral infection in a mouse model. Ghezzi P, Ungheri D. Int J Immunopathol Pharmacol. 2004 Jan-Apr;17(1):99-102.

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Role of Acetylcysteine Role of Tamiflu/Relenza

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Reactive Oxygen Species Cleavage Activation of Haemagglutinin By protease Anti-protease inactivated Role of anti-oxidant glutathione (GSH) in the epithelial lining fluid (ELF) of the lower respiratory tract GSH X

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Role of anti-oxidant N-acetylcysteine in preventing cleavage activation of haemagglutinin epithelial lining fluid (ELF) of the lower respiratory tract

Why High Dose N-Acetylcysteine ?(a) Animal study on survival on mice(b) Elevate GSH level in ELF of LRT : 

Why High Dose N-Acetylcysteine ?(a) Animal study on survival on mice(b) Elevate GSH level in ELF of LRT Supplement GSH in the epithelial lining fluid (ELF) of the lower respiratory tract to prevent inactivation of anti-protease by reactive oxygen species generated by influenza and secondary bacterial infection. The presence of anti-protease can prevent the amplified proteolytic cleavage activation of haemagglutinin of newly released influenza virus in the in the epithelial lining fluid (ELF) of the lower respiratory tract.

The dorminant anti-oxidant molecule both intracellular and in the epithelial lining fluid of the lower respiratory tract is GSH.  Intracellular and extracelluar soluble anti-oxiant : 

The dorminant anti-oxidant molecule both intracellular and in the epithelial lining fluid of the lower respiratory tract is GSH.  Intracellular and extracelluar soluble anti-oxiant In the lung, GSH is present in high concentrations in the epithelial lining fluid (ELF) of the lower respiratory tract, with normal levels in human more than 50- 150 fold greater than in the plasma. Human ELF contain all elements of the redox cycle of the GSH system including glutathione peroxidase and glutathione reductase.

N-acetylcysteine given by mouth is rapidly deacetylated to cysteine, with resulting increases in the concentrations of cysteine in plasma and of reduced glutathione in plasma and the airwaysCysteine and glutathione concentrations in plasma and bronchoalveolar lavage fluid after treatment with N-acetylcysteine Bridgman MME, Marsden M, MacNee W, Flenley DC, Ryle P. Thorax 46:39-42 (1991). : 

N-acetylcysteine given by mouth is rapidly deacetylated to cysteine, with resulting increases in the concentrations of cysteine in plasma and of reduced glutathione in plasma and the airwaysCysteine and glutathione concentrations in plasma and bronchoalveolar lavage fluid after treatment with N-acetylcysteine Bridgman MME, Marsden M, MacNee W, Flenley DC, Ryle P. Thorax 46:39-42 (1991). However when given at 600mg t.d.s, N-acetylcysteine does not produce a sustained increase in glutathione levels sufficient to increase the antioxidant capacity of the lungs. Effect of N-acetyl cysteine on the concentrations of thiols in plasma, bronchoalveolar lavage fluid, and lung tissue. M M Bridgeman Thorax 1994;49:670-675 Therefore N-acetylcysteine (NAC) was given in high dose and as an continuous infusion in our patients. Similar dosage and mode of NAC infusion has been given to patient with acetaminophen (paracetamol) overdose.

: 

Influenza virus hemagglutinin required cleavage into HA1, HA2 during activation HA is synthesised in the rough endoplasmic reticulum, and is transported to the cell surface via the Golgi apparatus. HA is synthesised as a precursor molecule (HA0), which undergoes proteolytic processing into two subunits (HA1 and HA2), which are held together by disulphide bonds) Cleavage of HA0 to HA1 and HA2

If the noninfectious HAO form of the virus is released from cells without being cleaved, extracellular proteases present in pulmonary surfactant can proteolytically cleave this protein (Kido et al. 1993). As a protective mechanism, anti-proteases are present on the surface of alveoli. However, the anti-proteases can be inactivated by ROS. In this regard, it is important to note that during lung inflammation phagocytes increase in number and produce ROS (McCusker 1992). : 

If the noninfectious HAO form of the virus is released from cells without being cleaved, extracellular proteases present in pulmonary surfactant can proteolytically cleave this protein (Kido et al. 1993). As a protective mechanism, anti-proteases are present on the surface of alveoli. However, the anti-proteases can be inactivated by ROS. In this regard, it is important to note that during lung inflammation phagocytes increase in number and produce ROS (McCusker 1992). In vitro study showed that oxidant-treated anti-protease is unable to prevent trypsin from cleaving HAO to HA1/HA2, resulting in a 10,000-fold increase in infectious virus (Hennet et al. 1992a). Oxidants and Antioxidants in Viral Diseases: Disease Mechanisms and Metabolic Regulation The Journal of Nutrition Vol. 127 No. 5 May 1997, pp. 962S-965S Ernst Peterhans

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Reactive Oxygen Species Cleavage Activation of Haemagglutinin By protease Anti-protease inactivated Role of anti-oxidant glutathione (GSH) in the epithelial lining fluid (ELF) of the lower respiratory tract  Prevent inactivation of anti-protease by ROS GSH

H5N1 Avian Influenza PandemicRole of High Dose NAC : 

H5N1 Avian Influenza PandemicRole of High Dose NAC Highly pathogenic H5 or H7 influenza A viruses possess the polybasic amino acid motif at the haemagglutinin-cleavage site (HA1-HA2) that allows cleavage via ubiquitous proteases produced or activated during bacterial coinfection. ? Role of high dose NAC to prevent cleavage activation of H5N1 influenza virus during bacterial co-infection – a process that allow H5 or H7 to cross organ barrier that leads to high mortality

Control of Co-infection in Important in Stopping Cleavage Activation of HA : 

Control of Co-infection in Important in Stopping Cleavage Activation of HA Dr. Lai Kang Yiu Intensive Care Unit Queen Elizabeth Hospital

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CA-MRSA Role of Antibiotic Therapy

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55 22 Pneumococcus 10 Staphylococcus 7 S. Pyogenes 6 HiB 1 In an analysis of lung tissue specimens from 77 confirmed fatal US cases of 2009 H1N1, in which deaths occurred from May 1 to August 20, 2009, bacterial coinfections were present in 22 (29%) cases. Of the 22 cases with bacterial coinfection, 10 were caused by S pneumoniae, 7 by S aureus, 6 by S pyogenes, 2 by S mitis, and 1 by Haemophilus influenzae. In 4 cases, there were multiple pathogens. Median age was 31 years (range, 2 months – 56 years), and half were men. CDC MMWR September 29 2009 Half are vaccine preventable H1N1 death

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In the Denver metropolitan area with active bacterial core surveillance (ABC) program, invasive pneumococcal disease has tripled from an average of 20 to 58 in October 2009. Most of that increase has been in adults under the age of 60. Dr. Anne Schuchat, director of the Centers for Disease Control and Prevention's National Center for Immunization and Respiratory Diseases Nov. 25 2009 20 58

Pneumococcal and Haemophilus influenza B Infection is Vaccine Preventable ! : 

Pneumococcal and Haemophilus influenza B Infection is Vaccine Preventable !

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(Not suitable for China)

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CA-MRSA Role of Antibiotic Therapy

Initial Antibiotic Regime Should Cover for Bacterial infection : 

Initial Antibiotic Regime Should Cover for Bacterial infection Patient should be screened for nasal carrier of MRSA State in I.C.U. Take Home Message

Theory Behind High Dose N-acetylcysteine Therapy for H1N1 Pneumonia : 

Theory Behind High Dose N-acetylcysteine Therapy for H1N1 Pneumonia Adaptive Immune response is necessary for clearing influenza virus infection N-acetylcysteine can improve the adaptive T cell response of influenza infection Maintenance N-acetylcysteine may be beneficial even during the recovery phase of influenza virus infection. "Attenuation of influenza-like symptomatology and improvement of cell-mediated immunity with long-term N-acetylcysteine treatment". S. De Flora, C. Grassi, L. Carati (1997).Eur Respir J: 1535–1541 Influenza Virus Evades Innate and Adaptive Immunity via the NS1 Protein Ana Fernandez-Sesma, Svetlana Marukian, Barbara J. Ebersole, Dorothy Kaminski, Man-Seong Park, Tony Yuen, Stuart C. Sealfon, Adolfo García-Sastre, and Thomas M. Moran1 Journal of Virology, July 2006, p. 6295-6304, Vol. 80, No. 13

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"Attenuation of influenza-like symptomatology and improvement of cell-mediated immunity with long-term N-acetylcysteine treatment". S. De Flora, C. Grassi, L. Carati (1997).Eur Respir J: 1535–1541 N-acetylcysteine 600mg b.d.

Selenium Supplement is Recommended during High Dose N-acetylcysteine Therapy : 

Selenium Supplement is Recommended during High Dose N-acetylcysteine Therapy Dr. Lai Kang Yiu Intensive Care Unit Queen Elizabeth Hospital

The Important Role of Selenium : 

The Important Role of Selenium Selenium (Se) is required for the activity of GPx (Se-GPx), the enzyme catalysing rate limiting step in the anti-oxidant effect of glutathione and protection against lipoperoxidation. The presence of selenocysteine, rather than cysteine, in the active site of an enzyme increases enzyme activity 100- to 1,000-fold. Selenium deficiency has also been shown to increase the M matrix protein mutation in animal study.

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Cytokine Storm TNF-alpha, IL-1beta, IL-6, and IL-8. Se Prevent M1 mutation Se-Px Role of Selenium In High Dose N-acetylcysteine Therapy

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GPx- Se GR Selenium (Se) is required for the activity of Glutathione Peroxidase (Se-GPx), the enzyme catalysing rate limiting step in the anti-oxidant effect of glutathione and protection against lipoperoxidation. . The presence of selenocysteine, rather than cysteine, in the active site of an enzyme increases enzyme activity 100- to 1,000-fold. Glutathione Peroxidase (Se-GPx) Glutathione Reductase (GR) Recycling and Redox Cycling of Vitamin E (An Phenolic Antioxidants)

Selenium Deficiency and Viral Infection Melinda A. Beck Orville A. Levander and Jean HandySupplement: 11th International Symposium on Trace Elements in Man and Animals The American Society for Nutritional Sciences J. Nutr. 133:1463S-1467S, May 2003 : 

Selenium Deficiency and Viral Infection Melinda A. Beck Orville A. Levander and Jean HandySupplement: 11th International Symposium on Trace Elements in Man and Animals The American Society for Nutritional Sciences J. Nutr. 133:1463S-1467S, May 2003

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Selenium deficiency in Influenza infection increase mutation in gene for the M1 matrix protein increase pro-inflammatory cytokines/chemokines suppress anti-inflammatory cytokines shift from a TH1 response to a TH2 response

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Selenium deficiency increases lung pathology in influenza-infected mice Selenium deficiency induces changes in cellular phenotype of lung infiltrating cells. Selenium deficiency has no effect on viral titers Selenium deficiency has no effect on antibody response Selenium deficiency alters cytokine and chemokine expression it was associated with an increase in the mRNA expression of proinflammatory cytokines and chemokines and a decrease in the expression of antiinflammatory cytokines. the immune response in the infected lung tissue was shifted away from a TH1 response to a TH2 response in the Se-deficient mice. Selenium deficiency increases the pathology of an influenza virus infection MELINDA A. BECK, HEATHER K. NELSON, QING SHI , PETER VAN DAEL , EDUARDO J. SCHIFFRIN , STEPHANIE BLUM , DENIS BARCLAY and ORVILLE A. LEVANDER The FASEB Journal. 2001;15:1481-1483.

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Selenium deficiency increases the pathology of an influenza virus infection MELINDA A. BECK, HEATHER K. NELSON, QING SHI , PETER VAN DAEL , EDUARDO J. SCHIFFRIN , STEPHANIE BLUM , DENIS BARCLAY and ORVILLE A. LEVANDER The FASEB Journal. 2001;15:1481-1483.

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The future threat starts in Hong Kong. The future solution starts in Hong Kong H1N1 and H5N1 The problem surfaced in 1997. The solution surfaced in 1997.

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Thank you for your attention