Do Not Start Methylprednisolone for Influenza A Requiring 15L Nasal Cannula
Corticosteroids should not be administered to patients with severe influenza pneumonia, as they are associated with increased ICU mortality and should not be used as co-adjuvant therapy. 1
Primary Evidence Against Corticosteroid Use
The most robust and recent evidence comes from a large propensity score-matched study of 1,846 critically ill patients with confirmed influenza pneumonia across 148 ICUs. This study demonstrated that corticosteroid administration was associated with:
- Increased ICU mortality (HR = 1.32,95% CI 1.08-1.60, p < 0.006) 1
- Higher crude mortality in the corticosteroid group (27.5%) versus no corticosteroid group (18.8%) 1
- This harm persisted even after rigorous propensity score matching to control for confounding factors 1
What You Should Do Instead
Immediate Antiviral Therapy
- Start oseltamivir 75 mg orally twice daily for 5 days immediately, even if the patient is beyond 48 hours from symptom onset 2, 3
- Severely ill hospitalized patients may benefit from antivirals started late, particularly when immunocompromised 2
- Reduce dose to 75 mg once daily if creatinine clearance <30 mL/min 2
Oxygen Management
- Maintain SpO2 ≥92% through high-flow oxygen delivery 3
- High concentrations of oxygen can safely be given in uncomplicated influenza pneumonia—do not hesitate 2
- Monitor oxygen saturations and inspired oxygen concentration continuously 2
- A patient requiring 15L NC is approaching the threshold for ICU transfer 3
Severity Assessment
- Calculate CURB-65 score to determine pneumonia severity 3
- Obtain chest X-ray to assess for bilateral infiltrates indicating primary viral pneumonia 3
- If CURB-65 ≥3 OR bilateral CXR changes, this represents severe pneumonia requiring aggressive management 3
Antibiotic Coverage
- Start IV antibiotics immediately with co-amoxiclav or second/third generation cephalosporin (cefuroxime or cefotaxime) PLUS a macrolide (clarithromycin or erythromycin) 2, 3
- Obtain blood cultures before antibiotic administration 3
- Send pneumococcal and Legionella urine antigens 3
- Antibiotics should be given within 4 hours of recognition 2
ICU Transfer Criteria
This patient is at high risk for ICU transfer. Transfer immediately if any of the following develop:
- Failing to maintain SpO2 >92% despite FiO2 >60% 3
- Severe respiratory distress with PaCO2 >6.5 kPa 3
- Rising respiratory and pulse rates with severe distress 3
- Shock or hemodynamic instability 3
- Altered mental status 3
Important Caveats About Corticosteroid Use
The Only Exception: Pre-existing COPD or Asthma Exacerbation
- If this patient has underlying COPD or asthma and is experiencing an acute exacerbation triggered by influenza, then corticosteroids are indicated for the exacerbation itself (not the influenza) 4
- In this specific scenario: prednisone 40 mg daily for 5 days 4
- Continue short-acting bronchodilators with or without anticholinergics 4
Why Some Older Literature Suggests Benefit
- Small case reports and case series from the 1980s-2010s suggested potential benefit 5, 6, 7, 8
- However, these were uncontrolled observations in highly selected patients, often with organizing pneumonia as a late complication 6
- The 2018 propensity-matched study of nearly 2,000 patients provides far stronger evidence and directly contradicts these earlier reports 1
Common Pitfall to Avoid
Do not confuse organizing pneumonia (a late complication occurring 2-3 weeks after initial infection) with acute severe influenza pneumonia. 6 If a patient develops refractory hypoxia with consolidation and ground-glass opacities at week 2-3 after initial improvement, organizing pneumonia should be considered and may warrant corticosteroids (methylprednisolone 1.5 mg/kg) 6. However, this is a distinct clinical scenario from your patient who is acutely ill with influenza requiring 15L oxygen.