Chapter 30

A 47-year-old previously healthy male physician presented to hospital with the acute onset of fever, nonproductive cough, dyspnea, and malaise. As an intensive care unit (ICU) physician, he had intubated the trachea of a known Severe Acute Respiratory syndrome (SARS) patient in the emergency department 2 weeks earlier. He began to have respiratory symptoms 1 week later. He was admitted and placed in an isolation room. Both sputum and blood cultures were negative. In spite of empiric treatment with broad-spectrum antibiotics, his respiratory status progressively worsened over the next 24 hours, necessitating ICU admission. His vitals on admission to the ICU were respiratory rate (RR) 24 breaths per minute, heart rate (HR) 100 beats per minute (bpm), BP 130/90 mm Hg, and temperature 38.6°C. Oxygen saturation was 95% on an FiO2 of 60%, and arterial blood gases (ABGs) revealed the following: pH 7.45, PCO2 30, PO2 60. With the PO2 to FiO2 ratio (PF ratio) determined to be 100, respiratory failure was diagnosed. The chest x-ray (CXR) showed progressive bilateral basal infiltrates. A complete blood count, electrolytes, creatinine, and liver function tests were all normal, but LDH was elevated. Neurological and cardiovascular systems were intact on examination.

Anesthesia was consulted regarding possible tracheal intubation for respiratory failure with an ARDS picture. The patient was agreeable to intubation. On airway examination he was noted to be of average body habitus (5 ft 10 in [176 cm] and 154 lb [70 kg]) with no obvious dysmorphic facial features. He had no beard and no history of obstructive sleep apnea. Although he was dyspneic, there was no evidence of stridor. With full dentition, the patient was able to open his mouth 5 cm, had a 4 cm thyromental distance, and had a Mallampati Class III pharyngeal view. He exhibited good jaw protrusion, and head and neck mobility was unrestricted. The cricothyroid membrane was easily palpable in the midline.

### 30.2.1 What Airborne Pathogens May Pose Serious Danger to Health Care Workers? What Is the Likely Pathogen that Caused the Illness of the Presented Patient?

Health care workers (HCW) are at risk of coming in contact with respiratory secretions from patients with febrile respiratory illness of unknown etiology. There are a number of airborne viruses or bacteria that can pose a risk to HCW. For instance, active pulmonary tuberculosis carries a high risk of transmission to HCW. Similarly, active anthrax pulmonary infection may also pose a significant risk to HCW.

In general, most airborne viruses which can potentially infect HCW are not associated with high morbidity or mortality. In 2009, a new influenza A H1N1 virus (also known as swine flu) caused a worldwide pandemic affecting millions of patients. At the time of writing this chapter, there were over 375,000 confirmed cases with over 4500 deaths.1 Fortunately, most infected patients ran a benign course. Rarely, patients presented to the hospital with a rapidly ...

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