Talking All Things Cardiopulm
This podcast is designed to discuss heart and lung conditions, treatment interventions, research, current trends, expert opinions and patient experiences.The goal is to learn, inspire and bring Cardiopulm to the forefront of conversation.
Talking All Things Cardiopulm
Episode 95: Influenza A Continues to Climb
Influenza cases and hospitalizations continue to be the leading respiratory disease nationwide this season. As of Jan 25, 2025, there have been 20 million illnesses, 250,000 hospitalizations, and 11,000 deaths (including 47 pediatric deaths). At the time of this recording Feb 6th, the CDC had not issued a weekly report in 2 weeks. I am happy to report that the CDC did release a weekly report on Feb 7th. Data continues to show an uptrend in Flu A.
Join me as we discuss the different types of influenza, including the most prevalent strains this season. Understand the transmission, signs and symptoms, antiviral meds available, use of vaccines, and precautions to help keep you safe this season.
In this episode:
- Incidence of Influenza as of Jan 25, 2025
- 3 forms of transmission
- Signs and symptoms of influenza
- Anti-viral meds available in the US
- Vaccine use and assistance from the WHO
- Precautions to take to help prevent spread and keep yourself safe
- PT assessment/treatment in the hospital setting
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Welcome to Talking All Things Cardiopulm. I am your host, dr Rachel Barisi, physical therapist and board-certified cardiopulmonary clinical specialist. This podcast is designed to discuss heart and lung conditions, treatment interventions, research, current trends, expert opinions and patient experiences. The goal is to learn, inspire and bring cardiopalm to the forefront of conversation. Thanks for joining me today, and let's get after it.
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Speaker 1:Today we're going to be talking about influenza A specifically, but we're going to give a little background information on just flu in general. Probably since late October, I want to say, flu A has been the primary respiratory illness that I have been seeing this season. Anecdotally Just really noticed a lot more positive cases very specific to flu A and it has continued throughout the season. It is continuing to increase across the country and there was actually recent reporting in Texas that I believe it was 650 students called out of school in one day related to influenza A. So this isn't just a Kansas thing. The numbers have increased throughout the country. But I only have the most recent numbers up until the end of week January 2025. That is the last time the CDC has done their weekly reporting numbers. Normally every week at the end of the week you get you know updated numbers. That has not been the case since January 25th. So the numbers I'm presenting today are from that time period.
Speaker 1:So week four, end of January 25th, that's about two weeks ago we had an increase in 29.4% of cases nationally and the predominant virus is influenza A, specifically H1N1 at 50.7% and H3N2 at 49.1% the week prior. Those two H1N1 versus H3N2, were just percents apart. So H1N1 took the lead in week four by a percent or so Across the country. In that week, week four of 2025, 38,255 hospitalizations occurred across the country. Specifically, there were 16 pediatric deaths in that week with 47 in total In the total season up until that point. So from October 1st, I think is when they claimed the start of the season to January 2025. I'm sorry, january 25th 2025. There have been 20 million illnesses reported, 250,000 hospitalization and 11,000 deaths in total. So this is something to be aware of.
Speaker 1:Flu is high incidence right now. It has been pretty high this entire season. We have two predominating strands at this moment, and so we're going to kind of break that down and talk about how it's transmitted, what things we can do to protect ourselves, and then we'll get into some things that we can keep in mind as PTs, specifically in the hospital setting, in the hospital setting. So influenza is a single-stranded, helically shaped RNA virus of the orthomixovirus. Now there are a ton of virus well, I can't say that word. There are a ton of virus names throughout this talk and I have practiced a few of them because they're not ones I say on a daily basis, so just kind of, you know, give me a little grace on this one. But influenza, single-stranded RNA virus.
Speaker 1:It has three main types that affect humans A, b and C. A and B are the most common. C is considered rare and when it does occur tends to be a mild case. A and B are predominant and, as I just mentioned, type A is the number one. Two strains of it are predominating across the country. There are a handful of B, but the numbers don't come anywhere close.
Speaker 1:So type A is determined by its surface antigen, specifically hemagglutinin and neuraminidase. See, I screwed up already. I had practiced that one a few times and it came out clean, but not this time. So we're going to call that H and N for E's of today, of today. But basically there are 18 subtypes of the hemagglutatin H, h1, h2, h3, h5. So that goes all the way up to H18. So there's a lot of variety in that protein. And then there are six subtypes of the noraaminidase the N, n1, n2, all the way up to 6. So H binds to the target antibody and basically causes the response, and then N facilitates the viral release, the cellular response.
Speaker 1:H is essentially the mediating. H is essentially H. Let me try that again. H mediates binding to its receptor, and so one of the receptors is alpha-2,6. And here's another I don't think I could even make this a wordy Wednesday Cialooligosaccharides, which are found in the upper respiratory system, and then there's alpha-2,3, which are found in the lower respiratory system. So this is where the virus attaches to.
Speaker 1:Type B has two types of lineages B Yamagata and B Victoria, and type B is more commonly seen in children. So hopefully I didn't butcher those words too bad. Apologies ahead of time, but essentially we have type A and type B that predominate in humans, and this has been for quite some time, actually since the 16th century. So a little bit of history here. A and B have been the most common cause of flu globally since the 16th century and they have distinct antigenic variation. And that is where change occurs.
Speaker 1:Mutation occurs in the antigen. Over time. It's known to have about four pandemics, global pandemics, over 100 years time. So 1918 is probably the most commonly known one the Spanish flu, that was an H1N1 variation. In 1957, there was the Asian flu, that was an H2N2 variation. In 1968, there was the Hong Kong flu, which is an H3N2 variation. And then, lastly, in 2009, we had the swine flu, which was also an H1N1 variation. So mutation is a big occurrence in the flu virus and that's what makes it occur in humans, potentially annually. Right, in theory, you could get the flu every year. We call this antigenic drift versus antigenic shift, so drift is more common. This is where you have small mutations over time and it results in a new novel strain. And again, this is why you could get the flu annually and this is why the flu vaccine needs to be updated annually. An antigenic shift is a major change in surface antigen. This is more rare, but it could lead to a pandemic where you have a pretty significant change in the virus.
Speaker 1:So how is the flu transmitted? Well, the flu is pretty contagious in general. It is very efficient in its ability to spread disease. The flu is pretty contagious in general. It is very efficient in its ability to spread disease and it's very efficient in spreading from human to human, and the reason why it's so efficient is that it doesn't just spread in one type of way. It has three modes of transmission airborne, droplet and contact. Primarily, this disease is spread by droplet, so we'll go through some of them in a little bit more specifics, but this is typically what you see in different viruses, right? They're either or even bacterial infections. It's either spread through airborne, droplet or contact. This one specifically, can spread all three ways, which makes it more efficient and also means that we have to be a little bit more diligent about hand hygiene, as well as cough etiquette, as well as potential mask use and even cleaning surfaces. Right, that could be thrown in there in the mix.
Speaker 1:So aerosols and droplets are essentially spread the same way. They are differentiated by the size of the droplet. So aerosols are defined as a respiratory particulate respiratory droplet that is less than five micrometers in size. It is smaller and therefore can be suspended in the air for longer periods of time and can typically travel further distances. For flu, the average is minutes to about two hours of time that it can be suspended in the air. I don't know if I mentioned this about TB last week, but TB can be suspended in the air for increased periods of time. Something along the lines of 14 hours can just kind of linger in the air, which is why it requires that type of ventilation system in the hospital.
Speaker 1:Droplet also spread via respiratory secretions. Droplets particulate, however you want to say it sneezing, coughing, talking, singing right, they all kind of come out the same way. They are defined by a higher or larger droplet size, so it's greater than five micrometers in size, and the difference between droplet and airborne is that it can't stay suspended in the air for prolonged periods of time. They are heavier and therefore drop to the floor faster, so they're not suspended as long and they can't travel as far. The average is around two to three meters, which is why that six foot three to six foot distance space is an important measurement when you're dealing with or around people who are productively coughing or coughing in general.
Speaker 1:Contact, on the other hand, is the spread of respiratory secretion, so to speak, on fomite. So, for instance, I cough on my hand, I then put my hand on a doorknob and then someone else touches that doorknob and then maybe puts their hand in their mouth or their eyes. So there's a mucosal transmission that someone with flu has touched. And just as a precaution in your own home, especially in this type of season, that you are cleaning surfaces that are highly touched doorknobs, light switches, countertops, things like that, handles to refrigerators, that kind of thing but that typically is the additional transmission step in flu. The virus can remain active on inanimate objects for up to about 48 hours. They typically don't live as long on the hand, so, like if I was to sneeze or cough in my hand, it's not going to last 48 hours on my hand, but if I was to cough let's just say, for example purposes, if I was to cough on a doorknob that virus could maintain activity for about 48 hours. So just being diligent about cleaning is part of that, as well as hand hygiene. This is where hand hygiene becomes very important as well, because if you do, for instance, touch said doorknob but you wash your hands frequently throughout the day, that would decrease the potential of you then having received that virus. So, um, after you have either breathe in said particulate, you have potential um droplet into mucosal area.
Speaker 1:The typical onset of symptoms is pretty abrupt. They say the incubation period averages around two days, with a range around one to four days, and then you're able to shed that virus between five to 10 days. In general the peak of spread is one to three days where you're most symptomatic, but it could linger, especially if you have prolonged symptoms. Tends to last longer in children and people who are immunocompromised. So overall symptoms for flu. I'm sure we're all pretty familiar with. That is systemically.
Speaker 1:We might see fever, chills, headache, myalgia, malaise, anorexia, where you have a poor appetite From a respiratory perspective, non-productive cough, nasal congestion, runny nose, sore throat. From a auscultation perspective, sore throat From a auscultation perspective, you might have crackles. They said about 25% and there is potential for diffuse ronchi, but I'm going to hold on to that one in a second. You also can have ocular symptoms, so photophobia, conjunctivitis, lacrimation, which is like runny eyes, pain with eye movement. And there are some GI symptoms vomiting, diarrhea which tend to be higher in kids.
Speaker 1:For the most part this disease process comes in quick and leaves quick, so abrupt symptoms and then rapid recovery is the typical progression of flu. But there are a number of times where we can have complications from flu. We can have respiratory decompensation. We can have changes on chest x-ray like diffuse bilateral infiltrates. We can have a secondary infection, like bacterial pneumonia, which typically occurs seven days later, where you have this recurrent fever. Now you have a productive cough, you have a positive bacterial sputum sample. Again you might see changes on chest x-ray like consolidation. Secondary infections, specifically bacterial pneumonia and potentially viral pneumonia, are the primary reason why we have increased mortality and morbidity with flu. There are some other complications that can occur, like non-pulmonary things, like rhabdomyolytis, myositis. You might have difficulty ambulating, there could be potential for progression of renal failure and there might be some neurologic manifestations.
Speaker 1:So how do you determine that a person has flu? Well, if you have symptoms, that's part of it, right Then like looking at the whole clinical picture and also getting tested early. So if you're able to get tested for flu, it's typically via a nasal swab. The earlier getting tested, the better it is if you are going to be prescribed medications, because most of the medications need to be taken within 48 hours of onset of illness. So the physicians will look at the signs and symptoms. They'll know if there's an increase case reporting of said influenza. Hopefully they're testing as well and that can be effective in general. There are other ways to test, but not in the outpatient setting. I believe mostly in the inpatient setting if you have progression of disease, like endotracheal aspirates is one of them. But you wouldn't have that ability to test unless you had an endotracheal tube. So nasal swabs seems to be the most common type of testing for flu.
Speaker 1:There are medications to help with flu. These medications are antiviral. There are not that many antiviral medications. There are four that are approved for treatment of flu in the US. The two most common is Tamiflu. That's an oral medication, typically taken twice a day for four, for five days. This is a Nora, I can't say it. I'm killing this one. I've practiced this one so many times. Noraminidase enzyme inhibitor and so this is probably. Tamiflu is probably the most commonly used flu medication that you have heard of that you may have potentially taken. It basically blocks the viral enzyme. It works for both flu A and B from my understanding, but there is possibility to have resistance to Tamiflu.
Speaker 1:There is a newer medication that I have been seeing in the hospital setting called Zofluza. This is a single dose medication and it also has to be taken within 48 hours of symptom onset. Same for Tamiflu, it seems to have lesser side effects. Still has side effects, things like cough, chest congestion, nausea, diarrhea, headache, runny or stuffy nose. So I mean similar, look similar to flu symptoms. In general. It's approved for children greater than five years old, with the side effects of potential vomiting, diarrhea. But the mechanism of action is different. It blocks the endonucleus activity of the viral polymerase. In simplicity, it prevents viral replication. So Zofluza prevents replication of said virus and again it's a one-time dose.
Speaker 1:Both Tamiflu and Zofluza seem to be pretty effective in assisting with treatment of flu. It seems like it helps decrease symptoms by one to two days, and it can also be taken prophylactically. There was a few studies that basically talked about adding one of these antivirals in settings like, for instance, a nursing home. If there is a flu outbreak, there is potential to give this type of medication. From a prophylactic perspective. It is not recommended to take this medication prophylactically instead of getting vaccinated.
Speaker 1:Vaccination is still the most recommended way to help prevent spread and also to help prevent severe infection. Vaccines can be more effective if their vaccine matches the current strain more closely. So the closer that vaccine is to the current strain, the better it is in helping to prevent infection and also preventing severity of said infection. There are three types of vaccines that are utilized in the US. There are inactivated virus, which is an intramuscular. There's live attenuated virus, which is intranasal, and then there's a recombinant hemagglutinin vaccine, which is also intramuscular, and again it's more effective the closer it is to the current strain.
Speaker 1:So every year these vaccines get updated and the WHO, the World Health Organization makes recommendations for the next season twice a year. So super important that we have the WHO involved to help us create effective vaccines for things like the flu. They typically are looking at updating the recommendation in February for the northern hemispheres and northern hemisphere and September for the southern hemisphere and then climates that are like the Caribbean where they might not have a true winter season. They can use either of the two is my understanding, but they play a pretty big role in helping us determine what vaccine is going to be most appropriate for the next season. So just another example of how important our communication with the WHO is and the conversation between CDC and the WHO, as well as the importance of the CDC being able to report incidents of said respiratory illnesses, which seems to potentially be on hold at the moment. It's unclear if they have any stoppage at this point, but their last weekly reporting was as of January 25th, so we've had over two weeks of no updated reporting. So current recommendation is still to vaccinate to help prevent disease.
Speaker 1:It is most important for people who have high risk of morbidity and mortality people over the age of 65, pregnant women, children over six months old, as they have a higher likelihood of having decline with the flu, as well as healthcare workers. Since I have been in healthcare so 2009, and probably the two to three years prior while I was a student, it is mandated for healthcare workers to have a yearly flu vaccine. I am not able to go to work in the hospital without proof that I have my yearly flu vaccine and, to be honest, I haven't had the flu. I don't even want to say it out loud, I can't even remember the last time I've had it. So, with that being said, vaccine very important to help prevent spread and to help prevent severe disease From a PT perspective. So I see patients with flu quite a bit in the hospital setting. I'm not sure what the percentage of home health PTs seeing patients with active flu are, but the recommendations from a precautions perspective are the same. You should be wearing a surgical mask, which is considered a level one mask, and gloves Because it is droplet. There is still some unconfirmed recommendation on eyewear. I have always been taught that droplet precautions was level one mask and eye protection as well as standard precautions. So gloves, hand hygiene, the normal routine.
Speaker 1:Someone asked me this question recently and I had seen like a precaution sign without eyewear, and so of course it made me go and kind of jump in and double check myself. And on the CDC website, on two different versions of the precautions isolation guidelines, droplet is mentioned, I'm sorry. Eyewear is mentioned for droplet on both and then in a couple of spots it's basically still undetermined if it's necessary. And so the reason and I don't know if I had mentioned this earlier when we were talking about transmission the problem with droplet or concern with droplet is that when the person with the disease coughs, speaks, sneezes their respiratory droplets to someone who's not currently infected, that is spread by mucosal contact. So respiratory droplet to mucosal as well as inhalation as well as inhalation. So what is mucosal outside of nose? Mouth is eyes. The most recent CDC guideline precaution on precautions said that the primary diagnosis that they actually looked at transmission with droplet was RSV. So it seems that they couldn't make the judgment across the board for other droplet diagnoses.
Speaker 1:That was my take on the undetermined piece of it. So at minimum you as the provider should be in a level one. Mask and gloves and then eyewear is a question mark. But if you're doing things like breathing and coughing and you're pretty close to that patient, to me it makes sense to wear eyewear From a contact perspective. In the hospital, you're wearing gown and gloves. So same thing for home health providers. I don't actually know the answer to this. I should find this out. If you wear contact gowns while entering homes with patients that have certain contact precautions at minimum, you're, you know, taking your clothes off when you get home and not sitting on surfaces and things like that. So that is a question. If you do know the answer to that and you're listening to this, hit me up with a DM email and shoot me that line, because that would be a great piece of information.
Speaker 1:I'm going to drop a document in the show notes because I think this is so important. I actually utilized this document quite a bit during the early time of COVID, during the pandemic, for assistance on precautions and recommendations, because SARS-CoV-1 is discussed in the original document, which was a 2007 guideline, and it breaks down each type of precaution, pretty much everything across the board, from flu to Ebola to COVID or not COVID at the time, sars-cov-1 to TB, and it breaks down each diagnosis what precaution should be utilized for each diagnosis. It breaks down what is an airborne precaution, what is a drop. It's a really I don't want to say profound document. It's a very detailed document, about 200 pages long, has a lot of great information, things we use on a daily basis in the hospital setting.
Speaker 1:When I did my podcast on TB last week, that document was still available on the CDC website. After I did that recording it must have been the next day I was starting to prep flu a bit more I went to open that document again and it's not on the CDC website, it's not in the archives. It brings you basically to a 404 page. So I'm not sure if this document is just not available anymore, if it's going to come back. Trying not to be panicky about that kind of stuff, but I did download it the week I was revisiting TB because it had last been updated September 2024 and my previous document hadn't been updated. That was earlier than that. It was probably closer to 2020, 21 when I was really utilizing that document quite a bit. So I'm going to. I have access to that document. If you want that document, I might put it in the show notes. It was available for the public up until last week, so I think that should be fine. Up until last week, so I think that should be fine.
Speaker 1:But anyway, back to PT perspective. You definitely want to at minimum be wearing a level one mask gloves, contact gown, potentially eyewear, Hand hygiene is very important. If you're in the hospital setting and your patient is coming outside of the room for any reason, whether you're increasing ambulation distance, whether you're trialing stairs, whatever it might be your patient should be wearing a level one mask. So anytime the person has a droplet precaution and they're leaving their room, they need to be wearing a level one mask because they spread disease via their respiratory particulate From a oh and also make sure that you're wiping down all surfaces that they might touch. Standard precautions essentially, but maybe more diligent From an auscultation perspective. Number one auscultation should be on your potential assessment techniques. On your potential assessment techniques likely will have positive crackles.
Speaker 1:A few of the articles I read talked about 25% having diffuse bronchi and that was talking about just flu in general. So I have my own questions about that. Typically, when you have bronchi, you have mucus For the most part in like a very general term. Most respiratory viral type diagnoses do not have mucus. They tend to have fluid just as a like. Across the board general statement Crackles is very common in most viral situations. For instance, viral pneumonia has crackles and fluid versus bacterial pneumonia which has mucus. So bronchi is something that you might hear. Reason why you should auscultate it helps you determine what is going on in those lungs and where the problem might be occurring.
Speaker 1:Absolutely checking vital signs blood pressure, heart rate, spo2, potentially respiratory rate. I had a patient the other day flu, a history of COPD, on higher levels of oxygen, respiratory rate, mid to high 20s, just resting, sitting in rescue breathing position. Those are things that are going to help you make decisions about what you're going to do. If you are actually going to see the patient, what things can you do to help them? What strategies can you give them? But definitely assessing vital signs at rest, during activity and post-activity. With infection you are likely going to see an increase in heart rate.
Speaker 1:There is potential for decrease in SpO2 in the specific patient population, especially if they have other comorbidities. So at least watching it to see if there is any changes is super important. If you are getting desaturation with SpO2, that you are monitoring how much oxygen they are on. Are you up titrating? Are they on room air desaturating and then require oxygen. Make sure that you have an order for an SpO2 goal. That can be very important, especially for patients who have underlying disease, just in general, so that you can titrate oxygen If you are doing things like ambulation, that you're building in rest breaks, that you're assessing vitals as you go so that you're not just barreling through thresholds and exaggerated response without checking.
Speaker 1:And then, from a very basic perspective, encourage those patients to be out of bed, increase upright time, more time out of bed, more short distance ambulation in the room to the bathroom, things like that to help maintain mobility while they're in the hospital. Because these things like that to help maintain mobility while they're in the hospital, because these patients tend to feel crummy, right, they don't really want to do a ton. So make sure that you're incorporating breathing exercises, that you're educating them on rest breaks, that you're educating them on signs and symptoms of exercise intolerance and, again, that you're assessing vitals with their activity to determine if they are actually indeed tolerating said activity. So typically, airway clearance stuff isn't going to come into effect unless they have a secondary bacterial infection, potentially bacterial pneumonia, and then everything in the airway clearance world is on the table. The airway clearance world is on the table assessing cough, huff, cough, potentially percussion, anything to help them clear that mucus but, like I said before, typically they don't. They have a non-productive cough, so that typically doesn't happen until they have a secondary infection, if they have a secondary infection. So lots of different things that we can do from a PT perspective. Education is a big piece of that, monitoring is a big piece of that, and then mobility to tolerance, keeping them active, keeping them up, encouraging deep breathing are all going to be things to help this person succeed across the board.
Speaker 1:All right, if you have any questions, please reach out to me. Sorry for butchering some of those terms. I really tried to practice before coming in here because I knew it was going to be hard on the spot. I got some some I failed on, so truly apologize for that. Hopefully this was helpful for you. If you're in a high populated setting, people are coughing. You don't feel comfortable. An easy thing to do is to wear a mask. If you are actively having symptoms and have a fever, stay home. If you actively have a cough, wear a mask, keep other people safe. That's all I have for you today. If you have any questions, please reach out to me, thank you. Thank you for tuning in. Thank you for listening. Truly is appreciated. I hope you all stay safe. Be kind, whatever you have to do, get after it.
