The majority of patients with primary influenza pneumonia require ventilatory support. Mortality is high but can be decreased with an optimal protective ventilatory strategy (tidal volume of not more than 6 mL per kilogram of predicted body weight, with a plateau airway pressure goal of not more than 30 cm H 2 O), as shown in Acute Respiratory Distress Syndrome Network clinical trials; this strategy is therefore recommended in acute lung injury [38, 39] . Maintaining an adequate fluid balance is also important for survival in acute lung injury. The hemodynamic status should be optimized by appropriate repletion of intravascular volume deficits during the early systemic inflammatory stage [40] . Once acute lung injury has become established, a conservative fluid management protocol, which was associated with beneficial effects in clinical trials, should be considered [41, 42] . In severe refractory cases of primary influenza pneumonia, some patients require venovenous extracorporeal membrane oxygenation support and continuous renal replacement for acute renal failure. Antiviral treatment should be initiated as soon as possible, particularly in patients at high risk of complications. The majority of treatment benefits are derived when antivirals are initiated within the first 48 hours from onset of symptoms. Unfortunately, most patients with primary viral pneumonia receive oseltamivir after 3 to 8 days of influenza onset [14] . However, the experience with seasonal influenza suggests that a reduction in mortality for hospitalized patients has been documented even when oseltamivir was initiated after the first 48 hours following illness onset [43] . Thus, being out of the ideal therapeutic window should not be a reason to withhold antiviral treatment at any stage of active disease.