Saving Patients When Ventilators Can’t

Her lungs were failing. One by one, Allison Morgan’s organs were shutting down. After a helicopter flew her from the carbon monoxide-filled RV at Talladega raceway where her husband died, to a rooftop at UAB, desperate attempts to save her life seemed futile. The ventilator simply wasn’t getting enough oxygen to her vital organs. She would be dead within hours if something didn’t change.

There was one possible option, but there were no reports in the medical literature of it ever being tried before. Most victims of carbon monoxide poisoning were either found dead, died in transit, or responded to standard treatment.

In severe flu cases where lungs began shutting down, UAB had been having some success using ECMO, Extra-Corporeal Membrane Oxygenation. The heart/lung bypass technology, originally developed for heart surgery, had advanced to the point that a more compact portable version, suitable for a wider range of applications, was available.

The team, led by Enrique Diaz, MD, associate professor in the Division of Pulmonary, Allergy and Critical Care Medicine and head of the UAB ECMO program, decided to go for it.

“ECMO takes on the work of the heart and lungs and gives the patient’s organs time to recover,” Diaz said. “The patient’s blood is routed through the machine where carbon dioxide is removed and oxygen is added before returning it back to the body. This seems to be the first reported use of this technology to save a patient from carbon monoxide poisoning,”

It worked. After a month in the hospital, Mrs. Morgan was able to go home just in time to celebrate her daughter’s fourth birthday. She is doing well and seems to be making a full recovery.

Word of UAB’s success in helping patients who are in danger of dying from severe flu and not responding to ventilators is also getting around.

“This flu season we’ve had 19 flu patients from across Alabama and the gulf coast,” Diaz said.” A doctor from Pensacola called me and said ‘I’m tired of watching healthy 35-year-olds die. Can you help?’ As it turned out, we could. The patient did well, and we started getting more referrals.”

That call led to a happy outcome. Diaz says that, unfortunately, he is also getting too many calls that are upsetting because they come too late.

“Some doctors and hospitals don’t know about the option, or they keep trying to turn the ventilators up higher, hoping they will work. Ventilators at high levels for extended periods tend to cause lung damage, and the longer organs continue to fail, the less likely they are to recover. Waiting a week or two weeks is too long,” Diaz said.

“If a patient isn’t showing improvement after using ventilators and traditional treatment for 12 to 24 hours, it’s time to call and at least give them the opportunity to be considered as a candidate for ECMO treatment.

“We have some very serious conversations before we make the decision to put patients on ECMO. Ethically, it’s important to make sure a patient has a chance for survival and a reasonably good quality of life. If a patient’s lungs and body are too damaged to recover, we don’t want to simply extend the suffering,” he said.

Considering ECMO’s success with flu and carbon monoxide, Diaz says he hopes to see clinical trials soon to determine whether ECMO might be help in cases of lung failure related to pneumonia and other conditions.

In addition to the equipment used in heart surgery, UAB has seven ECMO units that were able to handle the recent surge in referrals. If future flu seasons are more severe, or if applications of the technology continue to expand to other types of lung injuries and illnesses, is ECMO likely to become a common tool available everywhere? Perhaps not, or at least not in the near future.

“ECMO is a very specialized and complicated treatment. Typically only major academic medical centers have the expertise and are able to commit the resources necessary,” Diaz said. “These are very sick patients who must be followed closely by a full-time team of medical professionals, including intensive care specialists, surgeons, perfusionists, nurses, and respiratory and physical therapists trained in caring for patients undergoing ECMO treatment.

“In Europe there are networks of hospitals that send patients to an ECMO center, and when patients are well enough, they return to the hospital to continue their recovery. I’d like to see similar networks in the U.S.

“A better strategy for dealing with a potential flu outbreak is to prevent it,” Diaz said. “We have to help people understand how serious flu can be. It isn’t just a bad cold. Influenza kills otherwise healthy people in the prime of life. It’s important to get a flu shot and to make sure your family is protected, too.”

A carbon monoxide detector and taking special care with generators, heating units and other carbon monoxide-producing equipment is also a good idea.

At her daughter’s birthday party, Allison Morgan took a photo of her daughter, Carly, and herself that she delivered with thank-you cards to hospital staff who cared for her.

She and Carly had a lot to celebrate.