Lung transplant, H1N1 patients bypass ventilators with ECMO

Lung transplant, H1N1 patients bypass ventilators with ECMO


Liesbeth Stoeffler used to run marathons. By 2007, she could barely walk a block without taking a break. She began avoiding stairs and taking taxis instead of walking the eight blocks to work.
Before being diagnosed in 1995 with cystic fibrosis, an inherited disease in which the body produces unusually thick mucous that clogs the lungs and digestive tract, Stoeffler, now 50, was a vice president for AllianceBernstein, an investment management firm in Manhattan. She skied, did yoga and traveled.

Stoeffler eventually received a lung transplant and is now on the mend. But she might not have survived without a device that is proving to be a bridge to lung transplants and a possible alternative to ventilators.

ECMO (extracorporeal membrane oxygenation) devices have been around for about 20 years. Now simplified and portable, they are rising in popularity and even have a role in treating swine flu, or H1N1, patients.

Stoeffler, who had to resign from her firm and was forced to go on oxygen 24 hours a day, is one whose life was changed by the device.

Stoeffler found herself hospitalized on June 1 this year. That day, she went for routine blood work. Her oxygen levels were low, and she was very sick, says David Lederer, Stoeffler's pulmonologist. She was admitted to New York Presbyterian Hospital-Columbia's intensive care unit and placed on the ventilator.

Patients on ventilators are often partially sedated and unable to speak. There is also a high mortality rate for patients with cystic fibrosis on the ventilator, Lederer says.

Ordinarily, air is drawn into the lungs naturally when breathing. But a ventilator pushes air into the lungs instead, often causing lung damage from the pressure differences, says Matthew Bacchetta, Stoeffler's surgeon and director of the adult ECMO program at New York Presbyterian Hospital-Columbia.

"Patients usually have poor outcomes and die on the ventilator or never make it to transplant because they are so deconditioned," Bacchetta says.

He and Lederer decided to replace the ventilator with an ECMO device. Instead of pushing air into the lungs, ECMO machines bypass the lungs and directly oxygenate the blood.
With Stoeffler, the hospital used the device earlier than in most lung-failure cases and removed all "unnecessary" parts of the machine to make Stoeffler more comfortable and allow her to move, Lederer says. The device typically has two entrances into the body: one in the neck and one in the groin. But the team used only one entrance, the jugular vein in her neck, which allowed her to get up and walk.

"(Bacchetta) and I and the team decided to use ECMO in this novel fashion because we knew that once she was on that ventilator, her time was quite limited," Lederer says. But with ECMO, the team was able to improve her oxygen and carbon dioxide levels.
"You would never even know that this woman had these two tubes connected to the side of the neck," says Christina Restivo, Stoeffler's close friend.

On ECMO, Stoeffler could have most liquids and foods, which helped her gain weight and strength. She could eventually sit up, talk and even use her laptop and iPhone to document the events. "About five days into it, she told me it was the best she'd felt in years," Bacchetta says.
Bacchetta says ECMO can function as a bridge to transplant or a bridge to recovery; his patients have been on it for as long as three weeks. A young patient "literally dying" of swine flu in the spring was placed on ECMO to be transported to New York Presbyterian Hospital-Columbia and remained on the device until he recovered, he says.

"That's a patient who would've died otherwise," Bacchetta says. "We've had several other patients without this who have died."

ECMO could be used for pneumonia, pulmonary fibrosis and chronic obstructive pulmonary disease, Lederer says. It could be used during the swine flu outbreak, especially if hospitals are short of ventilators, he says.

For Stoeffler, ECMO allowed her to regain enough strength to remain eligible for a transplant.
She had double lung transplant surgery July 20. She returned home Sept. 4, without oxygen support.

"The ECMO was the bridge between my respiratory failure and the transplant," Stoeffler says. "If I had been intubated (a tube down the throat) like everybody else, I would've been sick. I don't think I would've survived that."

She recently started jogging. Though she has some muscle and weight to gain, Lederer says, there is a chance she could be running marathons again. But for now, she can walk around her apartment and talk without resting every few seconds. And she is free of the oxygen tank.