France: 2nd nCoV Patient Deteriorates, Placed On ECMO

 

Extracorporeal membrane oxygenation (ECMO) machine in a ICU patient in Santa Cruz

 

# 7280

 

While I’ve yet to find the official release, it is being widely reported this morning that the Centre Hospitalier Regionale et Universitaire de Lille has announced the condition of their second novel coronavirus patient has deteriorated since our last update (see France: Both Coronavirus Patients Remain In `Poor’ Condition) and he has now been placed on ECMO.

 

This from AFP.

 

Coronavirus: the health of the French second patient deteriorated

(AFP)

LILLE - The health of the roommate of the first confirmed case of novel coronavirus in France deteriorated Wednesday, Thursday announced the Lille University Hospital where both hospitalized patients.

 

"The health status of the second patient deteriorated in the last day. He was placed on ECMO (extracorporeal membrane oxygenation) to take over from his lung function," said the University Hospital in a statement

 

"His condition has stabilized but remains a serious concern," the statement said.

(Continue . . .)

 

 

France’s index case, a 65-year-old man who had recently traveled to the UAE, was hospitalized on April 23rd, and was placed on ECMO support on May 8th.

 

Both cases illustrate just how devastatingly virulent this infection can be.  Of 40 known cases, 20 have died, and many of the survivors have required significant and prolonged medical intervention.

 

For more on ECMO, and how it has been used for severe respiratory disease, you may wish to revisit.

 

JAMA: H1N1, ECMO, and Survivability

The ECMO Option

France: Both Coronavirus Patients Remain In `Poor’ Condition

 

Extracorporeal membrane oxygenation (ECMO) machine in a ICU patient in Santa Cruz Hospital, Lisbon, Portugalj - Wikipedia

# 7270

 

 

An update from the Centre Hospitalier Regionale et Universitaire de Lille, in France where two nCoV patients remain in their ICU; the index case who traveled to the UAE during the middle of April, and a second patient who shared a hospital room with him before he was diagnosed.

 

 

Checkup of the two patients coronavirus

14 May 2013 - 12

Both patients coronavirus ICU at University Hospital of Lille are still in a poor state of health.

 

The first patient remains in stable condition. No improvement is recognized by doctors for the moment.

 

The second patient is still under ventilatory support by ventilator.

 

His condition is not completely stabilized.

 

 

The index case – a 65 y.o. man who was hospitalized on April 23rd -  reportedly remains on an ECMO (Extracorporeal Membrane Oxygenation) machine.  Increasingly, we’ve seen ECMO support used for severe respiratory distress due to pneumonia, avian flu, and the novel coronavirus.

 

Normally patients with Acute Respiratory Distress Syndrome (ARDS) are placed on a mechanical ventilator and treated with a variety of drugs to reduce infection (antibiotics) and lung inflammation (corticosteroids, Nitric Oxide, etc.).

 

Despite these measures, ARDS is generally fatal in 50% of patients.

 

 

Which is why in 2009 some hospitals tried an expensive and controversial treatment called ECMO on some adult and adolescent patients with H1N1 related pneumonia, and early reports were encouraging.

 

ECMO is a specialized heart-lung bypass machine used to take over the body’s heart and lung function – for days or weeks if necessary – while the body heals from injury or illness.

 

ECMO is most commonly used in neonatal intensive care units for newborns in respiratory distress, although it is also used for pediatric and adult patients with severe heart or respiratory deficits.

 

In the fall of 2009 we saw a report in The Lancet  where UK researchers determined that ARF (Adult Respiratory Failure) patients that received ECMO support as opposed to conventional ventilation had a greater survivability without disability.

 

While often lifesaving, ECMO resources are extremely limited, and are simply not available in many regions of the world.  

 

For more on ECMO, and how it has been used for ARDS, you may wish to revisit.

 

JAMA: H1N1, ECMO, and Survivability

The ECMO Option

JAMA: H1N1, ECMO, and Survivability

 

 

# 5882

 

 

Despite its reputation as a `mild’ pandemic, the 2009 H1N1 `swine flu’ virus produced unusually severe respiratory infections in a very small subset of patients.  Thousands of people ended up in ICUs, with some requiring ventilator assistance for weeks on end.

 

Last month in mBio: Lethal Synergism of H1N1 Pandemic Influenza & Bacterial Pneumonia, we looked at a study that proposed that bacterial co-infections were behind many of these cases of ARDS (Acute Respiratory Distress Syndrome).

 

In late 2009, in Cytokine Storm Warnings I wrote about a study that appeared in the  American Thoracic Society's American Journal of Respiratory and Critical Care Medicine, that looks at the autopsy results of 21 pandemic flu victims.

 

Researchers found three separate types of severe lung damage, and point to signs of a cytokine storm response in some of these cases.

 

But whatever the cause (and there likely were several), many swine flu patients found themselves suffering from serious lung damage (see The View From The ICU).

 

Normally, patients with ARDS are placed on mechanical ventilation, and treated with a variety of pharmacological agents to reduce infection (antibiotics) and lung inflammation (corticosteroids, Nitric Oxide, etc.).

 

Despite these measures, ARDS is generally fatal in 50% of patients.

 

With H1N1-related pneumonia, mechanical ventilation often did not result in adequate oxygenation, as the lungs were too congested to allow oxygen exchange in the alveoli.

 

(Image adapted from Wikipedia)

 

In some hospitals an expensive and controversial treatment called ECMO was tried on some adult and adolescent patients with ARDS, and early reports were encouraging.

 

ECMO or Extracorporeal Membrane Oxygenation is a specialized heart-lung bypass machine used to take over the body’s heart and lung function – for days or weeks if necessary – while the body heals from injury or illness.

 

ECMO is most commonly used in neonatal intensive care units for newborns in respiratory distress, although it is also used for pediatric and adult patients with severe heart or respiratory deficits.

 

In the fall of 2009 we saw a report in The Lancet  where UK researchers determined that ARF (Adult Respiratory Failure) patients that received ECMO support as opposed to conventional ventilation had a greater survivability without disability.

 

 

Yesterday in JAMA (Journal of the American Medical Association) two articles appeared on the use of ECMO during the pandemic; a study and an editorial.

 

Noah MA, et al "Referral to an extracorporeal membrane oxygenation center and mortality among patients with severe 2009 influenza A(H1N1)" JAMA 2011; DOI: 10.1001/jama.2011.1471.

Checkley W "Extracorporeal membrane oxygenation as a first-line treatment strategy for ARDS: Is the evidence sufficiently strong?" JAMA 2011; DOI: 10.1001/jama.2011.1504.

 

 

The study – which was limited to patients at 4 hospitals with ECMO facilities in the UK – used `matched pairs’ of patients with similar history, age, symptoms, and other traits that would be expected to have an effect on outcome.

 

Across the board they found that ECMO patients were twice as likely to survive as were non-ECMO patients.

 

While these findings are both encouraging and intriguing, ECMO is hardly a panacea for a pandemic.

 

Even among those who received ECMO, more than 20% died. And ECMO therapy is invasive, expensive, requires anticoagulant drugs for the duration of treatment, and can result in serious complications. 

 

Furthermore, ECMO units are severely limited in number, with the number reported available in the United States during the pandemic as `a few hundred’.

 

The authors caution that the higher survivability of patients who received ECMO treatment may have been due to other factors, and that these results – while encouraging - should be taken cautiously. Still, they believe their results will help revitalize interest in ECMO as a viable treatment option of ARDS.

 

The accompanying editorial cautioned that randomized controlled trials of ECMO treatment for ARDS would be needed to prove its true value.

 

The JAMA research article, and the editorial are both available online, and worth reading. 

The View From The ICU

 

 

# 3828

 

 

While the H1N1 virus has proved to be a moderate illness for the vast majority of those infected, for a small percentage of mostly younger patients, infection has proved life-threatening. 

 

Betsy McKay of the Wall Street Journal has report today on the severity of illness being seen in ICUs around the world, and how that raises concerns on what we may see this fall and winter in the northern hemisphere.

 

 

• OCTOBER 12, 2009, 10:45 A.M. ET

Swine Flu Is Severe for Some, Studies Show

by BETSY MCKAY

Swine flu may be mild for most people, but some become so gravely ill that they require sophisticated techniques, equipment, and aggressive treatment in intensive-care units to survive, according to three new studies.

 

"This is the most severely ill that we've ever seen people," said Anand Kumar, lead author of one of the studies and ICU attending physician for the Winnipeg Regional Health Authority in Canada.

 

"There's almost two diseases. Patients are either mildly ill or critically ill and require aggressive ICU care. There isn't that much of a middle ground."

 

(Continue . . .)

 

JAMA  (The Journal of The American Medical Association) has a series of 4 articles published today on the impact of H1N1 on ICUs from around Canada, Mexico, and Australia & New Zealand.

These are freely available without subscription.

 

Critically Ill Patients With 2009 Influenza A(H1N1) Infection in Canada Published October 12, 2009.

 

Critically Ill Patients With 2009 Influenza A(H1N1) in Mexico Published October 12, 2009.

 

Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome Published October 12, 2009.

 

Preparing for the Sickest Patients With 2009 Influenza A(H1N1) Published October 12, 2009.

 

The first two studies outline the experiences of ICUs in Canada and Mexico. 

 

The 3rd study, on ECMO use in Australia & New Zealand, indicates that the average length of time severely ill patients required this heart-lung bypass was a remarkable 10 days.  Despite this intervention, patients placed on ECMO saw a 21% mortality rate.

 

For more information on ECMO, you may wish to revisit my blog The ECMO Option.

 

The last article is basically a summation of some of the information from the first 3 studies.  

 

All four are worth your time to review.

The ECMO Option

 

 

# 3754

 

 

ECMO or Extracorporeal Membrane Oxygenation is a specialized heart-lung bypass machine used to take over the body’s heart and lung function – for days or weeks if necessary – while the body heals from injury or illness.

 

ECMO is a highly specialized, and technically demanding life support option which is not available a most hospitals around the globe.  It is most commonly used in neonatal intensive care units for newborns in respiratory distress, although it is also used for pediatric and adult patients with severe heart or respiratory deficits.

 

One of the disturbing hallmarks of the novel H1N1 `swine’ flu virus is that it produces – in a very small percentage of victims – severe lung damage resulting in ARDS (Acute Respiratory Distress Syndrome).  

 

Over the summer, a number of these flu patients have been placed on ECMO machines, to give their damaged lungs time to heal, as demonstrated in the CBS Evening News Video below (hat tip mcphilbrick on FluTrackers).

 

 

 

 

Normally, patients with ARDS are placed on mechanical ventilation in ICUs, and treated with a variety of pharmacological agents to reduce infection (antibiotics) and lung inflammation (corticosteroids, Nitric Oxide, etc.).  

 

Despite these measures, ARDS is generally fatal in 50% of patients.

 

With H1N1 viral pneumonia, mechanical ventilation often does not result in adequate oxygenation, as the lungs are too congested to allow oxygen exchange in the alveoli.

 

(Image adapted from Wikipedia)

 

With ECMO, the burden of pumping and oxygenating the blood is taken from the heart and lungs, and they are given time to heal. 

 

A more detailed explanation is available in this emedicine article on ECMO (above image from that article).

 

In a Lancet Study, published earlier this week, UK researchers determined that ARF (Adult Respiratory Failure) patients that received ECMO support as opposed to conventional ventilation have a greater survivability without disability.

 

Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial

 

 

ECMO resources are extremely limited of course, and are not available in many regions of the world.  

 

Even in places where it is available, triage decisions regarding which severely affected H1N1 patients will get this sort of life support – and for how long – will become tougher as we progress into this flu season.

 

The number of staffed ECMO support beds available in the US appears to number in the low-to-mid hundreds. 

 

While ECMO can improve a patient’s odds of surviving, it is by no means a sure thing. Complications, including infection at the site of cannulation, are not uncommon.

 

This is a last ditch, heroic measure, reserved for those who cannot survive without it.   But for those with severe H1N1 induced ARDS, it may be their last, best option.