Extracorporeal Membrane Oxygenation (ECMO) Can Be Invaluable During Influenza Season

[B.C.]

Extracorporeal Membrane Oxygenation Can Be Invaluable During Influenza Season

NEW YORK -- September 15, 2009 -- Patients with severe acute respiratory failure (ARF) should be referred for treatment using extracorporeal membrane oxygenation (ECMO), rather than using conventional ventilator management, to improve their chances of survival without disability, according to a study published online first and appearing in an upcoming edition of The Lancet.

Giles Peek, MD, Department of Cardiothoracic Surgery and Extracorporeal Membrane Oxygenation, Glenfield Hospital, Leicester, United Kingdom, and colleagues compared treatment by a specialised ECMO team with care from specialist intensive care unit teams using conventional ventilation, and also assessed the cost-effectiveness of referral for ECMO care.

In the UK-based randomised controlled trial, 180 adults were randomly assigned to receive continued conventional management (n = 90) or ECMO (n = 90). Eligible patients were aged 18 to 65 years and had severe but potentially reversible respiratory failure.

The primary outcome was death or severe disability at 6 months after randomisation. Data about resource use and economic outcomes (quality-adjusted life-years [QALYs]) were collected.

Researchers found that 68 of the 90 patients (75%) assigned to consideration of ECMO actually received it. Of those referred for consideration of ECMO, 63% survived to 6 months without disability compared with 47% of those who were assigned to conventional management. This is equivalent to 1 extra survivor without disability for every 6 patients treated. Consideration of ECMO treatment led to a gain of 0.03 QALYs at 6-month follow-up.

The cost per case was twice that for conventional treatment, but the cost-effectiveness was still well within the range regarded as cost-effective by health technology assessment organisations such as the National Institute for Health and Clinical Excellence (NICE).

"This study shows a significant improvement in survival without severe disability at 6 months in patients transferred to a specialist centre for consideration for ECMO treatment compared with continued conventional ventilation," the authors wrote.

"The cost-effectiveness of ECMO would be improved if costs of both transport and provision of the technique could be reduced...We are confident that ECMO is a clinically effective treatment for acute respiratory distress syndrome, which also promises to be cost effective in comparison with other techniques competing for health resources."

Dr Peek added that "[Influenza A(H1N1)] causes a viral pneumonia which can result in severe respiratory failure in young adults. We have already used ECMO during the first wave of the pandemic with good effect and we are expecting ECMO to prove an invaluable weapon in the fight against the winter resurgence of the infection, as has already been seen during the Australasian winter."

SOURCE: The Lancet

http://www.docguide.com/news/content...25763200526CF4

[Shiloh]

Source: http://www.timesonline.co.uk/tol/new...cle6836642.ece

September 16, 2009
Doctors demand specialist lung treatment for swine flu victims
David Rose, Health Correspondent

The treatment received by Sharon Pentleton, who is pregnant, saves one life for every six, says the study

Patients with swine flu who experience severe respiratory failure should be given a specialist lung treatment, researchers say today.

The treatment — for which one Scottish woman, Sharon Pentleton was flown to Norway — saves one extra life for every six patients compared with conventional treatment for those who are critically ill, the study in The Lancet medical journal reports.

There is only one adult unit in the UK which offers the treatment, called extracorporeal membrane oxygenation (ECMO). It involves circulating the patient’s blood outside the body and adding oxygen to it artificially.

The Glenfield Hospital in Leicester has five ECMO beds and treats around 100 patients a year on average. The unit can be expanded to ten beds if necessary, but Ms Pentleton, who is pregnant, had to be flown to University Hospital in Stockholm for the treatment in July because the Leicester unit was full. She was successfully treated and has now returned to her Scottish home.


Giles Peek, who led the study at the ECMO unit at Glenfield Hospital, said there was likely to be a “big increase” in the need for ECMO as swine flu enters its second wave this autumn.

University Hospitals Leicester NHS Trust said it expected ECMO to be an “essential weapon” in the expected resurgence of illness due to the H1N1 virus this winter.

The study looked at 180 patients aged 18 to 65 with severe lung failure who were treated in Leicester. It found that 63 per cent of patients given ECMO survived to six months without disability compared with 47 per cent of those who were assigned to conventional treatment with a ventilator.

Patients with reversible respiratory failure should be treated with ECMO to “significantly improve survival without severe disability”, the researchers concluded.

But last week, Sir Liam Donaldson, the Government’s Chief Medical Officer, questioned the value of ECMO for adult patients, saying that medical opinion on the treatment was “divided”. He said that 13 nurses were required to run one ECMO bed, compared with six or seven for a normal intensive care bed, meaning the cost of providing the procedure was doubled.

Dr Peek said that Sir Liam was reflecting the scepticism felt about ECMO in some parts of the intensive care community. But he said this was because some units had “dabbled” with ECMO without proper training and had had little success.

In Leicester, of 13 swine flu patients treated so far with ECMO, 85 per cent have survived. But of an estimated 100 patients treated with the procedure for other respiratory illness in other hospitals in Britain, none had survived, Dr Peek said.

He called for the Government to fund the use of ECMO properly so there could be an expansion of the number of beds this winter if needed, but said that this should involve experts from Leicester advising other trusts rather than “people going it alone.”

Asked if he was concerned there would not be enough ECMO beds for swine flu patients this winter, he said: “Yes and no. It depends on the Government’s approach. If the chief medical officer is rubbishing [the research], I don’t think we are going to have an informed approach.”

ECMO units for children are based in specialist neonatal units in Great Ormond Street Hospital, Freeman Hospital in Newcastle upon Tyne, and Yorkhill Hospital in Glasgow.

The deaths of at least 75 people in Britain have been directly linked to swine flu.

[GennieF]

Lung Bypass Saves More Near-Death Swine Flu Cases, Doctors Say

By Jason Gale

Sept. 16 (Bloomberg) -- Swine flu patients whose damaged lungs make them unable to breathe may have a better chance of survival if they get an artificial lung technique that’s twice as expensive as standard treatment, researchers said.

Doctors in the U.K. compared a procedure that pumps blood through an artificial lung rather than using mechanical ventilation, when air is blown into the lungs at high pressure. Their study found that 63 percent of the patients in respiratory failure who were selected for the lung bypass technique survived for at least six months without disability, compared with 47 percent assigned to receive conventional ventilation.

The finding, reported today in the medical journal Lancet, suggests the bypass equipment made by companies including Medtronic Inc. could rescue more severe swine flu cases. In Australia’s New South Wales state, 1 in 7 patients critically ill with the new H1N1 strain received the procedure, known as extracorporeal membrane oxygenation or ECMO.

“We have already used ECMO during the first wave of the pandemic with good effect,” said Giles Peek, a surgeon at Glenfield Hospital in Leicester, England, and lead author of the study, in a statement. “We are expecting ECMO to prove an invaluable weapon in the fight against the winter resurgence of the infection.”

Severe swine flu may cause a viral pneumonia resulting in severe respiratory failure in young adults, Peek said. Acute respiratory distress syndrome, a complication of swine flu and other chest infections, is fatal in 34 percent to 58 percent of patients, Peek and colleagues wrote in the study.

Ventilators More Common

While doctors have favored so-called positive-pressure ventilators for helping patients overcome severe breathing difficulties since the polio epidemic in the 1950s, ECMO emerged as a treatment option in the 1980s. About 2,000 adult respiratory patients had been given ECMO, researchers from the Washington University School of Medicine said in a 2008 study.

Intensive care specialists in Australia and New Zealand, where swine flu cases peaked in July and August, ordered ECMO systems from companies including Maquet Cardiopulmonary AG, a subsidiary of Sweden’s Getinge AB, and Minneapolis-based Medtronic to cater for increased pandemic-driven demand.

“As flu season hits the northern hemisphere, Medtronic is seeing a spike in orders for our ECMO technology in the U.S, Canada and Europe,” John Liddicoat, vice president of Medtronic CardioVascular’s structural heart business, said in an e-mail today. “We are significantly ramping up production to meet what we anticipate will be a sustained increase in the need for ECMO throughout flu season.”

In severe cases, influenza can damage the capillaries surrounding the tiny grape-like sacs, known as alveoli, where gas is exchanged through the blood. Damaged alveoli can bleed, causing pulmonary hemorrhage and clots.

$88,000 Machine

ECMO allows the lungs to recover while a machine takes over gas exchange, said Joseph Zwischenberger, head of surgery at the University of Kentucky, who reviewed the Lancet study. The machines cost as much as 60,000 euros ($88,000), said Josef Bogenschütz, Maquet Cardiopulmonary’s chief executive officer.

The Lancet study, the largest randomized medical trial of ECMO in adults, found the procedure resulted in one additional survivor without disability for every six patients treated.

“Everybody is pleased to see that ECMO has a role in critically ill respiratory failure,” Zwischenberger said in a telephone interview today. “The key is patient selection and risk-cost benefit. It’s going to be a delicate balance.”

Hospitalization

While fewer than 0.5 percent of swine flu sufferers may need hospitalization, those who do may remain in intensive care for up to three weeks, occupying a bed that could be used for 15 heart bypass patients.

In the Lancet study, average health-care costs per patient were more than twice as high for those selected for treatment by ECMO than for patients sent for conventional management, the researchers said. The average cost for those on ventilators was 33,435 ($55,000) while the average ECMO treatment cost was 73,979 pounds.

Patients in the ECMO group spent about 24 days in intensive-care units, compared with a 13-day stay for patients on mechanical ventilators. Of the 90 patients designated to receive ECMO, 2 died in transit. Of the 68 who received treatment, 43 survived.

“Risks associated with ECMO were small, but the procedure is complex and labor-intensive,” the authors noted. In the medical trial, almost all patients flown to ECMO centers were transported by the Royal Air Force, which isn’t a routine service provider for the U.K.’s National Health Service.

To contact the reporter on this story: Jason Gale in San Francisco at j.gale@bloomberg.net.
Last Updated: September 15, 2009 21:23 EDT

http://www.bloomberg.com/apps/news?p...d=a3B182GF_auk

[Chuck]

http://latimesblogs.latimes.com/boos...a-victims.html

Bypassing lungs may help swine flu pneumonia victims
September 16, 2009 | 10:55 am

Patients with acute respiratory stress or pneumonia are typically placed on a ventilator, which assists breathing by forcing air into the lungs under pressure. While ventilation can be lifesaving, it also can damage lung tissues from oxygen toxicity and pressure injury. A new study in the medical journal Lancet has shown that oxygenating blood outside the body with a miniaturized version of a heart-lung machine reduces that damage and can reduce fatalities significantly. The study was not conducted on patients with pandemic H1N1 influenza, but should be directly applicable to them as well. The primary drawback of the approach is the high cost, nearly double that of conventional ventilation.

The technique is called extracorporeal membrane oxygenation, or ECMO for short. In it, blood is run through tiny porous tubes that allow oxygen to filter in and carbon dioxide to escape. The treatment takes stress off the lungs, allowing them time to heal.

Dr. Giles Peek of Glenfield Hospital in Leicester, England, and his colleagues studied 180 adults, ages 18 to 65, with severe breathing problems. They assigned half to consideration for ECMO and half to conventional ventilation. Only three-quarters of those assigned to ECMO actually received it. But 43 of the 68 who received ECMO survived for six months without disability, a total of 63%. In contrast, only 47% of those who were assigned to conventional ventilation survived for the same period without injury.

In a statement, Peek said, "We have already used ECMO during the first wave of the pandemic with good effect, and we are expecting ECMO to prove an invaluable weapon in the fight against the winter resurgence of the infection."

One problem is that most hospitals in Britain -- and the United States -- do not have the machines, which cost nearly $100,000. Although the technology has been around since the 1980s, a 2008 study said that only about 2,000 adult patients in the U.S. had received treatment with it.

One reason hospitals don't like to use it is that blood thinners like heparin must be used to keep clots from forming in the device. That means the patient must be constantly monitored--one therapist for one or two patients 24 hours per day. In contrast, a ventilator technician can monitor as many as 10 patients simultaneously. The average cost of treatment for ECMO patients was about $122,000, compared with an average of about $55,000 for those on ventilators. Six patients needed to be treated for every life saved, Peek said.

-- Thomas H. Maugh II

[Dreamer]

If everyone that progresses to ARDS in the pandemic is better off on ECMO than ventilation, there probably will be a shortage of ECMO equipment and oxygenators as well. I have some ideas that could alleviate that shortage. check it out at:
http://panvent.blogspot.com/2009/09/...o-do-ecmo.html


I have been concerned about the potential for a ventilator shortage for more than 2 years now. The initial concern was if there was an outbreak of H5N1 OR Avian Flu. It appears that the H1N1 Swine Flu pandemic could also be severe enough to cause ventilator shortages. There were calls for hospitals to double the number of ventilators that they have 2 years ago but this was not done. I started the Pandemic Ventilator Project as a way for concerned individuals to build ventilators from commercial grade equipment if the government did not heed the warnings to increase ventilator inventories. Individuals built ventilators to supply to hospitals during the polio epidemic when there were shortages. See the Pandemic Ventilator Project at www.panvent.blogspot.com There are ideas for basic ventilators, high frequency oscillatory ventilators and ECMO units.