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Hi, it’s Patrik Hutzel from INTENSIVECAREHOTLINE.COM where we instantly improve the lives for Families of critically ill Patients in Intensive Care, so that you can make informed decisions, have PEACE OF MIND, real power, real control and so that you can influence decision making fast, even if you’re not a doctor or a nurse in Intensive Care!
This is another episode of “YOUR QUESTIONS ANSWERED“ and in last week’s episode I answered another question from our readers and the question was
How to Stop the ICU Team from Pushing My Ventilated Daughter Out of ICU? Help!
You can check out last week’s question by clicking on the link here.
In this week’s episode of “YOUR QUESTIONS ANSWERED”, I am here with a live stream today, where I want to answer your questions if you have a loved one in intensive care. And this is one of the most commonly asked questions for families in intensive care and it’s a question that we get all time. And today’s live stream is about COVID-19 and ARDS- Proning vs ECMO Therapy which is more preferred?
COVID-19 and ARDS-Proning vs ECMO Therapy which is More Preferred? Live stream!
Welcome to another live stream of intensivecarehotline.com. Today’s topic is around, “COVID-19 ECMO versus proning, which option is preferred for ARDS, for COVID ARDS.”
My name is Patrik Hutzel and I’m a critical care nurse consultant and advocate for families in intensive care. You may wonder what makes me qualified talking about this topic. I’ve worked in intensive care as a critical care for over 20 years in three different countries. I have worked as a nurse unit manager for over 5 years in intensive care. I also run an organization called Intensive Care at Home, where we look after predominantly long-term intensive care patients. I have been consulting and advocating for families in intensive care all around the world for over 8 years now. Talking to families in intensive care, every day, again, all over the world.
So, let’s dive right into today’s topic, “When should proning be used versus ECMO (Extracorporeal Membrane Oxygenation) in COVID-19 ARDS?”, but even in other ARDS patients, when should proning be used versus ECMO? So, I’ll give you a little bit of background here so that you can understand what I’m saying.
My very first ICU was actually in 1999, that was in the last century, last millennium, even. I started out in intensive care in 1999, at the end of 1999. I do remember clearly, we had ARDS patients then, and there was no ECMO at that stage. We were proning patients for ARDS, and that seemed to be effective. Most of the time, you were putting patients on their tummy, head down, that was draining out secretions from the lungs. It was easier to expand lungs, to get air in. If patients are on their back all the time, it’s very difficult for the lungs to expand. Therefore, it was difficult to cure pneumonia, ARDS, and so forth.
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Then with the advent of ECMO, more and more patients were sort of avoiding proning and were getting ECMO, because proning is very taxing on the body, you got to sedate people heavily. You got to paralyze them often, so that they can tolerate proning, because again, it’s very taxing on the body. Therefore, the side effects are huge. Side effects talking like prolonged induced comas, muscle wastage, deconditioning. If patients did survive, they had a long recovery time, needed to learn to move again, needed to learn to walk again. The side effects were very negative coming out of prolonged induced comas with proning, and often, being on paralytics.
So then, as ECMO came in, more and more patients were avoiding prone positioning, and they were getting on ECMO. But ECMO being a specialist therapy, there’s also resource constraints. Intensive care as such is a very specialized area, whereas ECMO is even more specialized. You need the equipment; you need staff that can operate ECMO. Looking after a patient on ECMO is very different compared to looking after a patient that’s being proned, you got to do several blood tests a day, every few hours, you got to run several blood tests, you got to check the ECMO filter every hour, you got to run heparin, or many patients on ECMO end up on vasopressors, many patients that are proned end up on vasopressors too. But it’s still a different sort of skillset to look after someone that’s being proned versus someone that is being on ECMO.
Any ICU, I argue, can prone a patient, not every ICU can provide ECMO treatment. The last ICU that I worked at, we had around 45 beds and we could accommodate up to 10 ECMO patients at a time, so you could see how limiting that is, and there aren’t many other hospitals that offer ECMO in the metropolitan area that I’m in. You can see, 10 ECMO beds for a population of 6 or 7 million people is probably not enough, and that was pre-COVID. So now, we are in this worldwide pandemic. Some people that catch COVID, especially the ones with premedical conditions, end up in ICU with COVID ARDS. Then often, if mechanical ventilation and the standard treatment, which is from what I understand, remdesivir, steroids, sometimes it’s nitric oxide, sometimes it’s Flolan, sometimes it’s sildenafil/Viagra, if patients have pulmonary hypertension on top of the COVID ARDS.
If that doesn’t work, if the standard approaches to ARDS don’t work, patients end up being proned. If proning doesn’t work, the next step should be to refer them to ECMO. But from what we are seeing across the board, that doesn’t happen quick enough. The question needs to be made at the beginning of COVID ARDS, does someone need to be referred to ECMO right here and then, before we start proning, or do we start proning, do this maybe for the next 5 to 7 days, and if it doesn’t work, do we then refer them onto ECMO?
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Now, what we are seeing in practice is this, that if patients are being proned for 5 to 7days and it’s not working, they’re not being referred to ECMO, because ICUs are claiming that if proning doesn’t work ECMO wouldn’t work and they’re too deconditioned already, which doesn’t make them a candidate for going on ECMO. Now, I dispute that, that is why it’s so important for any family in intensive care to do their research early on. I dispute that you can’t go on ECMO after 5 to 7 days of proning. Are there risks attached? Yes, of course, but the COVID-19/ARDS population that ends up in ICU seems to be young across the board.
We were just talking to someone this week, a 37-year-old man, being proned, and then ending up on ECMO. But from my perspective, that was the right course of action, someone being proned for 2 or for 3 days, a young patient, 37 years of age, didn’t work, and then they put him on ECMO. That’s how it should be from my experience, you start with proning and then you go onto ECMO, if it doesn’t work.
Now, here is one of the challenges, it’s not the only challenge, but here is one of the challenges, a lot of ICUs don’t have ECMO available. They simply do not have ECMO available, because again, it’s a very specialized area, and you need perfusionists, you need ICU nurses, you need ICU doctors that are competent and confident to operate ECMO. ECMO is very challenging, and you need to know what you’re doing. If someone is in ICU with COVID-19 ARDS and it doesn’t help, proning doesn’t help, they need to be referred to another hospital often for ECMO. What do other ICUs do? They put the patients on ECMO that are an in-patient in the ICU, first and foremost.
If someone doesn’t respond to proning, they would put that patient in that unit on ECMO first, and then they would look at external hospitals next. But COVID beds were in high demand before the pandemic and let alone they’re in even higher demand now during this pandemic, because COVID obviously causes ARDS, and ARDS causes patients needing either proning or ECMO, meaning the demand for ECMO has gone through the roof. It also depends where you are, are you in a rural area? Are you in a metropolitan area? It’s much easier to probably get an ECMO bed if you are in a metropolitan area, there’s just more resources available.
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Sorry, I just want to quickly welcome Helene as well, thank you for coming onto the call. When do I start live chats? I do believe that this is actually live chats. Helene, if you type in questions, I can respond to them. I’m not actually sure whether there is another way for me doing that, so I do apologize if I don’t have live chat. It seems to be beyond my control, but I do believe when… I can see your questions, but I’m actually not sure what you mean with live chat, I can see your questions in real time, I believe. In any case, if you have any questions, please type them in so I can respond to them and answer the question here, live on the call.
The other thing that is important to understand when it comes to proning versus ECMO, especially for ARDS, ECMO can be used for a bridge to a lung transplant. What that means is this, so let’s just say someone is coming into ICU and has lung fibrosis, let’s just say, and sometimes lung fibrosis can be caused secondary to ARDS too. But someone comes in with lung fibrosis, they can’t breathe any longer, the lungs are failing completely, the lungs are shut down. You put them on ECMO to take over the function of the lungs, and then you could put them on a lung transplant list, and you could give them time to wait if a set of donor lungs can be found for them. There’s no guarantee for that, and there’s also a limited time window. There’s a limited time window for how long you can put someone on ECMO.
Now, the longest that I’ve seen is sort of 3 weeks, maybe a little bit longer than that, but no longer than 3 weeks. That, again, was pre-pandemic, what we’re seeing at the moment is that I’ve seen patients now up to 4 weeks on ECMO, which brings up a whole set of issues. The longer you stay on ECMO, and you can’t be weaned, the risk of complications is huge. Patients on ECMO are on, heparin infusion, there’s risk of bleeding. There’s risk of embolism on the other end, so the risk of being on ECMO is high with complications to occur. Therefore, it’s good if you had a plan going on ECMO and know what’s on the other end. Sometimes ECMO can be used just for the lungs to heal, but with ARDS, what we are seeing is if ARDS can’t be cured, the lungs are stiff, non-compliant, high lung resistance, scar tissue, fibrosis, and that can’t be cured, so it’s very difficult.
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So, let’s look at both pathways. Proning is time limited, because you can’t be proning forever and a day. Again, there’s side effects for that too, especially, main side effect is if proning works and the lungs can be healed by draining secretions, by opening up alveoli, that’s great, but you can’t be proning for 4 to 6 weeks with sedation. Paralytics, when patients come out of a prolonged induced coma, recovery for them could be very prolonged, there could potentially be neurological deficits, so both options have their limitations.
Helene, you’re saying, “I did not learn about your service until back in 2019., Mom passed in 2016, and I had no idea that I could have contacted you.” Sure, look, some families learn about the service when unfortunately, it is too late. The good news is on that end, we are reaching more and more people. We’re reaching more and more people, which is great. We are increasing the traffic numbers to our website, and there we have more and more views on YouTube of the videos, which is great.
I’m so pleased to see that we can help people, and often, we can only help people by having peace of mind. I would be foolish to say that we are in a position to save a life. Bear in mind, we have done that with our consulting and advocacy, we have saved lives just simply by advocating and not letting people die. Just simply by advocating for continuing treatment, we have saved lives. But there are situations where people inevitably do approach the end of life, and in those situations, we can’t help. The only way we can help if someone is inevitably approaching the end of life is helping families to come to terms, and helping families to understand what is happening clinically, and why a particular life can’t be saved.
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Coming back to proning versus ECMO for ARDS in COVID, when someone does go on ECMO for COVID-19 ARDS, even then, the time is limited for the lungs to heal. Whilst ECMO can buy time for the lungs to heal, if the lungs don’t heal within a certain period of time, ECMO won’t be a life saver either.
One of the advantages of ECMO is you can probably lighten sedation, if someone is proned, you need to sedate them, you need to paralyze them, which means deconditioning can be very rapid. Whereas, in ECMO, you don’t need to sedate as heavily as during proning. Some patients you can have them even awake, especially if they had a tracheostomy already, you can wake them up even on ECMO. Which means you can start some physical therapy; you can start some range of motion therapy. Therefore, can have a better outcome, better recovery, because you can already start doing some movements, you can have people awake. You don’t have the side effects of the sedative, the opiates, the paralytics. There are definitely advantages with ECMO too, but there are also specific risks for ECMO, one of the risks specifically around bleeding, because patients need to be on heparin.
Heparin is a blood thinner, and you need a blood thinner, because when you do ECMO, blood is being extracted from the body. It runs through a plastic tube; it runs through a filter through the bypass machine. When it runs through the filter and through the plastic tubing, the risk for a blood clot to occur is very high. Therefore, you need to anticoagulate to keep the blood thin with heparin and your therapeutic APTT or activated partial thromboplastin time, which is the measurement for heparin. The time it takes for blood to clot needs to be higher, which increases the risk of bleeding, and therefore the risk, for example, for a hemorrhagic stroke is real. I have seen patients on ECMO with heparin having hemorrhagic stroke and die whilst their lungs were potentially healing.
There are risk on both ends, and you can’t keep a patient on ECMO forever. It is, to a degree, a sink or swim approach, but at least you have an approach. You can then work on other aspects of therapy, such as epoprostenol, such as continuing the steroid therapy, such as maybe sildenafil, or Viagra. There are things that can be done, but it is also time limited and time sensitive.
We were working with a client not too long ago in India, the client was on ECMO for 4 weeks. Which even though the lungs were slowly improving, what ended up happening, the patient ended up with a gastric bleed. Which might have been caused by two things, might have been caused by stress, being in ICU for so long on ECMO, would’ve been a very stressful experience.
Number two, obviously the client was on heparin, and that increases the risk of bleeding, and the client in the end passed away because of massive gastric bleed. Those are the risks that you’re dealing with when you have someone on heparin for prolonged periods, because of the ECMO. So, the best way to use ECMO is early, especially with COVID ARDS, use it early, give the lungs time to rest and heal. It’s less taxing on the body, because you need less sedation, generally speaking.
Also, because you can basically bypass the function of the ventilator. If you don’t use ECMO and the lungs have ARDS, it’s very difficult to ventilate the lungs. That’s why you need proning, that’s why you often need a lot of sedation, paralytics. If you do ECMO and you can’t ventilate, well, it doesn’t really matter, because the ECMO is 100% taking over the function of the lung gas exchange and CO2 two exchange is happening outside of the body, through the bypass machine. Therefore, you can have the ventilator on minimal support, you don’t need the ventilator, giving the lungs time to rest and heal.
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Another issue that we’re seeing at the moment is, I was just talking to a client this morning, where they had their loved one in ICU, ARDS, has been proned, no ECMO yet, and they are paralyzed, because they can’t breathe. The ventilator cannot push any oxygen in, which means patients breathe against the ventilator, which is also called dyssynchrony. Then they need more sedation, more paralytics, so that you can ventilate at all. If you have a patient fighting the ventilator, you need to sedate and paralyze them, so that you can at least get some oxygen into the body. You can see that the more sedatives, the more paralytics you are using, the more damaging it can be as well. Therefore, you can see why ECMO can be more advantageous than proning.
You can see that by me explaining that you can probably see that outside of the pandemic, the demand for ECMO beds was not as high as it is now, and you can see how that puts restraints on the resources that are there. I’ll give you another example, so you can understand why I think this topic is so important today.
We were working with a client couple of weeks ago, again, COVID-19, ARDS, was proned. Then, the family came to us as the ICU was approaching them for end-of-life care, because proning didn’t help this particular client. He was 52, proning didn’t help, ICU was pushing towards end of life. The family contacted us, and obviously, we were talking to the doctors, and I asked the doctors, “Is ECMO an option?” They said, “No, ECMO is not an option. He’s passed that time, proning didn’t work, he’s too deconditioned, ECMO is no longer an option.” Then it turned out that the ICU where the client was at had ECMO available, and the family never knew, because the ICU never mentioned it to them.
It was only after we started talking to the doctors where we found out, well, ECMO was actually available, but they never shared that with the family. They never mentioned to the family early on that ECMO might be an option for this client, and the client unfortunately passed away. That’s why it’s so important that you do your research, if you have a family member going into ICU with COVID-19 ARDS, you should ask straight away, “Can my family member have ECMO? Is ECMO an option?” If ECMO is not an option in a particular ICU, could they send them out to another ICU? Do they have the contacts there, the relationships, and so forth? Very important questions to ask.
You’ve heard me say before that the biggest challenge for families in intensive care is that you don’t know what you don’t know. You don’t know what to look for, you don’t know what questions to ask, you don’t know your rights, and you don’t know how to manage doctors and nurses in intensive care. We see this all the time, we see this all the time that if you are not asking early enough, things might have gone down the drain, and it can literally be a life-or-death situation. It’s a once in a lifetime situation that you can’t really get wrong.
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Helene, you’re asking, “Is there a risk of carbon dioxide build up from opioids sedation?” Yes, absolutely, if someone has too many opiates and is not ventilated appropriately, they can absolutely buildup of carbon dioxide. You can manage that, if someone is ventilated and they have an opiate buildup of carbon dioxide, you can manage that if someone is ventilated. But if someone is breathing spontaneously and they’re taking too many opiates, their breathing would be inhibited, and therefore, CO2 would go up.
Coming back to the ECMO, so it’s really important that you ask early on, “Is ECMO an option?” The other thing that you might want to keep in mind is, depending on the ICU, you will find some doctors in ICU that may not even had exposure to ECMO, so they may not even know how good it can be if you use it early on. Don’t suspect that every doctor you’re meeting in ICU has experience with ECMO, that’s not necessarily the case. The more research you do, the better equipped you’ll be to manage the challenges that are in front of you.
I also want to quickly talk about ECMO as a bridge to lung transplant, and how it might occur with ARDS and ECMO. If someone goes into ICU with ECMO or with ARDS, goes on ECMO, and God forbid, the lungs are not recovering. Chances are that your loved one might end up on a lung transplant list, a few things need to fall into place there, of course. Again, it’s a very difficult situation there too, but at least you’re increasing the chances for that to happen. So, you need to ask the right questions early on, very important.
I just want to also repeat the treatment even before someone goes on ECMO, or is being proned with ARDS, often what happens is the first step in some units, not in all units, is to put them on nitric oxide as well. Very minimal doses because nitric oxide in high doses can be toxic. You start using with very minimal doses of nitric oxide, that can often open up alveoli, at least temporarily, and that can often help. But if it doesn’t help, then you need to look at other treatment therapies again, such as epoprostenol, flolan, or sildenafil/Viagra, and see whether that helps. If that doesn’t help, proning or ECMO is the next step. Other treatment options are, for ARDS, for COVID, remdesivir and steroids.
What we’re also seeing at the moment is that actually COVID can get cured, we can see that too. But then, because of prolonged ventilation, often patients then end up with a fungus pneumonia. They end up with a bacterial pneumonia, and then the cycle starts all over again. Now you’ve gotten rid of COVID, but now you’re dealing with a yeast pneumonia, or with a Pseudomonas pneumonia, whatever it is.
It is very challenging, and unfortunately, we do see as part of our daily practice, we do see that not all COVID-19 patients with ARDS survive. It’s very challenging, very challenging out there, but that’s also a reminder that you need to do your research from day one. You can’t leave this to chance, the stakes are simply too high to leave this to chance. I wish people would contact us on day one, rather than when they are confronted with end-of-life care.
I hope that helps for today.
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If you have any questions, please type them in the chat pad before I want to close the session for today.
We are living in difficult times at the moment, with COVID running rampant in all countries, really. Also, difficult times for ICU staff, ICUs are full all over the world now, very challenging times, and you got to be prepared. You also got to stay clean, you got to take precautions, social distancing. If you feel like you need to get vaccinated, get vaccinated, if you think that helps you. Wash your hands, use hand sanitizers, and so forth, that’s my advice.
Conscious of the time, I do want to close this off for today.
Thank you so much for coming on to the call.
I will do another live stream next week. I will announce later in the week what I’m going to talk about next week, and I hope you have a good night, a good morning, wherever you are. Thank you for watching and go and check out intensivecarehotline.com.
If you have a loved one in intensive care, go to intensivecarehotline.com. Call us on one of the numbers on the top of the website, or simply send us an email to [email protected].
Like this video, if you want to like this video, if you feel there’s value in it. Subscribe to my YouTube channel and comment below what questions and insights you have from this video.
I also offer one-on-one consulting and advocacy for families in intensive care, you can book a call with me, and I’ve put the details for that below this video. I’ve put a link there, and you can also find a link on our website, intensivecarehotline.com, where you can book a time with me or simply call me on one of the numbers on the top of the website or below this video.
Thank you so much for watching and I’ll talk to you next week.
Take care.
How can you become the best advocate for your critically ill loved one, make informed decisions, get peace of mind, control, power and influence quickly, whilst your loved one is critically ill in Intensive Care?
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