Drs. Goligher and Ferguson in hospital room
Drs. Ewan Goligher (L) and Niall Ferguson have studied the potential benefits of early ECMO for severe respiratory failure patients. (Photo: UHN)

What started as an apparent ear infection, soon evolved to a life-threatening condition. Renee Alkass recalls going to the local hospital in September 2017. She was 18 years old.

Treated with antibiotics, Renee was better for a while but months later she felt low in energy. She found herself often short of breath and her hearing loss from the presumed infection didn't get better.

In January of this year, Renee was back to the hospital, this time she was spitting blood. The doctors upped her medication as all signs still pointed to infection.

In February, the infection spread to her lungs and she was rushed to the intensive care unit (ICU) with pneumonia. Renee had Acute Respiratory Distress Syndrome (ARDS) – a rapidly progressive condition in which the lungs fill with fluid and become stiff, making it very hard or impossible to breathe.

She was transferred from Barrie, about 100 kilometres north of Toronto, to Toronto General Hospital, so she could receive an advanced treatment called Extracorporeal Membrane Oxygenation (ECMO). The highly-specialized treatment consists of using a complex machine that can completely replace the lungs by oxygenating the blood. This allows for the lungs to rest and be treated more gently until they recover.

"If it wasn't for ECMO and the staff at Toronto General, I wouldn't be here today," says Renee. "I owe a lot to this machine."

Renee was later diagnosed with a rare autoimmune disease named Granulomatosis with polyangiitis (GPA), formerly known as Wegener's, which was the cause of all of her medical problems.

 Patient on ECMO machine
Renee says recovery was mentally, physically, and emotionally challenging, but that she is very grateful for this treatment that saved her life. (Photo: Courtesy Renee Alkass)

During her battle for survival, Renee lost 30 pounds and now has a raspy voice since her trachea was damaged by consecutive intubations. She says recovery was mentally, physically, and emotionally challenging, but that she is very grateful for this treatment that saved her life.

"I had never heard of ECMO before, and at first it was hard to understand how that machine was breathing for me.

"I remember the sound of the machine and tubes connected to my neck and my leg. It was very odd, but after two weeks I felt more awake, stronger physically and mentally."

Renee's still following up with her doctors regarding her GPA treatment, but she fully recovered from the ARDS.

The potential to save lives

Renee's story is a perfect example of a change in thinking about how often and when specifically ECMO can help patients with severe ARDS.

ECMO was traditionally used as a last-resort rescue therapy for adults. In the past decade however, physicians started using ECMO earlier for patients like Renee, in acute respiratory distress.

According to Dr. Niall Ferguson, Head of Critical Care Medicine at UHN and Senior Scientist at Toronto General Research Institute, doctors developed renewed interest in using ECMO during the 2009 H1N1 epidemic, commonly called swine flu, which killed between 151,700 and 575,400 people worldwide. Many of these patients died of ARDS from the flu.

As a result of the high mortality of the flu and advancements in ECMO technology, physicians began using it more and more as a life-saving treatment, especially for patients with ARDS, a severe form of lung injury and inflammation that can result in life-threatening reductions in oxygen and the need for prolonged support on mechanical ventilators.

About 35 to 40 per cent of these patients die from this illness in the ICU, and it is estimated that there are more than 17,000 Canadian cases per year.

Renee Alkass
Renee says she’s extremely grateful to ECMO and to the UHN team. (Photo Courtesy Renee Alkass)

In these cases, doctors observed that mechanical ventilation, the traditional treatment for ARDS patients, could be potentially harmful due to the excessive pressures required to ventilate which can  harm stiff lungs that are not easily stretched, such as in ARDS patients. Using ECMO to replace the lungs allows gentle ventilation with low pressures, permitting a more gentle approach by stretching lungs minimally, giving them a better chance to recover.

"For many years, doctors didn't realize they were harming people with complications from mechanical ventilation," Dr. Ferguson says.

Dr.  Ewan Goligher, who works with Dr. Ferguson in the Medical Surgical Intensive Care Unit (MSICU) at Toronto General Hospital is the lead author of a study published this week in The Journal of the American Medical Association. The study is the first to convincingly demonstrate the effectiveness of early use of ECMO in severe ARDS patients.

By analyzing previously collected data from 249 severe ARDS patients, the study showed early ECMO increased chances of survival in more than 90 per cent of cases.

Using a novel approach called the Bayesian method, the authors looked at previous data in a new way. Unlike conventional statistical analysis, this approach allows researchers to build on the knowledge gained in previous studies and incorporate it into their analyses.

"In light of observed data, what is the likelihood that the treatment will benefit the patient?" is the new question the researchers asked.

The answer to that question goes to the heart of what doctors and patients need to think about when deciding whether to proceed with treatment, emphasizes Dr. Goligher, adding that these decisions can be especially difficult to make in an intensive care unit.

"Our findings mean that we are going to be much more inclined to offer ECMO at an earlier stage because it improves outcomes. Simply put, this approach can save lives," says Dr. Goligher, adding that in his early training in 2007-2012 he had witnessed patients die from ARDS because ECMO was rarely used.

"It was heartbreaking to watch patients die from low oxygen levels and I think we can do better for these patients." 

He notes that the analysis supports a change in practice because it demonstrates that ECMO very likely improves the chances of survival for ARDS patients. 

"You have a patient on death's door, with oxygen dropping rapidly, and difficult to ventilate with conventional means. What do you do?" he asks. "If you put them on ECMO, their condition improves immediately: oxygen levels go up to 100 per cent, their blood pressure gets better, and inflammation goes down. The lungs begin to heal. In most cases, that patient now has a better chance of surviving."

Provincial resource

This study also reinforces the importance of having UHN as a provincial resource for ECMO, the authors say.

Currently, UHN already counts more than 100 patients per year treated with ECMO. In the past, the large majority of these patients were surgical – using ECMO as a bridge to or from lung transplant. Today, clinical patients with severe ARDS already represent around 40 per cent of ECMO patients at UHN.

"We are glad that we can be this regional and even provincial resource offering these very sick patients a better chance of survival," says Dr. Ferguson.

To offer this level of care for patients across the province, UHN today has a team of more than 200 trained healthcare professionals, including intensive care physicians, thoracic surgeons, perfusionists and nurses.

"To be an ECMO centre requires resources and a lot of effort, but it often means the ability of saving patients who are at death's door, and that includes young previously healthy patients like Renee," says Dr. Ferguson.

Eight months after her ordeal battling several infections and having the support from the ECMO team at UHN, Renee is now restarting her life. She's back to school pursuing her Bachelor of Arts degree in Psychology and back to her regular life, going out with friends and exercising at the gym.

"I want to help to raise awareness to my condition and to the fact that no matter your age, you could end up having acute respiratory failure," she says.

"The work done with ECMO at UHN is amazing. It's a treatment that can save your life."​

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