ECMO: Extracorporeal Life Support

Podcast Transcript

Raed Dweik, MD (00:04):

Hello, and welcome to the Respiratory Inspirations Podcast. I'm Raed Dweik, Chairman of the Respiratory Institute at the Cleveland Clinic. This podcast series of short, digestible episodes is intended for patients and families and covers topics related to respiratory health and disease. My colleagues and I will be interviewing experts about timely and timeless topics in the areas of pulmonary, critical illness, sleep, infectious disease, and related disciplines. We will share with you information that will help you take better care of yourself and your loved ones. I hope you enjoy today's episode.

Eduardo Mireles-Cabodevila, MD , MD (00:39):

Hello, everyone, and welcome to the Respiratory Inspirations Podcast. I'm your guest host, Eduardo Mireles-Cabodevila, MD . I currently serve as the Director of the Medical Intensive Care Unit at the Cleveland Clinic Main Campus.

(00:52):

My guest today is Dr. Sudhir Krishnan, who serves as the Medical Director of the Medical ICU Acute Respiratory Care Unit and the ECMO team in the department of Critical Care Medicine. Today, we'll be talking about extracorporeal support in the ICU, that is ECMO.

(01:09):

Sudhir, welcome to the podcast.

Sudhir Krishnan, MD (01:12):

Eduardo, thank you for having me. It's a pleasure to be here.

Eduardo Mireles-Cabodevila, MD (01:15):

So I would like to ask you as the director of the ECMO Team to explain to us what, what is ECMO and how do you use this model?

Sudhir Krishnan, MD (01:25):

So Eduardo, ECMO, in the simplest form, consists of plastic tubes that siphon the blood off from your body, but into an artificial oxygenator or artificial lung, suffuses it with oxygen, takes the bad gas carbon dioxide off, and then pushes it back into your body into a vein if it's a lung failure, and pushes it back into an artery if it's a heart failure. So it's a machine that can be used to support a failing heart and a failing lung.

Eduardo Mireles-Cabodevila, MD (01:56):

Hmm. So, tell me, why do you use this?

Sudhir Krishnan, MD (01:59):

ECMO is used as a measure of last resort. When you fail every therapy and the patient is in extremes, so when a cardiologist or a cardiothoracic surgeon or an ICU physician or a lung physician entertains this treatment therapy, he's under the belief that he's exhausted conventional treatment therapy and the only recourse to save the patient is to siphon the blood off, put into an artificial heart-lung machine and suffuse it back into the patient. So, essentially, what you're talking about is a machine that is keeping you alive and taking over the function of the heart and the lung.

Eduardo Mireles-Cabodevila, MD (02:38):

So this sounds a little bit like dialysis of the kidneys. It's the same for the lungs?

Sudhir Krishnan, MD (02:43):

Well, it is more so than just dialysis. You can get by without dialysis for a few days. But if you truly need ECMO and that's not provided to you with a sense of urgency or emergency, it's unlikely you're gonna survive for any length of time.

Eduardo Mireles-Cabodevila, MD (02:58):

So you need it continuously. Once they put you on, you're on it until you're off.

Sudhir Krishnan, MD (03:03):

No, Eduardo, that's a great question. So you need, you need ECMO therapy for only as long as it's required for the heart and lung to recover.

Eduardo Mireles-Cabodevila, MD (03:12):

Mm-hmm.

Sudhir Krishnan, MD (03:13):

Once the lung and the heart recover, every effort is made by the physician in charge to separate you from the ECMO therapy.

Eduardo Mireles-Cabodevila, MD (03:19):

Wow. So Sudhir, this is great. It seems that it's as device that it's needed. Why is it only used at the moment in which mechanical ventilation didn't, couldn't, cannot do it, when the maximum support is given? Why don't we do it earlier on other patient?

Sudhir Krishnan, MD (03:41):

Eduardo, what a fabulous question, you know. So ECMO therapy for respiratory failure as it exists currently in its current form because of how resource intensive it is, it's saved for a given group of patients who are in need of it and only after having exhausted conventional therapy because one is mindful about the complications that can happen with ECMO. It's not entirely a benign treatment therapy.

Eduardo Mireles-Cabodevila, MD (04:06):

Will there be a time in the near future where it could supplant the mechanical ventilator and you will have no mechanical ventilators?

Sudhir Krishnan, MD (04:14):

I think it's a possibility. If you can send a spaceship to Mars and a man to the moon-

Eduardo Mireles-Cabodevila, MD (04:19):

(laughs)

Sudhir Krishnan, MD (04:21):

... and you can have cars that can fly, then I think this is in the realm of possibility and I believe this therapy is in an inflection point. And in this decade, I believe there will be substantial developments in this ECMO therapy where it will be miniaturized enough, will become economical enough where it'll be commonplace in the ICU.

Eduardo Mireles-Cabodevila, MD (04:42):

Fabulous. So at this time, I mean, can you explain to me how do you choose patients to undergo ECMO and what happens if the patient does not meet the criteria to be ECMO at this time?

Sudhir Krishnan, MD (04:57):

Yeah. So ECMO for lung failure in the Cleveland Clinic Main Campus is decided upon after the patient has failed conventional therapy in the medical ICU that involves after updating their treatment and therapy on a mechanical ventilator, using medications to facilitate lung injury, adjustments to the mechanical ventilator. And there comes a threshold or a crossroads in patient care when the physician realizes there's only so much that he can do with the mechanical ventilator, that any more manipulations of the mechanical ventilator would add salt to the injury. And the physician then chooses to disengage from the mechanical ventilator and default to an ECMO machine because there is no recourse to treatment and therapy anymore. Can be a good clear indications of when that can be done based off the amount of oxygen that's physically dissolved in the patient's plasma, the levels of carbon dioxide.

(05:56):

And there are other criteria with regards the patient's underlying clinical condition that comes into play. We are loath to considering patients with multiorgan failure or patients who are moribund who are at death's door, patients with metastatic malignancies whose prognosis are very poor. But every effort is made to make sure that the person who needs it, ECMO therapy for lung failure gets to that therapy as soon as he can at the right clinical juncture.

Eduardo Mireles-Cabodevila, MD (06:25):

So this is interesting. So, we have talked about that even though this is a life-saving therapy, it comes with its, at this point in time, with its complications. It's a prolonged course. And there's a group of patients that may not be appropriate to go under it because even with it, they may not do well. Is that what I'm understanding?

Sudhir Krishnan, MD (06:51):

That is true, Eduardo. And the second part of the question is what if in case they can't go on ECMO therapy? Unfortunately, for those patients who are not deemed candidates for ECMO therapy, nature will take its course. And as much as we hope and pray that they improve without ECMO therapy, the outcomes could be otherwise and, at that juncture, the discussions with the family are honest.

(07:17):

But our goal is to continue to care for our patients, even if we can't cure them, and it's not unusual for us to engage our palliative care colleagues to care for the patient and for the family as they negotiate this uncertain outcome.

Eduardo Mireles-Cabodevila, MD (07:33):

Yeah. It's a very difficult time because there's big decisions to be made during that time.

Sudhir Krishnan, MD (07:39):

Yeah, Eduardo. The distress that the family goes through is tremendous because, essentially, what we just said is that from that point onwards, the outcome is not known and I can only imagine what the families are going to go through.

Eduardo Mireles-Cabodevila, MD (07:57):

So I mean, let's say that the patient goes on extracorporeal life support, then you put them on ECMO, what should a family member expect?

Sudhir Krishnan, MD (08:08):

All right. So... ECMO machines are very imposing in nature. It's hard not to walk in to see their blood flowing out of a patient's body into a machine and not be a bit frightened by the sight. It's not unusual for the patient to be connected to multiple life support devices so for a layperson, it can be a bit much.

(08:29):

But as the shock slowly starts wearing off, what I would love for the families to do is to coordinate with the nurse at the bedside and with their permission take control, be involved in the patient's care. Small things that they can do: hold the patient's hand, talk to the patient, play them their favorite music. Even when they're asleep, I believe that they hear your voice and their family with their voice. That can be very reassuring. If the nurse allows you, massage the hands and legs, rub a lotion and it allows you to participate in care. A physiotherapist or a nurse can help you guide with passive range of motions that you can do for your loved one at the bedside.

(09:15):

Make sure that you have regular conversations with the physicians. We allow our family members to join the physician rounds in the morning. And once we're done with the medical discussions, we make it a point to discuss the patient's daily management in layman's terms to the family at the bedside. In addition to that, once a week we hold a family conference where multiple subspecialists get together to update the patient's family. So I would encourage the family to be engaged with the physicians, engaged with the nurses, and contribute to patient care at the bedside. You will feel in control. You will feel better.

Eduardo Mireles-Cabodevila, MD (09:53):

So Sudhir, I mean, the runs in ECMO sometimes can be very short, sometimes can be very long and that can also be very tiring for the family that we are used to or we want to expect rapid recovery of the events. What in general should they be expecting in terms of time for recovery of their loved ones in general?

Sudhir Krishnan, MD (10:17):

That's a great question, Eduardo. Well, I would be mindful about the clinical context in which the ECMO supported has been initiated. If it's ECMO is a bridge to lung transplant, then the family should expect a protracted ECMO run, until such time as a lung is transplanted. That could be days, weeks, or even months. We have cared for patients on ECMO therapy for months together with successful lung transplantation at the end. There are other patients who have not made it after protracted ECMO therapy period.

(10:53):

On an average, ECMO therapy for lung failure, and I'm saying only for lung and respiratory failure, expected a run of therapy that could last between four to six weeks. ECMO therapy for a given disease process might be shorter and we realize that patients who committed to ECMO for serious or severe exacerbations of asthma do not require weeks of ECMO therapy. They usually require days of ECMO therapy.

(11:17):

And like I said, every patient is different as to how long an ECMO run could last depends upon the clinical context in which it's bigger. So asthma runs I would expect it to be shorter. Frank lung injury because of ERDS or a pneumonia, maybe way longer.

Eduardo Mireles-Cabodevila, MD (11:36):

You've talked to a lot of family members of patients. What are their common concerns?

Sudhir Krishnan, MD (11:43):

Common concerns, well, the elephant in the room is, "Is he gonna get better? When is he gonna get better? When is the ECMO gonna come off? Is he gonna go back to this usual self?"

Eduardo Mireles-Cabodevila, MD (11:56):

Mm-hmm.

Sudhir Krishnan, MD (11:57):

And that begs the question again as to when I remind the families of the clinical context in which the ECMO therapy has been initiated. Most of the discussions usually happen when the relatives in the family are more informed about a given situation. So it's not unusual for you to update the family regarding an event or a turn in the patient's clinical condition and the conversation goes down that, "How are you managing this" and "What can I expect" and "When can recovery happen" and "Have you called the consultants?" But the elephant in the room has always been, "Is he gonna get better? When is he gonna get better? When is he coming off ECMO? When can he go home?"

Eduardo Mireles-Cabodevila, MD (12:36):

So you put somebody on ECMO and there's usually things, levels of support that they're gonna require. I know that there's blood transfusions, there may be other interventions like tracheostomies. Can you talk to us a little bit about this?

Sudhir Krishnan, MD (12:52):

Sure. Once the patient is committed to ECMO therapy for lung failure, the patient's clinical course dictates the need for more treatment and therapy. It is not unusual for patients to lose blood off a patient so that cell is to be destroyed by the machine in some cases for patients to bleed on and the patient need blood transfusion. We are very conservative with our blood transfusion targets over here. We try our best to minimize, you know, blood transfusion. But if it's required, it's done. Blood transfusion and transfusion of other blood products, platelets are commonplace.

(13:29):

So daily management of the patient, there's a clear agenda that's set during the day. If we can, the patient is woken up and the ask is that the patient interact with the surroundings, with family members and the nurses. The mechanical ventilator settings are guided by the requirements of that day. The ECMO machine manipulations are made to achieve a certain level of oxygenation or oxygen levels. Every effort is made to feed the patient as early as we can. Blood products and blood transfusions are protocol depending on how anemic the patient is and every effort is made for the patient to have physical therapy in bed, while he's in bed and here at the clinic, we go the extra mile in that the patient is wide awake then the patient is asked or made to ambulate on ECMO therapy.

Eduardo Mireles-Cabodevila, MD (14:22):

Mm-hmm.

Sudhir Krishnan, MD (14:22):

And that's something that we pride on here at the Cleveland Clinic. We try to do that for all our patients as much as we can, but more so for our patients who are bridged to transplant and who are on ECMO therapy for months together.

(14:34):

Tracheostomy is considered in most patients because we anticipated a protracted vein from our liberation from the mechanical ventilator. So the the usual process is to disengage from ECMO first, and the mechanical ventilator later. Tracheostomy adds a certain level of comfort for the patient and allows us to quickly disengage or engage with mechanical ventilation as, if and when need to be. And on the opportune time, the patient is decannulated or even the tracheostomy tube is taken away.

Eduardo Mireles-Cabodevila, MD (15:08):

So I presume that there's a lot of doctors that the family members are gonna see at the bedside. Is that a normal thing?

Sudhir Krishnan, MD (15:14):

It is not unusual for the patient to be cared for by perhaps 50 or one hundred health care providers during the course of an ECMO run as the shifts change, as the physicians change, as the nurses change. But what we pride here at the Cleveland Clinic is continuity in care. There's always one physician in charge who dictates the course of the patient's clinical care. And because we're a multidisciplinary team, everybody is in touch with everybody else so it is quite, literally, as if there's no discontinuation in care. The patient has been continuously cared by the same days to the same ecosystem and there's no compromising in medical care.

(16:01):

But it's a true fact. The patients are cared for multiple health care providers, multiple subspecialists and I would ask the families, if it's possible, to interact with the subspecialists, interact with the physicians, keep their names, keep their specialities in a record so you know who you spoke to as you negotiate this difficult process.

Eduardo Mireles-Cabodevila, MD (16:25):

Yeah, I can imagine it can super confusing with all that army of people coming into the room. You all do a very nice job in having meetings daily with the family and, obviously, once a week you recap this thing. But another practice that the team here at the clinic has created was to involve palliative care in the care of all these patients. Why do you do that, Sudhir? What's the reason for that?

Sudhir Krishnan, MD (16:56):

Yeah. Eduardo, like I said at the outset, you know, the families are in tremendous amount of distress because, essentially, the outcome is unknown. And our palliative care colleagues do a phenomenal job of providing both psychosocial and emotional support to the families, not just the patients. The patients are usually sedated, they're being cared for by the intensives and nurse at the bedside. Early palliative care is normally solely for the families. I mean, for them to be a tremendous resource. Their continued patient care facilitates one of many things. They're actively involved in ongoing discussions about escalation of medical therapy and deescalation of medical therapy or withdrawal of medical therapy. Early introduction of palliative care services and the relationship that the palliative care physician develops with the family serves the group well when we have difficult decisions to be made, especially with regards to withdrawal of care. So they facilitate goals of care discussion.

(18:05):

But another thing that caught my attention during COVID times, Eduardo, was, you know, as we negotiated this difficult cases, I think my colleagues in palliative care medicine served as an emotional support for the frontline providers. It wasn't unusual for me to have a discussion with my PCM colleague about the challenges that I faced, and I'm sure it was same for the intensives and the nurses. They were a sounding board or a shoulder to cry on so I find them to be a terrific resource for frontline and most patients, too.

Eduardo Mireles-Cabodevila, MD (18:40):

That's wonderful, Sudhir. So after ECMO, you have so many good stories from survivors. So what I would like to know is can you tell us as patients come off ECMO, can they go home?

Sudhir Krishnan, MD (18:54):

Yes, Eduardo. So, like I said, you know, and I could divide the phases of ECMO, the three phases of ECMO, early care for the patient, when he's severely ill, when he's coming off ECMO or she's coming off ECMO and slowly getting better, then the third is surviving ECMO and coming back home. So our goal is always to get the patient home, but it would be foolish for anybody who does extracorporeal life support, both for lung or heart failure, to believe that it will not require time. So remember these patients, I mean, laid in bed for weeks and days to get they are physically debilitated and some of them, you know, emotionally so. So recovery is protracted and it is not unusual for the patients to go to an acute care facility and then be transferred to a nursing facility before they go home. Home is the ultimate goal, but it's possible that the road to home could pass through an acute care facility, a nursing facility and then home.

Eduardo Mireles-Cabodevila, MD (19:57):

Yeah. I mean, they go from a lot of support to less support to less support until they are able to be on their own.

Sudhir Krishnan, MD (20:03):

Absolutely, yeah. You put that very well, yes.

Eduardo Mireles-Cabodevila, MD (20:05):

Yeah. So what are the consequences that patients that survive ECMO have to deal with?

Sudhir Krishnan, MD (20:13):

Yeah. So ECMO takes a toll on the human body. ECMO survivors can have, not necessarily so, but can have physical, cognitive and emotional disabilities that may not be evident immediately, but manifest over the course of time. It's not unusual for them to have an anxiety. Some patients do have frank depression. Some patients do have post-traumatic stress disorder-like condition.

(20:48):

It's not unusual for them to be physically debilitated to a point where coming back home and negotiating stairs and going back to activities of daily living are easier said than done. They may not necessarily be able to get back to work immediately. And those are the few things that have kind of caught my attention. So ECMO therapy, ECMO survivors, not all of them, some of them go on to develop both cognitive, emotional and physical disabilities that could last from weeks to months. So what I would say is that post-ECMO therapy, expect the patient to recover in months, rather than weeks.

Eduardo Mireles-Cabodevila, MD (21:34):

Is there something available to help recover them to talk to someone after they have come out of this and be, start having those feelings or those disabilities? What is your recommendation there?

Sudhir Krishnan, MD (21:49):

So, already here at the Cleveland and now we are imminently aware of these challenges that ECMO survivors face. And both in our post-ICU recovery clinic and in the ECMO clinic, every effort is made to connect the patient with the resources that the patient requires to thrive. Need continued physiotherapy and occupational therapy as an inpatient or as an outpatient. Connection to mental health resources if required to be. Connection to subspecialist expertise if required to be. And we believe that the survivors who thrive and who do the best are people who continue to engage with the health care establishment as they navigate the post-ECMO survivor period.

Eduardo Mireles-Cabodevila, MD (22:40):

Yeah. I mean, and the family also needs to be aware of that, right?

Sudhir Krishnan, MD (22:43):

Well, absolutely. And that's one thing I remind all families, is that as you care for the patient on ECMO, you must make an effort to care for yourself. This takes health care... People who care for patients who are sick, who are infirm in the hospital, go through a similar process of mental, physical and emotional trauma and not to the extent of the patient, but I'm acutely aware of the mother or the father, the daughter or the brother sitting at the beside, you know, caring for that patient on extracorporeal life support all in their hand. It is a tremendous insult to the patient's mental psyche. So one of the asks is as you care for your family members, make an effort to care for yourself, too.

Eduardo Mireles-Cabodevila, MD (23:33):

Yeah. So search for help. So without a doubt, this is a therapy that saves lives and helps patient continue their life while they recover. But it comes at a cost and that cost requires attention from the team after the patient is discharged to get them through all of this.

(23:58):

Sudhir, this has been a fantastic recount and I want to thank you for being here. I want to thank everyone for listening to our podcast today. I'm your guest host, Eduardo Mireles-Cabodevila, MD , and my guest today was Dr. Sudhir Krishnan, who serves as the Medical Director of the Medical Intensive Care Unit, Acute Respiratory Care Unit and ECMO Team at the Department of Critical Care Medicine at the Cleveland Clinic. Today we talked about extracorporeal life support. Thank you, Sudhir.

Sudhir Krishnan, MD (24:29):

Thank you, Eduardo, for having me and my pleasure.

Raed Dweik, MD (24:32):

Thank you for listening to this episode of the Respiratory Inspirations Podcast. For more stories and information from the Cleveland Clinic Respiratory Institute, you can follow me on Twitter at @RaedDweikMD.