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Inhaled Epoprostenol to Facilitate Safe Transport in Legionnaires’ Disease

Published online by Cambridge University Press:  09 January 2020

Corrine Foster
Boston MedFlight, Bedford, MassachusettsUSA
Michael A. Frakes
Boston MedFlight, Bedford, MassachusettsUSA
Erica Puopolo
North Shore Medical Center, Boston, MassachusettsUSA
Francis McNulty
Boston MedFlight, Bedford, MassachusettsUSA
Mark S. Saia
Boston MedFlight, Bedford, MassachusettsUSA
Mike Hourihan
Boston MedFlight, Bedford, MassachusettsUSA
Margaret Flynn
Boston MedFlight, Bedford, MassachusettsUSA
Susan R. Wilcox
Boston MedFlight, Bedford, MassachusettsUSA Massachusetts General Hospital, Boston, MassachusettsUSA
E-mail address:


Hypoxemic patients often desaturate further with movement and transport. While inhaled epoprostenol does not improve mortality, improving oxygenation allows for transport of severely hypoxemic patients to tertiary care centers with a related improvement in mortality rates. Extracorporeal membrane oxygenation (ECMO) use is increasing in frequency for patients with refractory hypoxemia, and with increasing regionalization of care, safe transport of hypoxemic patients only becomes more important. In this series, four cases are presented of young patients with severe hypoxemic respiratory failure from Legionnaires’ disease transported on inhaled epoprostenol to ECMO centers for consideration of cannulation. With continued climate changes, Legionella and other pathogens are likely to be a continued threat. As such, optimizing oxygenation to allow for transport should continue to be a priority for critical care transport (CCT) services.

Case Report
© World Association for Disaster and Emergency Medicine 2020

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Gamage, SD, Ambrose, M, Kralovic, SM, Roselle, GA.Water safety and Legionella in health care: priorities, policy, and practice. Infect Dis Clin North Am. 2016;30(3):689712.CrossRefGoogle ScholarPubMed
Kashif, M, Patel, R, Bajantri, B, Diaz-Fuentes, G.Legionella pneumonia associated with severe acute respiratory distress syndrome and diffuse alveolar hemorrhage - a rare association. Respir Med Case Reports. 2017;21:711.Google ScholarPubMed
Marx, G, Vangerow, B, Hecker, H, et al.Predictors of respiratory function deterioration after transfer of critically ill patients. Intensive Care Med. 1998;24(11):11571162.CrossRefGoogle ScholarPubMed
Singh, JM, MacDonald, RD, Bronskill, SE, Schull, MJ.Incidence and predictors of critical events during urgent air-medical transport. CMAJ. 2009;181(9):579584.CrossRefGoogle ScholarPubMed
Papadopoulos, N, Ahmad, A-S, Marinos, S, Moritz, A, Zierer, A.Extracorporeal membrane oxygenation for influenza-associated acute respiratory distress syndrome. Thorac Cardiovasc Surg. 2013;61(6):516521.Google ScholarPubMed
McCarthy, FH, McDermott, KM, Kini, V, et al.Trends in US extracorporeal membrane oxygenation use and outcomes: 2002–2012. Semin Thorac Cardiovasc Surg. 2015;27(2):8188.CrossRefGoogle Scholar
Natt, BS, Desai, H, Singh, N, Poongkunran, C, Parthasarathy, S, Bime, C.Extracorporeal membrane oxygenation for ARDS: national trends in the United States 2008–2012. Respir Care. 2016;61(10):12931298.CrossRefGoogle Scholar
Noah, MA, Peek, GJ, Finney, SJ, et al.Referral to an extracorporeal membrane oxygenation center and mortality among patients with severe 2009 influenza A(H1N1). JAMA. 2011;306(15):16591668.CrossRefGoogle Scholar
Peek, GJ, Mugford, M, Tiruvoipati, R, et al.Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicenter randomized controlled trial. Lancet. 2009;374(9698):13511363.CrossRefGoogle Scholar
Wilcox, SR, Richards, JB, Genthon, A, et al.Mortality and resource utilization after critical care transport of patients with hypoxemic respiratory failure. J Intensive Care Med. 2018;33(3).CrossRefGoogle ScholarPubMed
Wilcox, SR, Saia, MS, Waden, H, et al.Improved oxygenation after transport in patients with hypoxemic respiratory failure. Air Med J. 2015;34(6).CrossRefGoogle ScholarPubMed
Germann, P, Pöschl, G, Leitner, C, et al.Additive effect of nitric oxide inhalation on the oxygenation benefit of the prone position in the adult respiratory distress syndrome. Anesthesiology. 1998;89(6):14011406.CrossRefGoogle ScholarPubMed
Tabrizi, MB, Schinco, MA, Tepas, JJ, Hwang, J, Spiwak, E, Kerwin, AJ.Inhaled epoprostenol improves oxygenation in severe hypoxemia. J Trauma Acute Care Surg. 2012;73(2):503506.CrossRefGoogle ScholarPubMed
Leoni, E, Catalani, F, Marini, S, Dallolio, L.Legionellosis associated with recreational waters: a systematic review of cases and outbreaks in swimming pools, spa pools, and similar environments. Int J Environ Res Public Health. 2018;15(8):1612.CrossRefGoogle ScholarPubMed
Gamage, SD, Ambrose, M, Kralovic, SM, Simbartl, LA, Roselle, GA.Legionnaires disease surveillance in US Department of Veterans Affairs medical facilities and assessment of health care facility association. JAMA Netw Open. 2018;1(2):e180230.CrossRefGoogle ScholarPubMed
Mercante, JW, Winchell, JM.Current and emerging Legionella diagnostics for laboratory and outbreak investigations. Clin Microbiol Rev. 2015;28(1):95133.CrossRefGoogle ScholarPubMed
Barnes, SL, Branson, R, Gallo, LA, Beck, G, Johannigman, JA.En-route care in the air: snapshot of mechanical ventilation at 37,000 feet. J Trauma. 2008;64(2 Suppl):S129134; discussion S134–135.CrossRefGoogle ScholarPubMed
Seymour, CW, Kahn, JM, Schwab, CW, Fuchs, BD.Adverse events during rotary-wing transport of mechanically ventilated patients: a retrospective cohort study. Crit Care. 2008;12(3):R71.CrossRefGoogle ScholarPubMed
Wilcox, SR, Saia, MS, Waden, H, Frakes, M, Wedel, SK, Richards, JB.Mechanical ventilation in critical care transport. Air Med J. 2016;35(3).CrossRefGoogle ScholarPubMed
Kallet, RH, Burns, G, Zhuo, H, et al.Severity of hypoxemia and other factors that influence the response to aerosolized prostacyclin in ARDS. Respir Care. 2017;62(8):10141022.CrossRefGoogle ScholarPubMed
Repessé, X, Vieillard-Baron, A.Right heart function during acute respiratory distress syndrome. Ann Transl Med. 2017;5(14):295.CrossRefGoogle ScholarPubMed
Torbic, H, Szumita, PM, Anger, KE, Nuccio, P, LaGambina, S, Weinhouse, G.Inhaled epoprostenol vs inhaled nitric oxide for refractory hypoxemia in critically ill patients. J Crit Care. 2013;28(5):844848.CrossRefGoogle ScholarPubMed
Ammar, MA, Bauer, SR, Bass, SN, Sasidhar, M, Mullin, R, Lam, SW.Noninferiority of inhaled epoprostenol to inhaled nitric oxide for the treatment of ARDS. Ann Pharmacother. 2015;49(10):11051112.CrossRefGoogle ScholarPubMed
Searcy, RJ, Morales, JR, Ferreira, JA, Johnson, DW.The role of inhaled prostacyclin in treating acute respiratory distress syndrome. Ther Adv Respir Dis. 2015;9(6):302312.CrossRefGoogle ScholarPubMed
Guérin, C, Reignier, J, Richard, J-C, et al.Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368(23):21592168.CrossRefGoogle ScholarPubMed
Wilcox, SR, Ries, M, Bouthiller, TA, Berry, ED, Dowdy, TL, DeGrace, S.The importance of ground critical care transport: a case series and literature review. J Intensive Care Med. 2017;32(2).CrossRefGoogle Scholar
Reily, DJ, Tollok, E, Mallitz, K, Hanson, CW3rd , Fuchs, BD.Successful aeromedical transport using inhaled prostacyclin for a patient with life-threatening hypoxemia. Chest. 2004;125(4):15791581.CrossRefGoogle ScholarPubMed
Kahn, JM, Linde-Zwirble, WT, Wunsch, H, et al.Potential value of regionalized intensive care for mechanically ventilated medical patients. Am J Respir Crit Care Med. 2008;177(3):285291.CrossRefGoogle ScholarPubMed
Barbaro, RP, Odetola, FO, Kidwell, KM, et al.Association of hospital-level volume of extracorporeal membrane oxygenation cases and mortality. Analysis of the Extracorporeal Life Support Organization Registry. Am J Respir Crit Care Med. 2015;191(8):894901.CrossRefGoogle ScholarPubMed
Hirshberg, E, Miller, RR3rd , Morris, AH.Extracorporeal membrane oxygenation in adults with acute respiratory distress syndrome. Curr Opin Crit Care. 2013;19(1):3843.CrossRefGoogle ScholarPubMed
Patroniti, N, Zangrillo, A, Pappalardo, F, et al.The Italian ECMO network experience during the 2009 influenza A(H1N1) pandemic: preparation for severe respiratory emergency outbreaks. Intensive Care Med. 2011;37(9):14471457.CrossRefGoogle ScholarPubMed
Wallace, DJ, Angus, DC, Seymour, CW, et al.Geographic access to high capability severe acute respiratory failure centers in the United States. PLoS One. 2014;9(4):e94057.CrossRefGoogle ScholarPubMed
Hicks, LA, Garrison, LE, Nelson, GE, Hampton, LM.Legionellosis--United States, 2000–2009. Am J Transplant. 2012;12(1):250253.Google ScholarPubMed
Neil, K, Berkelman, R.Increasing incidence of Legionellosis in the United States, 1990–2005: changing epidemiologic trends. Clin Infect Dis. 2008;47(5):591599.CrossRefGoogle ScholarPubMed
Cassell, K, Gacek, P, Warren, JL, Raymond, PA, Cartter, M, Weinberger, DM.Association between sporadic Legionellosis and river systems in Connecticut. J Infect Dis. 2018;217(2):179187.CrossRefGoogle ScholarPubMed
Cebrián, F, Montero, JC, Fernández, PJ.New approach to environmental investigation of an explosive Legionnaires’ disease outbreak in Spain: early identification of potential risk sources by rapid Legionella spp immunosensing technique. BMC Infect Dis. 2018;18(1):696.CrossRefGoogle ScholarPubMed

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