Bri and Brayson at home
A young mom’s remarkable transition from Lung Rescue to lung transplant
The Penn Lung Rescue team had kept Bri Iacona alive in the Heart & Vascular Intensive Care Unit for two months with the most advanced form of life support for lung failure. But by the end of October, they knew that a lung transplant was her only chance for survival.
Iacona, an active, 30-year-old elementary school math teacher from Delaware with an 18-month-old son, was gravely ill with severe COVID-19–associated acute respiratory distress syndrome. She received her first dose of the vaccine shortly before the start of the school year, but before the first week of class was over, she contracted the virus. Within days, the disease had progressed so quickly that she was put on a ventilator to force air through her lungs, and when that didn’t work, she was put on extracorporeal membrane oxygenation (ECMO), a machine that temporarily replaces a patient’s heart, lungs, or both when their organs are too weak or sick to function on their own. Iacona was placed on venovenous ECMO, which solely replaces the function of the lungs.
ECMO is a measure of last resort used for the sickest COVID patients. Blood is drained from the patient’s body, pumped through a filter that puts oxygen in the blood and removes carbon dioxide as healthy lungs would, and then pumped back into the patient. ECMO isn’t a treatment; it’s meant to buy time while doctors work to reverse the lung failure.
“Sometimes, patients’ lungs are so sick and there’s so much fluid in them that the ventilator can’t work. It’s like they’re drowning. Their lungs are so damaged and the ventilator can’t oxygenate them,” said cardiovascular anesthesiologist Asad Usman, MD, MPH, a member of the lung rescue team who coordinated Iacona’s ECMO treatment for months along with anesthesiologists Jacob Gutsche, MD, Audrey Spelde, MD, and William Vernick, MD.
Once doctors saw that Iacona’s lungs weren’t making any recovery, they started working toward transplant. But Iacona needed to be up and moving to qualify – and she wasn’t even awake. She had been heavily sedated and medically paralyzed for several weeks in order to reduce the amount of oxygen her body needed and allow her lungs to rest.
“The lung transplant team wanted her to be functional, awake, and have a decent amount of strength, because lungs are scarce and the demand is so high they have to ensure that they only list patients with the highest chance of survival after transplant,” said Kelsey Tirona, BSN, RN, CCRN, a critical care nurse in the HVICU. “That was her one barrier holding her back from transplant.”
The Road to Transplant
From left to right: PPMC HVICU nurses Dolores Risica, Elizabeth Haemmerle, and Kelsey Tirona
The timing was just right for Tirona, who, with fellow HVICU nurses Elizabeth Haemmerle, BSN, RN, CCRN, and Dolores Risica, BSN, RN, CCRN, had recently kicked off a project to get ventilated patients up and moving earlier to improve their outcomes. Studies show that immobility can lead to cardiovascular decline, muscle weakness, decreased cognitive function, and increased risk of delirium. Mobilizing vented patients earlier has shown to improve their outcomes, including reducing their time spent on the ventilator and in the ICU, Tirona said.
Since this was a new practice in the HVICU, the nurses worked closely with physical therapist Kathryn Siciliano, PT, DPT, occupational therapist Abigail Sossaman, MOT, OTR/L, and their teams, to learn the skills necessary to safely mobilize these complex patients.
In early November, the HVICU nursing staff, in partnership with physical and occupational therapists, respiratory therapists, and perfusionists – specialists who manage the ECMO circuit – got to work bringing Iacona out of sedation and getting her moving.
“She was literally not able to lift a finger,” Tirona said. “That’s how weak and deconditioned she was from laying in a bed for weeks and weeks.”
The team started by lifting Iacona’s arms and legs, and within a couple of weeks, she was able to sit on the side of the bed with assistance. Just getting her into a seated position took a crew of six people monitoring her vital signs, IV lines, the ventilator, and the ECMO circuit.
Then they got Iacona on a rehab bike that she could use from her bed, even with ECMO tubes in her legs.
The whole time, Iacona couldn’t speak because she had a breathing tube in her trachea connecting to the ventilator. Her husband Phil and the care team used a chart with letters and common expressions on it for her to communicate, and the nurses put up photos of her family on the light above Iacona’s bed to keep her motivated.
“The whole staff at Penn Presbyterian, they’re just amazing people,” Phil Iacona said. “Everyone cares so much. They all wanted her to get through this and they worked with her through and through.”
Ready for Surgery
Bri Iacona with her husband Phil and son Brayson at HUP after Bri’s lung transplant
Iacona was transferred to the Hospital of the University of Pennsylvania on Dec. 1, 2021, for a double lung transplant. Christian Bermudez, MD, director of thoracic transplantation at HUP, performed the surgery shortly after Christmas.
“With COVID for the past two years, we as nurses felt so helpless. We didn’t know how to help these patients or how to improve their outcomes,” Tirona said. “To see someone like Bri, who had no options other than a new set of lungs – and the only thing stopping her was her mobility – and for us to feel empowered that we could make that difference … it’s so rewarding.”
Gutsche, associate chief medical officer of critical care at Penn Medicine, said Iacona was the first patient brought to PPMC for lung rescue that bridged to being awake and participating in physical therapy on ECMO, and then transferred to HUP for a transplant.
“This case showcases the teamwork demonstrated by the lung rescue team, the PPMC HVICU with PT help, and then collaboration with HUP lung transplant,” Gutsche said in an email.
Going Home
On March 4, 2022, nearly six months after entering the hospital, Iacona got to go home.
Iacona doesn’t remember anything from her 97 days on ECMO – even when she was awake for the mobility work, she was still so critically ill, and on some sedative and pain medications – but her husband has been telling her bits and pieces of the story, holding back more details until she’s ready to hear them.
One thing she’ll never forget is the feeling of her son in her arms when she finally came home.
“After really only seeing my son through video chat, my anticipation of seeing him and holding him for the first time couldn’t be contained,” Iacona said. “He ran into the room screaming ‘Mommy!’ and jumped onto the couch and into my arms. The feeling was indescribable. I was reminded why I fought so hard. I’m grateful for everything that the doctors and nurses did for me, because if not, I wouldn’t be here to see him anymore.”