COVID-19 Treatments: Ventilators Now Being A Point Of Contention As Some Experts Say It Might Harm Some COVID-19 Patients
Source: COVID-19 Treatments Apr 16, 2020 4 years, 1 week, 2 days, 21 hours, 6 minutes ago
COVID-19 Treatments: A major medical debate has emerged among healthcare professionals treating COVID-19 as to when should patients who need help breathing be placed on ventilators and could intubation do some patients more harm than good?
Currently it has emerged as one of the biggest medical dilemma.
Supporting research studies and data is scarce and there aren't yet formal studies on the subject since the disease itself is so new and many do not have the benefit of hindsight.
As many doctors are saying, it is also impossible to know for sure whether the patients placed on ventilators would have died anyway because of the severity of their conditions.
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It must be noted that many treatment protocols and drugs being adopted by many countries were based on earlier preliminary studies, guidelines and reports issued by China which many are now questioning as some of these initial studies were done in the most unprofessional settings and manner while it has also emerged that the Chinese government has been deliberately withholding lots of critical data and research while also manipulating certain research that were made available on public domains to suit its interests.
A number of doctors who adhere to the Chinese way of treatment protocols have said that COVID-19 patients appear to fade rapidly when they are put on ventilators and tubes are placed down their windpipes.
However, in recent weeks, American hospitals have started doing what they can to delay having to use the breathing machines of which the federal government has ordered 130,000 of, fearing a shortage.
It must be noted that the first warning signs came from Italy, where the vast majority of patients placed on artificial breathing died.
Interestingly, the statistics are also bad in the United Kingdom and in New York, where 80 percent of intubated patients die, according to the state's governor, often after spending a week or two in intensive care in which they are placed in an artificial coma and their muscles atrophy.
In the start of the pandemic, patients who were completely out of breath were treated under well-established protocols for a severe lung condition called Acute Respiratory Distress Syndrome (ARDS).
Typically, this condition, which prevents the lungs from taking in enough oxygen to pass on to other organs, can be triggered by infection, such as pneumonia, or by physical injury.
The condition is very dangerous, with studies placing the overall fatality rate at around 40 percent.
For a while, the standard procedure for these patients is to intubate relatively early, and this is how COVID-19 patients have generally been treated.
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However medical experts and doctors have begun to realize lung complications among COVID-19 patients weren't quite the same as "typical" ARDS patients, at least not in all cases. https://www.thailandmedical.news/news/must-read-research-reveals-that-covid-19-attacks-hemoglobin-in-red-blood-cells,-rendering-it-incapable-of-transporting-oxygen--current-medical-protoco
Typically when a physician says that a patient has pneumonia, from whatever cause, be it the flu or COVID-19 that means that the lungs are infected and inflamed. The air sacs can start filling up with pus or fluid, becoming clogged, so they can no longer transfer oxygen to the capillaries. The less surface area you have in your lungs, the less well oxygenated one would be. An oximeter is able to assess that condition.
A typical serious condition that’s being seen in the sickest of COVID-19 patients is called Acute Respiratory Distress Syndrome (ARDS). This condition also isn’t exclusive to the coronavirus as it can happen when someone’s lungs have been badly injured, which could include events like near-drowning and inhalation of harmful chemicals, as well as during a severe pneumonia. When patients develop ARDS, fluid builds up in the air sacs and oxygen levels plummet. A healthy lung’s air sacs are normally coated with surfactant, a slippery substance that helps the sacs inflate and deflate with ease. In ARDS, the surfactant breaks down, making the lungs stiffer. Inflammation makes things worse by increasing the gap between the air sacs and the web of capillaries around them, so that oxygen can’t jump over to feed the bloodstream.
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Typically a simple way to administer oxygen to a patient is to use the most gentle tool, which is a nasal cannula, which is a tube with two prongs that is placed on a patient’s nostrils.. While it can give a patient a higher concentration of oxygen than what’s available in the air, it’s still up to the patient to breathe on his or her own.
Should a patient needs more help, doctors can move up to what’s called a non-rebreather mask, which still requires a patient to be able to breathe unassisted but can deliver much higher concentrations of oxygen up to 100%.
However oxygen concentration isn’t the only thing that doctors have to consider. Sometimes the small branches of the lungs that lead into the air sacs can collapse under the weight of the fluid building up around them, and then even the highest concentrations of oxygen can’t get in. Medical staff then think about increasing the pressure of the air the patient is breathing in. The high-pressure air helps to “prop open” these small airways to allow oxygen and carbon dioxide to flow more freely.
Prior to the COVID-19 pandemic, doctors would often turn to a device called a BiPAP machine. It’s a noninvasive device that delivers pressurized air to a patient via a mask. The problem during the coronavirus pandemic has been that BiPAP masks are leaky, so virus particles could escape and put health care workers at risk of infection.
Hence when a patient’s oxygen levels keep falling, doctors are turning to a ventilator.
To put a patient on a ventilator, they are first put to sleep with sedatives and pain relieving medications before a breathing tube is inserted. The medications are also continued after intubation, so patients won’t feel any discomfort or fight the breathing tube.
The moment the tube is in place, a small inflatable cuff is puffed up around it, inside the windpipe, forming a seal that’s intended to prevent viral particles from getting out. Then, the ventilator machine is turned on and starts to push air through the tube, in and out of the patient’s lungs.
Utilizing a ventilator gives a medical team many more options for how to manage a patient’s breathing. Oxygen levels and pressure can be dialed up or down. The team can also control the number of breaths per minute and the size of those breaths. Taking smaller breaths rather than deep gasping breaths can help protect damaged lungs.
It must be noted that ARDS looks different in COVID-19 patients, according to physician at a New York hospital that’s now treated more than 1,700 COVID-19 patients. The ICU and respiratory medical specialists, who asked to speak anonymously because he’s not authorized to speak on behalf of his facility, described typical ARDS as a “flash flood,” in which a patient could crash over 12 hours, going from having a little difficulty breathing to going on a ventilator. But from what he’s seen, “it’s not like a flash flood.” In COVID-19 patients, ARDS often behaves “like a slow storm, where the waters keep rising and rising.”
Many medical experts are also surprised to see how long patients stay on ventilators. Typically, influenza patients stay on a ventilator for less than two weeks that’s the point at which they’d transition a patient from the breathing tube to a tracheostomy tube, a hollow tube placed in the neck, which provides a more permanent connection to a ventilator. Many of the COVID-19 patients have been on a ventilator for more than two weeks.
What’s more, “in a normal situation, when doctors take the tube out, maybe one out of 10 has to have the tube put back in,” “Right now, in all of the US centers, we’re talking about up to a third having to have the tube put back in after a day or so, and unfortunately, those people have quite high death rates.” It was noted that these numbers are preliminary, and so estimations of how many patients need to be reintubated may change as time goes by.
Currently many US hospitals are now recommending patients “prone,” or lie on their stomachs, because there’s more surface area on the backside of the lungs, so when any fluid is shifted toward the patient’s front, that can increase surface area for oxygen to reach.
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Doctors are saying that proning is very helpful. “You’ll get called for a rapid response and we’ll all walk into the room and say, ‘Put them on the belly!’ and they do, and magically their oxygen will be in the 90s, 95.” In most hospitals now, they ask patients who aren’t yet in the ICU to try and stay on their bellies for 16 hours a day.
Doctors say the difficulty is getting patients to comply, because most people don’t like lying on their belly for that many hours of the day.
Also there are now discussions about how to best utilize ventilators. Some doctors think ventilators are being overused, while others suggest adjustments as to how they are used, such as changing settings to use the lowest possible pressure.
Initially, many hospitals initially said they were planning to let two or more patients share a ventilator if necessary, seeing it as a life-saving measure when resources were scant; byearly April, most New York City institutions said they were cutting back on the practice because it appeared to endanger patients.
https://www.thailandmedical.news/news/covid-19-warning-various-medical-organizations-warn-against-multiple-patients-per-ventilator
In a study, published in the journal Lancet Respiratory Medicine, tracked 52 critically ill patients at a single hospital in Wuhan, China. Thirty-seven needed mechanical ventilation, the authors reported. After 28 days, 30 of those 37 patients had died, and three remained on ventilators. https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30079-5/fulltext
While another, published in the journal JAMA, tracked 1,591 critically ill patients admitted to the ICU in the Lombardy region of Italy. Not all of the patients had complete data available, but out of 1,300 with information on respiratory support, 88% received mechanical ventilation and 11% received noninvasive ventilation. The researchers didn’t break out mortality rates by therapy. At the time they published, 26% had died, 16% had been discharged and 58% were still in the ICU. https://jamanetwork.com/journals/jama/fullarticle/2764365?
A small study from the Seattle region was published in The New England Journal of Medicine on March 30. Doctors tracked 24 patients admitted to intensive care units across nine Seattle-area hospitals. Three quarters were put on a ventilator. At the time the paper was published, half the patients had died, which included four patients who had a do-not-resuscitate order on admission. Of the 12 surviving patients, five had been discharged home, four had left the ICU but remained in the hospital and three continued to be on ventilators in the ICU. https://www.nejm.org/doi/pdf/10.1056/NEJMoa2004500?articleTools=true
The study authors wrote, “Of the patients who were extubated, the age range was 23 to 88 years, which suggests that age may not be the sole indicator for successful extubation.”
Also reported by New York University Langone Health has also reported results from 4,103 coronavirus patients, of which nearly half were hospitalized and 445, or nearly 11%, needed a ventilator. The paper, which is available as a preprint that means it hasn’t yet been peer-reviewed but has been posted online while it awaits journal publication, shows that among the patients who needed a ventilator, 16 were discharged at the time of publication, 22 were able to come off a ventilator but were still in the hospital, 162 had died or were in hospice and 245 just over half were still on a ventilator.
https://www.medrxiv.org/content/10.1101/2020.04.08.20057794v1.full.pdf
New protocols are being studied along with the use of certain drugs to solve the respiratory complications and also the use of normal oxygen supplies or oxygen concentrators and even BiPAP machines.
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