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Some doctors are questioning the way ventilators are being used for people with serious cases of COVID-19. Why? More data shows a high death rate for patients treated under current ventilator practices.
At the same time, these doctors are saying their patients behave more like they have high altitude sickness than a viral infection. They talk about two different types of COVID-19 patients with differing severe lung problems.
While some patients respond to treatment as expected, doctors also describe patients whose lungs seem relatively fine, but who still can't get enough oxygen into their blood. These patients may make up the majority with severe infections.
This is why some are asking other doctors to consider changing how they treat some people in severe condition from COVID-19.
This conflict in treatment approaches shows in real time how doctors are adjusting their tactics against a novel and dangerous infection.
And it shows the persistence and diligence necessary to shift the medical establishment's practices once a treatment protocol has been established, even when evidence begins to show that treatment is less effective than once believed.
NY Doctor Finds Odd Lung Patterns
Assessing the outcomes of COVID-19 patients on ventilators, Brooklyn emergency room physician Dr. Cameron Kyle-Sidell found worse outcomes than expected. He told Medscape that around 70% of COVID-19 patients on ventilators never recover, based on his research.
What's more, the doctor noticed disturbing patterns he had never seen before. COVID-19 patients on ventilators sometimes showed extremely low blood-oxygen concentrations during ventilation, he said. Despite doctors' best efforts, he reported seeing concentrations of oxygen in blood at 10% to 20%, and sometimes even lower – a healthy blood oxygen level is above 95 percent, according to the British Lung Foundation.
Not only that, but some COVID-19 patients seem less obviously impaired by their low blood oxygen levels than he expected.
"In the past, we haven't seen patients who are talking in full sentences and not complaining of overt shortness of breath, with (blood oxygen) saturations in the high 70s," he said. "You get used to seeing certain patterns, and the patterns I was seeing did not make sense."
How Successful Are Ventilators for COVID-19?
Doctors and scientists studying the mortality rate of COVID-19 patients on mechanical ventilators say the available data is tricky to assess. Some studies put the death rate for coronavirus patients put on ventilators as low as 25%. But many report much higher rates, ranging anywhere from about 50% to as high as 98% in one instance.
For example, in a UK study of 98 COVID-19 patients who received "advanced respiratory support," which included invasive ventilation and tracheostomy, 66% died, according to the nation's Intensive Care National Audit and Research Center (ICNARC).
New York City hospitals have reported an even higher COVID-19 ventilator death rate. Roughly 80% or more of patients placed on ventilators there have died, according to AP News. The agency reports that typically only about 40% to 50% of patients on ventilators for non-COVID-19-related lung problems die. The percentage is high compared with the prognosis for some other medical procedures because, in general, doctors hold off on administering invasive ventilation until it is medically necessary, which means the illness is already quite serious before intubation.
Though data continue to emerge, some doctors feel enough already exists to justify new approaches to treating the most serious COVID-19 cases.
Why Ventilators Are Used for COVID-19
Facing COVID-19 for the first time, healthcare workers have largely relied on treatments that have worked in the past.
ARDS is not the same as COVID-19, but ARDS may be one of the conditions caused by the coronavirus disease. ARDS, a lung condition that leads to low oxygen levels in the blood, can be caused by various infections and injuries, according to an article edited by MedicineNet medical editor Melissa Conrad Stöppler, MD. She said these causes may include pneumonia, lung injury, and bacterial sepsis.
Some patients with severe COVID-19 appear to improve using ARDS treatment protocols. However, "an overwhelming number of patients" in northern Italy showed characteristics "in sharp contrast to expectations for severe ARDS," according to a letter to the editor published in late March by the American Journal of Respiratory and Critical Care Medicine.
The letter's author, anesthesiologist Dr. Luciano Gattinoni, led Brooklyn's Dr. Kyle-Sidell to change his approach at the front lines of treatment. But his efforts to shift the protocol forced the New York doctor to step down from his ICU position to work in the emergency room instead, where he could ethically use his experience and new techniques outside the standard ICU protocol.
Based on Dr. Gattinoni's observations, as well as his own experiences and those of colleagues, Dr. Kyle-Sidell began to look for other conditions as a model—specifically "the bends," or depressurization sickness experienced by SCUBA divers, and high-altitude sickness.
"Clinically (some COVID-19 patients) look a lot more like high-altitude sickness than they do pneumonia," he said.
What Is High Altitude Sickness?
"As altitude increases, the concentration remains the same but the number of oxygen molecules per breath is reduced," Dr. Shiel said.
This is a danger familiar to mountain climbers, who have to take long breaks from their upwards climb to let their bodies adjust to working with less oxygen, he said.
High altitude sickness often improves with taking breaks when needed, staying hydrated, and eating a proper diet. He also says that two drugs can be taken to help prevent the condition, but also warns of their serious side effects:
- DIAMOX (acetazolamide): DIAMOX (acetazolamide) allows a person to breathe faster and so metabolize more oxygen, thereby minimizing the symptoms caused by poor oxygenation.
- Dexamethasone (a steroid): It decreases brain and other swelling reversing the effects of acute mountain sickness (AMS). However steroids have been shown to be unhelpful in treating ARDS, and may worsen symptoms instead.
Dr. Shiel advises that these medications only be taken at the recommendation of a doctor. A study published March 30 specifically warns against treating COVID-19 patients with steroids, as the WHO has reported conflicting evidence with respect to their use in treating viral infections.
Proposing an 'Oxygen First' Strategy
Dr. Kyle-Sidell was influenced to treat his patients differently after reading Dr. Gattinoni's letter.
He described what he found in the letter was a description of two different types of patient with severe lung problems from COVID-19.
"If you think of the lungs as a balloon, typically when people have ARDS or pneumonia, the balloon gets thicker," Dr. Kyle-Sidell told Medscape. "So not only do you lack oxygen, but the pressure and the work to blow up the balloon becomes greater. So one's respiratory muscles become tired as they struggle to breathe. And patients need pressure. What Gattinoni is saying is that there are essentially two different phenotypes, one in which the balloon is thicker. (But) imagine if the balloon is not actually thicker but thinner, so they'd suffer from a lack of oxygen. But it is not that they suffer from too much work to blow up the balloon."
In other words, some COVID-19 patients have little trouble "blowing up the balloon" of their lungs, yet still suffer from low oxygen.
For patients of COVID-19 who show these symptoms, Dr. Kyle-Sidell began to apply an "oxygen first" treatment method.
This means getting patients' blood-oxygen levels as high as possible, and doing so using the lowest air pressure possible, he said.
And for him, that meant stepping down from his role in the intensive care unit.
"These didn't fit the protocol, and the protocol is what the hospital runs on," he told Medscape. "We ran into an impasse where I could not morally, in a patient-doctor relationship, continue the current protocols which, again, are the protocols of the top hospitals in the country. I could not continue those. You can't have one doctor just doing their own protocol. So I had to step down."
The role switch may be good news for the doctor and his 'oxygen first' strategy; in his new emergency room role at Maimonides in Brooklyn, Dr. Kyle-Sidell is setting up to use a new ventilation strategy based on Dr. Gattinoni's latest recommendations.