When Does a COVID-19 Patient Need to Go on a Ventilator
When COVID-19 leads to ARDS, a ventilator is needed to help the patient breathe. ARDS reduces the ability of the lungs to provide oxygen to vital organs

According to the World Health Organization, 1 out of every 6 COVID-19 patients becomes seriously ill and has difficulty breathing, as the virus primarily affects the lungs. Lungs that are infected or damaged are less effective at transporting oxygen from the air to the bloodstream.

If your immune system fails to fight the infection, it can spread to the lungs and cause acute respiratory distress syndrome (ARDS), which is a potentially fatal condition. 

When COVID-19 leads to ARDS, a ventilator is needed to help the patient breathe. ARDS causes severe lung inflammation and leads to fluids accumulating in the alveoli, which are tiny air sacs in the lungs that transfer oxygen to the blood and remove carbon dioxide. This reduces the ability of the lungs to provide enough oxygen to vital organs. 

Other indications for starting ventilation in a patient include:

  • Bradypnea (abnormally slow breathing)
  • Apnea (cessation of breathing)
  • Tachypnea (abnormally rapid breathing)
  • Inefficient exchange of gases
  • Respiratory muscle fatigue

What are potential complications of intubation?

Sedation is required for ventilation, during which a breathing tube is placed in the patient's windpipe through intubation. Doctors control the pressure and amount of oxygen delivered by the ventilator.

Complications can occur during intubation or ventilation, which can sometimes be life-threatening.

Complications of intubation

  • Upper airway and nasal trauma
  • Tooth displacement (avulsion)
  • Injury to the mouth, throat, vocal cords, or trachea
  • Prolonged intubation can cause:
    • Sinusitis
    • Tracheal stenosis (narrowing) or necrosis (tissue death)
    • Edema in the vocal cords
    • Infection in the respiratory system
    • Pneumonia
    • Sepsis

Complications of ventilation

  • Ventilator-induced lung injury that leads to alveoli rupture and lung collapse
  • Oxygen toxicity from too much oxygen
  • Ventilator-associated pneumonia caused by infections in the lung
  • Medication side effects and reactions
  • Adverse effects on blood circulation, heart, kidneys, and abdomen
  • Ventilator malfunction
  • Inability to wean off from the ventilator
  • Sepsis

Why do some COVID-19 patients require oxygen support?

Coronavirus is primarily a respiratory virus that severely impairs lung function. Inflammation in the lungs and respiratory tract can reduce the flow of oxygenated blood throughout the body, causing a patient to gasp for air. 

Normal oxygen saturation levels range between 94%-99%. When SPo2 levels fall below 93% it is a sign that oxygen therapy is required. Oxygen therapy is beneficial in cases in which a patient has:

  • Pneumonia or ARDS
  • Dyspnea (severe shortness of breath)
  • Hypoxia (oxygen deprivation on the tissue level without the presence of other physical symptoms)

According to current clinical management guidelines, supplementary oxygen can be administered at home or in a hospital setting, depending on the patient's condition and other symptoms. Oxygen support may be provided for an extended period depending on the severity of the disease.

Why are different types of breathing supports for COVID-19 patients?

Patients who are severely ill with COVID-19 may require breathing support to maintain optimal oxygen saturation. The amount of oxygen required is determined by the patient’s oxygen levels and severity of symptoms. According to clinical management protocols, patients typically require 5 L/min oxygen flow. Some patients, however, may end up using less oxygen (2-3 L/min).

Breathing supports available for COVID-19 patients include:

  • Oxygen therapy: The primary reason for being admitted to the hospital with COVID-19 is to receive supplemental oxygen, which increases the amount of oxygen in the lungs and blood. Supplemental oxygen can be given through the nose with plastic tubing or through a loose-fitting face mask.
  • Continuous positive airway pressure (CPAP): If breathing extra oxygen isn't enough to increase the patient’s blood oxygen level, a CPAP therapy can be used to help deliver oxygen through a tight-fitting mask that is connected to a machine through plastic tubing. The patient remains awake, and doctors can control the pressure and amount of oxygen delivered. However, this treatment requires a large amount of oxygen, which may be scarce in hospitals treating a large number of COVID-19 patients.
  • Invasive mechanical ventilation (IMV): A small percentage of seriously ill COVID-19 patients are placed on a ventilator. With IMV, a machine breathes for the patient. Some ventilated patients benefit from being positioned on their chest and stomach, possibly because it opens up more of the lung and thus allows for better gas exchange between air and bloodstream. Patients who require only basic oxygen therapy may benefit from this position.
  • Extracorporeal membrane oxygenation (ECMO): ECMO is used to treat a very small number of critically ill patients whose lungs have been severely damaged but who were otherwise fit and healthy prior to COVID-19. This treatment requires the use of a machine that consists of two parts: a pump that moves blood between the body and machine, and a membrane that acts as an artificial lung and allows the body's lungs to rest, giving them a better chance of healing. It is only available in a few specialist centers across the country.

What is the outcome of patients who require ventilators due to COVID-19?

As many countries scramble to obtain enough of these life-saving machines, ventilators have become a focal point of the coronavirus pandemic. For patients who require a ventilator, it can often mean the difference between life and death.

However, for the 50% who survive and eventually come off ventilation, many face a long, slow, and traumatic period of recovery from the disease and its treatment. Because of the high level of medical intervention required, those who come off a ventilator usually require physical therapy to master basic functions such as swallowing, speaking, breathing, and walking. Recovery may include periods of confusion, impaired thinking, hallucinations, anxiety, and depression.

These effects are in addition to the potential long-term damage to multiple organ systems caused by coronavirus complications. Emerging evidence suggests that COVID-19 can affect the liver, heart, kidneys, gut, and brain, in addition to the respiratory system.

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Medically Reviewed on 1/10/2022
References
Image Source: iStock Images

Ventilators and COVID-19: What You Need to Know: https://www.yalemedicine.org/news/ventilators-covid-19

Oxygenation and Ventilation: https://www.covid19treatmentguidelines.nih.gov/management/critical-care/oxygenation-and-ventilation/

COVID-19: https://iris.paho.org/bitstream/handle/10665.2/52577/PAHOIMSEIHCOVID-19200012_eng.pdf

COVID-19: Management of the intubated adult: https://www.uptodate.com/contents/covid-19-management-of-the-intubated-adult

Outcomes of mechanically ventilated patients with COVID-19 associated respiratory failure: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0242651