Special report: As the virus progresses, doctors rethink the rush to ventilate

BERLIN (Reuters) – When he was diagnosed with COVID-19, Andre Bergmann knew exactly where he wanted to be treated: the Bethanien Hospital lung clinic in Moers, near his home in northwest Germany.

The clinic is known for its reluctance to put patients with respiratory difficulties on mechanical ventilators, the type that involves tubes down the throat.

The 48-year-old doctor, a father of two and an aspiring triathlete, feared an invasive ventilator would be harmful. But soon after entering the clinic, Bergmann said, he struggled to breathe even with an oxygen mask, and felt so ill that the ventilator seemed inevitable.

Still, his doctors never put him in a machine that could breathe for him. A week later, he was well enough to go home.

Bergmann’s case illustrates a change in the front lines of the COVID-19 pandemic, as doctors reconsider when and how to use mechanical ventilators to treat critically ill patients, and in some cases whether to use them. While doctors initially filled intensive care units with intubated patients, many are now exploring other options.

Machines to help people breathe have become the primary weapon for doctors fighting COVID-19, which has so far killed more than 183,000 people. Within weeks of the global onset of the disease in February, governments around the world were quick to build or buy ventilators, as most hospitals said they had a critical shortage.

Germany has ordered 10,000 of them. Engineers from Britain to Uruguay are developing versions based on automobiles, vacuum cleaners, or even wiper motors. The administration of the President of the United States, Donald Trump, is spending $ 2.9 billion on almost 190,000 fans. The US government USA It has hired automakers such as General Motors Co and Ford Motor Co, as well as medical device manufacturers, with full delivery expected by the end of the year. Trump declared this week that the United States was now “the king of fans.”

However, as doctors gain a better understanding of what COVID-19 does to the body, many say they have become more moderate with the equipment.

Reuters interviewed 30 doctors and medical professionals in countries such as China, Italy, Spain, Germany and the United States, who have experience in treating patients with COVID-19. Almost everyone agreed that fans are vitally important and have helped save lives. At the same time, many highlighted the risks of using the most invasive types of them, mechanical ventilators, too soon or too often, or of non-specialists who used them without adequate training in crowded hospitals.

Medical procedures have evolved in the pandemic as doctors better understand the disease, including the types of medications used in treatments. The change around fans has potentially far-reaching implications as countries and companies increase production of the devices.

“BEST RESULTS”

Many forms of ventilation use masks to help carry oxygen to the lungs. Doctors ‘primary concern is mechanical ventilation, which involves placing tubes in patients’ airways to pump air, a process known as intubation. Patients are heavily sedated, to prevent their respiratory muscles from fighting against the machine.

Those with severe oxygen shortages, or hypoxia, have generally been intubated and hooked up to a ventilator for up to two to three weeks, with a survival probability of fifty to fifty, at best, according to doctors interviewed by Reuters and research. recent medical. The picture is biased and evolving, but suggests that people with COVID-19 who have been intubated have had, at least in the early stages of the pandemic, a higher mortality rate than other ventilator patients who have conditions such as bacterial pneumonia. or collapsed lungs.

This is not proof that ventilators have accelerated death: the link between intubation and death rates needs further study, doctors say.

In China, 86% of 22 COVID-19 patients did not survive invasive ventilation in an intensive care unit in Wuhan, the city where the pandemic began, according to a study published in The Lancet in February. Typically, according to the document, patients with severe respiratory problems have a 50% chance of survival. A recent British study found that two-thirds of COVID-19 patients who received mechanical ventilators ended up dying anyway, and a study in New York found that 88% of 320 COVID-19 patients with mechanical ventilation had died.

More recently, none of the eight patients who used ventilators at the Abu Dhabi hospital had died as of April 9, a doctor told Reuters. And an ICU doctor at Emory University Hospital in Atlanta said he had had a “good” week when nearly half of the COVID-19 patients were successfully removed from the ventilator, when he expected more to die.

Experiences can vary dramatically. The average time a COVID-19 patient spent with a respirator at all five Scripps Health hospitals in California’s San Diego county was just over a week, compared to two weeks at the Hadassah Ein Kerem Medical Center in Jerusalem and three at the Universiti Malaya Medical Center in Malaysia’s capital Kuala Lumpur, hospital doctors said.

In Germany, as patient Bergmann struggled to breathe, he said he was too desperate to worry.

“There came a time when it just didn’t matter anymore,” he told Reuters. “At one point I was so exhausted that I asked my doctor if I was going to get better. I was saying that if I didn’t have children or a partner, it would be easier to stay alone. ”

Instead of putting Bergmann on a mechanical ventilator, the clinic gave him morphine and kept him in the oxygen mask. Since then, the test was done without infection, but did not fully recover. The head of the clinic, Thomas Voshaar, a German pulmonologist, has strongly advocated early intubation of patients with COVID-19. Doctors, including Voshaar, worry about the risk of ventilators damaging patients’ lungs.

Doctors interviewed by Reuters agreed that mechanical ventilators are crucial life-saving devices, especially in severe cases when patients suddenly deteriorate. This happens to some when their immune systems are overloaded in what is known as a “cytokine storm” of inflammation that can cause dangerously high blood pressure, lung damage, and eventual organ failure.

The new coronavirus and COVID-19, the disease causing the virus, have been compared to the 1918-19 Spanish flu pandemic, which killed 50 million people worldwide. Now as then, the disease is new, serious, and spreading rapidly, pushing the limits of public health and medical knowledge necessary to address it.

When coronavirus cases began to emerge in Louisiana, doctors from the state’s largest hospital system, Ochsner Health, saw an influx of people with signs of acute respiratory distress syndrome, or ARDS. ARDS patients have inflammation in the lungs that can make it hard for them to breathe and breathe quickly.

“Initially, we were intuiting these patients fairly quickly as they began to have more respiratory distress,” said Robert Hart, medical director of the hospital system. “Over time, what we learned is trying not to do that.”

Instead, the Hart hospital tried other forms of ventilation with masks or thin nasal tubes, as did Voshaar with his German patient. “It seems like we are seeing better results,” Hart said.

CHANGED LUNGS

Other doctors painted a similar image.

In Wuhan, where the new coronavirus emerged, doctors at Huazhong University of Science and Technology Tongji Hospital said they initially resorted to intubation rapidly. Li Shusheng, head of the hospital’s intensive care department, said several patients did not improve after ventilator treatment.

“The disease,” he explained, “had changed his lungs beyond our imagination.” His colleague Xu Shuyun, a doctor of respiratory medicine, said the hospital adapted by reducing intubation.

Luciano Gattinoni, visiting professor in the Department of Anesthesiology, Emergency Medicine and Intensive Care, University of Göttingen in Germany, and a renowned ventilator expert, was one of the first to ask questions about how they should be used to treat COVID-19.

“I realized as soon as I saw the first CT scan … that this had nothing to do with what we had seen and done in the past 40 years,” he told Reuters.

In an article published by the American Thoracic Society on March 30, Gattinoni and other Italian doctors wrote that COVID-19 does not lead to “typical” respiratory problems. The patients’ lungs functioned better than they would expect for ARDS, they wrote, they were more elastic. So, he said, mechanical ventilation should be given “at a lower pressure than we are used to.”

Ventilating some patients with COVID-19 as if they were standard ARDS patients is not appropriate, he told Reuters. “It’s like using a Ferrari to go to the store next door, you hit the gas and hit the window.”

The Italians were quickly followed by Cameron Kyle-Sidell, a New York doctor who gave a YouTube talk saying that in preparing to put patients on ventilators, hospitals in the United States were treating “the wrong disease.” Ventilation, he feared, would lead to “an enormous amount of damage to large numbers of people in a very short time.” This is still his opinion, he told Reuters this week.

When the outbreak broke out in Spain in mid-March, many patients went directly to the ventilators because lung radiographs and other test results “scared us,” said Delia Torres, a doctor at the Alicante University General Hospital. Now they focus more on breathing and the general condition of the patient than only on x-rays and tests. And they intubate less. “If the patient can improve without it, then there is no need,” he said.

In Germany, lung specialist Voshaar was also concerned. A mechanical ventilator in itself can damage the lungs, he says. This means that patients stay in intensive care longer, block specialty beds, and create a vicious circle where more ventilators are needed.

Of the 36 acute patients with COVID-19 in his ward in mid-April, Voshaar said, one had been intubated, a man with a severe neuromuscular disorder, and was the only patient who died. Another 31 had recovered.

“IRON LUNGS”

Some doctors warned that the impression that the rush to ventilate is harmful may be due in part to the large number of patients in the current pandemic.

People who work in intensive care units know that the mortality rate of patients with ARDS who are intubated is around 40%, said Thierry Fumeaux, head of an ICU in Nyon, Switzerland, and president of the Swiss Society of Medicine Intensive Care. This is high, but it can be acceptable in normal times, when there are three or four patients in a unit and one of them does not.

“When you have 20 or more patients, this becomes very evident,” said Fumeaux. “So you have this feeling, and I’ve heard a lot, that ventilation kills the patient.” That is not the case, he said. “No, it is not ventilation that kills the patient, it is lung disease.”

Mario Riccio, head of anesthesiology and resuscitation at the Oglio Po hospital near Cremona in Lombardy, the worst-affected region in Italy, says the machines are the only treatment to save a COVID-19 patient in serious condition. “The fact that people who were placed under mechanical ventilation in some cases die does not undermine this claim.”

Originally nicknamed “iron lungs” when it was introduced in the 1920s and 1930s, mechanical fans are sometimes also called respirators. They use pressure to blow air, or a mixture of gases like oxygen and air, into the lungs.

They can also be configured to exhale, effectively taking over the patient’s entire breathing process when their lungs fail. The goal is to give the body enough time to fight an infection and be able to breathe independently and recover.

Some patients need them because they are losing the strength to breathe, said Yoram Weiss, director of the Hadassah Ein Kerem Medical Center in Jerusalem. “It is very important to ventilate them before they collapse.” At his hospital, 24 of 223 people with COVID-19 had received ventilators before April 13. Of them, four had died and three had left the machines.

AEROSOL SPRAYS

The simplest forms of ventilation, such as face masks, are easier to administer. But respirator masks can release droplets known as sprays that can spread the infection. Some doctors said they avoided the masks, at least initially, because of that risk.

While mechanical fans do not produce aerosols, they carry other risks. Intubation requires that patients be heavily sedated so that their respiratory muscles are completely surrendered. Recovery can be prolonged, with risk of permanent lung damage.

Now that the initial wave of COVID-19 cases has peaked in many countries, doctors have time to examine other ways to control the disease and are fine-tuning their approach.

Voshaar, the German lung specialist, said some doctors were approaching COVID-19 lung problems as they would with other forms of pneumonia. In a healthy patient, oxygen saturation, a measure of the amount of oxygen that hemoglobin contains in the blood, is about 96% of the maximum amount that blood can hold. When doctors check patients and see lower levels, indicating hypoxia, Voshaar said, they can overreact and run to intubate.

“Lung doctors see this all the time,” Voshaar told Reuters. “We see 80% and still do nothing and let them breathe spontaneously. The patient is not feeling well, but he can eat, drink and sit by his bed. ”

He and other doctors think that other tests may help before intubation. Voshaar looks at a combination of measures including how fast the patient is breathing and their heart rate. His team is also guided by lung scans.

“HAPPY HYPOXICS”

Several doctors in New York said they, too, had begun to consider how to treat patients, known as “happy hypoxic,” who can speak and laugh without signs of mental clouding even though their oxygen may be critically low.

Rather than rushing to intubate, doctors say they are now looking for other ways to increase patients’ oxygen. One method, known as “pronation,” that is, or helping patients roll over and lie on their foreheads, said Scott Weingart, head of emergency critical care at Stony Brook University Medical Center on Long Island.

“If patients stay in one position in bed, they tend to desaturate, they lose oxygen in the blood,” Weingart said. Lying down facing forward displaces any fluid in the lungs to the front and releases the back of the lungs to expand better. “The changes in position have radically impressive effects on the patient’s oxygen saturations.”

Weingart recommends intubating a communicative patient with low oxygen levels if they begin to lose mental clarity, experience a cytokine storm, or really begin to have difficulty breathing. He feels that there are enough ventilators for such patients in his hospital.

But for the happy hypoxic, “I still don’t want these patients to use ventilators, because I think it’s hurting them, not helping them.”

QUALITY, SKILL

As governments in the United States and elsewhere are struggling to increase fan production, some doctors fear that fast-building machines may not measure up.

Doctors in Spain wrote to their local government to complain that the ventilators they had purchased were designed for use in ambulances, not in intensive care units, and some were of poor quality. In the UK, the government has canceled an order for thousands of units of a simple model because more sophisticated devices are needed.

Most importantly, many doctors say, the additional machines will need highly trained and experienced operators.

“It’s not just about running out of ventilators, you’re running out of experience,” said David Hill, a pulmonary and critical care physician in Waterbury, Connecticut, who serves at Waterbury Hospital.

Managing long-term ventilation is complex, but Hill said some US hospitals. USA They were trying to get non-critical care doctors up to speed quickly with webinars or even tip sheets. “That is a recipe for bad results.”

“The intensivists don’t ventilate by protocol,” Hill said. “We can choose initial settings,” he said, “but we adjust those settings. It’s complicated.”