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I work with medicine emergency for thirty years. In 1994, I invented an imaging system to teach intubation, the procedure for inserting breathing tubes. So I started researching this procedure and later I started teaching airways courses to doctors worldwide in the last two decades.
Then in late March, when a crowd of patients from covid-19 began to overload hospitals in the city of New YorkI volunteered to spend ten days in Bellevue, helping the hospital where I graduated. During those days, I realized that we are not detecting the pneumonia deadly that the virus causes early enough and we could be doing more to prevent patients from needing ventilators and dying.
On the long journey from my home in New Hampshire In New York, I called my friend Nick Caputo, an emergency physician in the Bronx, who was already in the eye of the hurricane. I wanted to know what I was going to face, how to guarantee my safety and what were his ideas about managing the airways in this disease. “Rico,” he said, “I have never seen anything like this in my life.”
He was correct. Pneumonia caused by coronavirus It had an impressive impact on the city’s hospital system. Typically, an emergency room cares for a suite of patients ranging from serious conditions, such as heart attacks, strokes, and traumatic injuries, to conditions that do not pose a risk of death, such as minor injuries, poisoning, injuries. orthopedics and migraine
However, during my recent visit to Bellevue, almost all the patients in the emergency room had covid-19 pneumonia. In the first hour of my first shift, I inserted breathing tubes into two patients.
Even the patients without respiratory discomfort had covid pneumonia. The patient stabbed in the shoulder, whom we radiographed because we feared that one of his lungs had collapsed, he actually had covid pneumonia. We also found covid pneumonia in patients in whom we performed CT scans to detect falls. The same was true for elderly patients who fainted for unknown reasons and several diabetic patients.
Here’s what really surprised us: These patients reported no sensation of breathing problems, even though chest x-rays showed diffuse pneumonia and oxygen It was below normal. How could this happen?
We are only beginning to understand that covial pneumonia initially causes a form of oxygen deprivation that we call “silent hypoxia,” silent because it is insidious and difficult to detect.
Pneumonia is an infection of the lungs in which the alveoli fill with fluid or pus. Typically, patients experience chest discomfort, pain when breathing, and other respiratory problems. But when covid pneumonia strikes, patients experience no difficulty breathing, even when oxygen levels drop. And when they finally have difficulty breathing, they have alarmingly low oxygen levels and moderate to severe pneumonia (as seen on chest x-rays). The normal oxygen saturation for most people at sea level is between 94% to 100%; The covid pneumonia patients I saw even had oxygen saturations of only 50%.
To my surprise, almost all the patients I saw said they had been sick for a week, with fever, cough, headache. stomach and fatigue, but they only gasped the day they went to the hospital. Clearly, their pneumonia had settled days earlier, but when they felt they had to go to the hospital, they were already in critical condition.
In emergency departments, we insert breathing tubes into critically ill patients for various reasons. But in my thirty years of experience, most of the patients who needed emergency intubation were in shock, with altered mental status, or difficulty breathing. Patients who need intubation due to acute hypoxia are often unconscious or use all possible muscles to breathe. They are under extreme suffering. Covid pneumonia cases are quite different.
The vast majority of covid pneumonia patients I treated at the hospital had extraordinarily low oxygen saturation during screening, at levels seemingly incompatible with life. But they kept playing on their cell phones when we put them on the monitors. Although they breathed faster, they seemed to be suffering relatively little, despite dangerously low oxygen levels and terrible pneumonia on chest X-rays.
We are beginning to understand why this happens. The coronavirus attacks lung cells that produce surfactant. This substance helps keep the alveoli of the lungs open between breaths and is essential for normal lung function. When the inflammation from covid pneumonia begins, it causes the air sacs to collapse and oxygen levels to drop. However, the lungs initially remain “in compliance,” not yet stiff or fluid-filled. This means that patients can still expel carbon dioxide and, without carbon dioxide build-up, patients do not experience difficulty breathing.
Patients compensate for low oxygen in the blood by breathing faster and deeper, and this happens without them noticing. This silent hypoxia and the patient’s physiological response to it cause even more inflammation and further collapse of the air pockets. Pneumonia worsens and oxygen levels plummet. The truth is, the patient is hurting his own lungs as he breathes harder and harder. Twenty percent of covid pneumonia patients move into a second, deadlier phase of lung injury. Fluid builds up and the lungs become stiff. Carbon dioxide increases and patients develop acute respiratory failure.
When patients begin to have visible breathing difficulties and arrive at the hospital with dangerously low oxygen levels, many need a ventilator.
The fact that silent hypoxia rapidly progresses to respiratory failure explains the cases of covid-19 patients who die suddenly, without even feeling short of breath. (It appears that most covid-19 patients have relatively mild symptoms and overcome the disease in one to two weeks without treatment.)
One of the main reasons why this pandemic is affecting our health system is the alarming severity of patients who come to the emergency room with lung injuries. Covid-19 kills the lungs mercilessly. And, as many patients don’t visit the hospital until pneumonia is well advanced, many end up needing ventilators, causing a shortage of devices. And even when they are on the fans, many die.
Avoiding the use of a ventilator is a great victory for the patient and the health system. The resources required for ventilator patients are staggering. Ventilated patients require various sedatives to avoid resisting ventilation or accidentally removing the breathing tubes; they need intravenous and arterial accesses, intravenous pumps, and medications. In addition to the tube in the trachea, they need tubes in the stomach and bladder. The teams need to move each patient twice a day, turning their backs and then their backs, to improve lung function.
There is a way to identify more covid pneumonia patients earlier and treat them more effectively, without having to wait for a coronavirus test in a hospital or doctor’s office. This is the early detection of silent hypoxia by means of a common medical device, which can be bought without a prescription in most cases. pharmacy: a pulse oximeter.
Performing pulse oximetry is as simple as using a thermometer. Simply press the button to turn on the device and place it at your fingertips. In a few seconds, the screen shows two numbers: oxygen saturation and heart rate. Pulse oximeters are extremely reliable in detecting oxygenation problems and high heart rates.
Pulse oximeters helped save the lives of two emergency room doctors I know by alerting them early on to the need for treatment. When they realized that their oxygen levels were dropping, they both went to the hospital and recovered (one of them needed more time and treatment). Apparently hypoxia detection, early treatment and careful monitoring also worked for the British Prime Minister, Boris Johnson.
Widespread pulse oximetry screening for covid pneumonia, with people testing themselves with home devices or going to clinics and doctor’s offices, could establish an early warning system for the types of respiratory problems associated with covid pneumonia .
People who use home devices would have to consult their doctors to reduce the number of people who go to hospitals unnecessarily due to an error in the interpretation of the device data. There may also be some patients with unknown chronic lung problems and with limited or slightly low oxygen saturation unrelated to covid-19.
All patients who have tested positive for coronavirus should monitor pulse oximetry for two weeks, during which time covid pneumonia usually develops. Everyone with a cough, fatigue, and fever should also monitor the pulse oximeter, even if they have not had a virus screening test or if the test has been negative, because these tests are only 70% accurate. The vast majority of Americans who have been exposed to the virus do not know it.
There are other things we can do to avoid using intubation and the ventilator right away. Patient positioning maneuvers (with patients lying on their stomachs and on their sides) open the lower and posterior lungs, the most affected parts in covid pneumonia. Oxygenation and positioning helped patients breathe easier and apparently prevented the disease from progressing in many cases. According to a preliminary study by Dr. Caputo, this strategy helped prevent three out of four patients with advanced covid pneumonia from needing a ventilator in the first 24 hours.
To date, covid-19 has killed more than 40,600 people across the country, more than 10,000 in New York State alone. Oximeters are not 100% accurate and are not a panacea. There will be deaths and bad consequences that cannot be prevented. We still don’t know for sure why certain patients get so sick or why some develop multiple organ failure. Many older people, already weakened by chronic disease, and people with underlying lung disease are very ill with covid pneumonia, despite aggressive treatment.
But we can do more to fight the virus. Many emergency services are currently being devastated by this disease, or awaiting its impact. We must direct resources to identify and treat the early stage of covid pneumonia earlier, by examining silent hypoxia.
It is time to get ahead of this virus, instead of chasing it. / / Translation by Renato Prelorentzou.
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