Some Doctors Pull Back on Using Ventilators to Treat Covid-19

[question everything]

It is another medical mystery of the coronavirus pandemic: Large numbers of Covid-19 patients arrive at hospitals with blood-oxygen levels so low they should be unconscious or on the verge of organ failure. Instead they are awake, talking—not struggling to breathe.

Although nobody is quite sure what about the coronavirus causes these patients to react this way, they are rapidly changing how many doctors are treating the disease. Instead of rushing to put such patients on mechanical ventilators for fear of them suddenly getting worse and dying, some doctors are now holding off on the invasive treatment, believing that many of these patients will do just fine without them.

Pre-Covid, doctors looking to boost a patient’s blood-oxygen levels would often turn first to less invasive methods of support such as CPAP or BiPAP machines that push air into a patient’s airway through a face mask, or high-flow nasal cannulas—prongs that blow heated, humidified oxygen into a patient’s nostrils. If that didn’t work, physicians would use mechanical ventilators.

(snip)

Doctors have dubbed these patients “happy hypoxemics,” a reference to the paradox of abnormally low levels of oxygen found in their blood combined with an ability to breathe relatively easily. In recent weeks, doctors at Stony Brook Hospital have used ventilators less on these patients, turning instead to the CPAP or BiPAP machines or high-flow nasal cannulas.

Dr. Weingart remembers one of his first such patients in March—a 42-year-old man with blood-oxygen levels so low he should have been unconscious. Instead, he was sitting up, smiling and talking. He was breathing quickly, but seemed fine otherwise. Dr. Weingart and his team used a high-flow nasal cannula to boost the patient’s oxygen levels. They also turned him on his front, a method known as “prone positioning” that doctors have found can also help boost oxygen levels partly by reducing the pressure of the heart and diaphragm on the lungs. The patient was never put on a ventilator and was discharged in a week, Dr. Weingart said.

(snip)

Ventilators play an important part in care, but there are serious risks to being on one for too long. Patients can get secondary infections like bacterial pneumonia. They can get urinary tract infections from being bed-bound and are at higher risk of kidney failure and getting blood clots. If the ventilator isn’t set properly, patients can sustain lung injury. Recently published data also suggest ventilators may not be as effective at keeping seriously ill Covid-19 patients alive as they are with other patients with severe respiratory problems.

(snip)

In a study recently published in the American Journal of Respiratory and Critical Care Medicine, Dr. Medoff and other researchers at MGH and Beth Israel Deaconess Medical Center said 50 of the 66 patients on mechanical ventilators between March 11 and March 30 at those hospitals were discharged from the ICU, while 11 of the patients died.

“We don’t have to think too much outside of the box here,” Dr. Medoff said.

https://www.wsj.com/articles/some-doctors-pull-back-on-using-ventilators-to-treat-covid-19-11589103001 (subscription)

[Chainfire]

1. On the job training

[question everything]

2. New situations, not much choice

Better than keeping enlarging lobotomies or keeping cutting to the bone around a cancerous breast.

Too many think that physicians know everything. They don’t. The best are good diagnosticians. Most are not trained as researchers. We should be grateful that some, under the immense pressure do find a minute to yes, look outside the box.

[Hoyt]

3. Great that more effective -- and relatively simple -- treatments are emerging.