Monday, May 11, 2020

More Docs Question Use of Ventilators in Covid-19 Fight

More doctors are questioning the use of ventilators in treating severe Covid-19 symptoms.  Ventilators are rough on a patient and often cause collateral damage.  Covid-19 patients also have a lower survival rate once they are placed on a ventilator compared to overall ventilator patients.  The Wall Street Journal reported today:

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.

But people with Covid-19 began showing up at the hospital with rarely seen, ultra-low blood-oxygen levels. Even for those who weren’t struggling to breathe, doctors were concerned that patients’ conditions could suddenly worsen, which with Covid-19 could swiftly turn deadly. So they often intubated sooner....
However, some ER docs wondered if ventilators were the right treatment for Covid-19 patients.  Dr. Scott Weingart pointed out in a podcast (posted here on April 5.) that patients often didn't suffer breathing problems until the insertion of the dreaded vent.  The Mount Sinai graduate said he was using Bipap machines with filters that earned more favorable outcomes.  Sure enough, the Journal continues: 

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.

Several other doctors said they are having success with such simpler approaches. That, in turn, is reducing demand for ventilators—a critical concern early in the crisis—and easing strain on hospital staff, they say.

JJ posted a retired nurse's account of a similar experience with her husband in The Federalist.  Making her oncologist husband stay on his stomach increased his oxygen level from 92% to 95%.   Earlier post. 

New Orleans has been the Southern epicenter of the Wuhan Virus in America.  Ochsner reported similar observations and results:

Abdul Khan, medical director for Ochsner Medical Center’s West Bank intensive care unit in Gretna, La., has also encountered these so-called “happy hypoxemic” Covid-19 patients.

“We’ve learned that they are able to tolerate these lower levels of oxygen for a significant period of time,” he said. Dr. Khan and his colleagues now use ventilators as a last resort for such patients...
Make no mistake, ventilators are rough on a patient.  Such patients unfortunately have a poor survival rate:

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.

In the U.K., 58.8% of Covid-19 patients on invasive breathing support had died as of May 7, according to data from the country’s National Health Service. That compares with a 34.5% death rate among patients with other types of viral pneumonia who receive invasive breathing support, according to historic data. Of the Covid-19 patients placed on basic breathing support, 17.8% died.

In New York, 88% of 320 Covid-19 patients placed on mechanical ventilation in the state’s Northwell Health System died, according to a study in the Journal of the American Medical Association. Of the 2,314 who didn’t receive mechanical ventilation, 11.7% died.

Experts note that the studies may at least partly reflect that Covid-19 patients who start ventilation tend to be the sickest, and therefore the least likely to survive.
Thankfully, doctors on the front lines are ignoring the eggheads in DC and Atlanta and instead are believing their own lying eyes: 

At University College Hospital, a large teaching hospital in central London, doctors are placing patients on less-invasive breathing support, and only progressing them to ventilators if they are still struggling. Under that system, around half of patients are managing with simpler breathing support.

“It’s worked out well for us,” said Mervyn Singer, an intensive care consultant who said UCH adopted this approach on the advice of doctors in China and Italy. “We’ve been able to retain our capacity to ventilate because we haven’t immediately put lots of people on ventilators.”

At the outset of the pandemic, doctors rushed to put Covid-19 patients on ventilators in part due to concerns that less invasive methods—where the air patients breathe in and out isn’t contained in tubes—posed a greater infection risk to health-care workers.
Of course, there is an opposing school of thought: 

Benjamin Medoff, chief of the division of pulmonary and critical care medicine at Massachusetts General Hospital in Boston, said his hospital continues to recommend against the routine use of these less invasive methods because the devices can potentially push virus particles into the air and CPAP and BiPAP masks can leak. (Dr. Khan of Ochsner West Bank and Dr. Weingart of Stony Brook said their hospitals place filters on these masks, and use specially ventilated rooms to keep their staff safe.)

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.
It appears the doctors on the front lines are ignoring the eggheads in DC and Atlanta and instead are believing their own lying eyes.

Kingfish note: Check out Dr. Weingart's blog as he and his team fight the virus.  There is some good information posted.


Anonymous said...

Had several docs tell me hospitals getting 35k if they put you on the the vent.

Anonymous said...

Inching towards the truth...

All that drama over shortage of ventilators, and they are not the best course.

All that money being paid to put people on vents, and they are not the best course.

Praying these medical folks keep speaking up!!

Anonymous said...

11:12 - If a hospitalized patient came through the ER via ambulance, the hospital makes for money as well. Does that convince you to have your family drag you through the front door rather than utilize ambulance and ER? Newsflash: Some procedures have a higher cost than others.

Anonymous said...

This is why we should continue to mitigate the spread of the virus as much as possible. We are learning more effective treatments every day. The longer we can keep people from getting infected the better their chances are for survival.

Anonymous said...

Speak up? Are you kidding physicians have been speaking up only to be purged by media and social media mainly... people in media that wanted to speak only science!!! Well the issue was this we were speaking in science rather than politics and they shut us down. Say at home for all wasn't the best strategy as Georgia has proven by lower cases each day after reopening. Nor was ventilators. Remember many physicians in the US as well as Europe and Australia have been praising hydroxy-chloroquine for weeks and media shut us down. Speaking in terms of science must've been code for political.

Albert Schweitzer said...

Much of this is not only simplistic but wrongheaded.

Most patients who undergo general anesthesia are ventilated. With a ventilator.

For those critically ill and in pulmonary failure being ventilated or placed on ECMO
Are the last defenses to save life. Sure, it is better to first use face mask oxygen.
CPAP, BiPAP and if those modalities work why use more expensive and dangerous
Mechanical ventilation.

Sure, many being ventilated do not survive. But this is more likely of a
Precipitous decline than of being ventilated.

No one I know ever considered ventilating a patient for the purpose of income
Or of increasing income for a hospital. Those who believe that are simply in a position
To view their colon as they have their head up their ass.

Anonymous said...

Is there a shortage of tinfoil? Because you conspiracy minded folks need to give it a rest. Nurses and Doctors are frontline heroes in a war on Covid-19. Which is the real enemy. Not the Hospitals.

Anonymous said...

It is unfortunate for those who refuse to recognize the fact that COVID-19 has been politicized, and the real experts - being the doctors and nurses on the front lines of this who see what works and what doesn't - are being silenced or drowned out by the CDC, WHO and other agencies and entities that DO have an agenda.

Never forget that a crisis for some is an OPPORTUNITY for others.

Anonymous said...

@7:55 AM
You sound as unhinged as a 9/11 Truther. The only things you left out are Bill Gates and 5G internet.

Anonymous said...

@8:21, exaggerate much?

Anonymous said...

And cue the trial lawyers in 3......2.......1.......GO!!

Anonymous said...

Good Grief!

I don't fault doctors for sharing their experiences with Covid 19, but they ought to know that their anecdotal experiences may be the result of unknown variables rather than their treatment. Their patients may just not have been as severely ill or maybe have the Acer 1 enzyme some researchers think might protect against the virus.

I don't know but neither do the rest of us. We do know now that Remdesivir seems helpful and combinations of other viral drugs are being researched.

6:23 am Georgia cases have increased by 40% after reopening. Research showed Hydroxy-chloroquine had dangerous side effects with no verifiable benefit.

If commenters are getting their information from UTube and Podcasts, you are foolish. You don't know these people. They are doing what they do for profit. They can and do invent "credentials" out of whole cloth. They are fed false tales by China, Russian and Iran hackers and some are no doubt in the pay of our enemies. Some have literally been diagnosed as mentally ill. You can check on their credentials ( like does their " college or university" actually exist other than on an internet site that lets you buy a PhD). You can search for the actual research publications.
Before you "believe" someone, you should at least find out if they've ever been arrested and convicted for crimes or institutionalized for mental illness or even finished high school.

Anonymous said...

I wonder how many of you stable genius Right Wingers that are spreading conspiracy theories about the Covidd-19 response in US hospitals and ventilator usage will also argue that the USA for-profit Health System is the BEST IN THE WORLD and that Canada and they UK are literally Cuba tier with long waits and death panels??

Anonymous said...

Am I supposed to take the word of Anonymous 8:57 AM? What are your credentials? You seem invested in toeing the government line and trying to drive the narrative of this thread. I bet you are 7:07 AM and 8:21 AM also. Sucks being out of your university cocoon.

Anonymous said...

Oooh!!!!! Look at me, I’m a “Frontline Hero” for doing the job I was hired and paid to do and I didn’t even have to do anything extraordinary.

Anonymous said...

Speaking of Doctors and hospitals, UMMC is mandating paycuts for all for the next 3 months. Doesn't UMMC get some sort of federal bailout money? How can they do this while other state run institutions have kept people employed and at home? Something about this isn't right.

Anonymous said...

Vents are life-saving measures. They should only be used in extreme cases. The early use of them for Covid-19 patients having the difficulty of breathing has, unequivocally, caused more damage than assistance. This is factual and inarguable information.

But trust what one doctor says because he says something different from what another doctor says.

Anonymous said...

First, these "oracles" were neither the first nor the only ones to suggest, in view of LONG TERM worries about vent supplies, to suggest CPAP type devices to alleviate shortages. A quick Google search shows other docs, at reputable hospitals, bantering about this before.

It's just new to certain conspiracy websites, and, of course, we have to allege that the big bad hospital system is gouging folks.

Now, "the eggheads" in Atlanta and DC? You mean CDC? NIH? CMS? Or just MDs and PdDs? You do know that CDC is not a clinical setting, I hope?

So, here's a snippet from April 8, "To be sure, many physicians are starting simple. “Most hospitals, including ours, are using simpler, noninvasive strategies first,” including the apnea devices and even nasal cannulas, said Greg Martin, a critical care physician at Emory University School of Medicine and president-elect of the Society of Critical Care Medicine. (Nasal cannulas are tubes whose two prongs, held beneath the nostrils by elastic, deliver air to the nose.) “It doesn’t require sedation and the patient [remains conscious and] can participate in his care. But if the oxygen saturation gets too low you can achieve more oxygen delivery with a mechanical ventilator.”

Yet another "egghead" from Atlanta, right?

This running out with conspiracy theory website crap is disappointing. No, KF, you didn't "uncover" some vast money grubbing conspiracy. Did the other docs just happen to have Italian (like Fauci, a target of RWNJ death threats) or Jewish names???

And, this information was being considered in December, as the virus raged in China.

Totally agree that vent use is a subject of debate, but when someone's level is in the 70s, do you just try a CPAP for a while? It's a hell of a gamble.

Do you understand that placing patients on stomachs to improve outcomes was very early reported among clinicians?

"Wuhan study shows lying face down improves breathing in severe COVID-19

March 24, 2020
American Thoracic Society
In a new study of patients with severe COVID-19 (SARS-CoV-2) hospitalized on ventilators, researchers found that lying face down was better for the lungs. The research letter was published online in the American Thoracic Society's American Journal of Respiratory and Critical Care Medicine. "

The "eggheads" in DC and Atlanta, and at Emory and Harvard and UMMC I trust. Nutjob podcasters who repeat drivel, with a paranoid twist, I do not.

Kingfish said...

That "nutjob podcaster" is a Mount Sinai ER Intervenist.

I get most of this stuff from doctors or medical-related website, not conspiracy sites. There is not a damn thing stopping you from sending this sort of article to me. I suppose the NABR working paper I posted Sunday was from a conspiracy website as well. You probably think Dr. Osterholm is a crackpot too.

Anonymous said...

Family member was diagnosed with COVID-19, sent home on CPAP with O2 and put in a pron position. Recovered well and is doing fine now. This seems to be emerging as an effective therapy.

Anonymous said...

@9:33a- You truly are clueless about the medical field. On a normal day, far before COVID-19 was released into the wild, I didn’t trust “hospital” doctors at all. ANY patient with pre-existing conditions will tell you that hospitalists are extremely dangerous. They try to revoke care plans that have been in place for years and that are not the cause of any issues for admission as part of their “process of elimination.” I had to stand up to many and DEMAND my parent’s specialists come and tell me they agree with the hospitalist’s action(s). Needless to say, the specialists ALL agreed with ME!! You don’t play guessing games with the type of people most affected by this virus.

The reality about nurses... I respect them and am grateful for them. However, they are essentially robots. Ever been inpatient?? They can’t give your gauze, alcohol pads, a bandaid, or Tylenol without a doctor’s orders. They aren’t allowed to think and make choices. They can ONLY do what the doctor has ordered on the computer screen in their faces. I have had this conversation with MANY nurses during hospital stays... they know and admit this is true.

Lastly, for those of you dogging on us “conspiracy theory” folks... there’s (another) new article out about a large number of COVID deaths being the result of INCORRECT treatments.

Anonymous said...

the hundreds of well choreographed tik tok videos prove that "frontline heroes" had way more time on their hands than they let on.

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