Special Report: As virus advances, doctors rethink rush to ventilate

In China, 86% of 22 COVID-19 patients didn't survive invasive ventilation at an intensive care unit in Wuhan, the city where the pandemic began, according to a study published in The Lancet in February. Normally, the paper said, patients with severe breathing problems have a 50% chance of survival. A recent British study found two-thirds of COVID-19 patients put on mechanical ventilators ended up dying anyway, and a New York study found 88% of 320 mechanically ventilated COVID-19 patients had died.

More recently, none of the eight patients who went on ventilators at the Cleveland Clinic Abu Dhabi hospital had died as of April 9, a doctor there told Reuters. And one ICU doctor at Emory University Hospital in Atlanta said he had had a "good" week when almost half the COVID-19 patients were successfully taken off the ventilator, when he had expected more to die.

The experiences can vary dramatically. The average time a COVID-19 patient spent on a ventilator at Scripps Health's five hospitals in California's San Diego County was just over a week, compared with two weeks at the Hadassah Ein Kerem Medical Center in Jerusalem and three at the Universiti Malaya Medical Centre in the Malaysian capital Kuala Lumpur, medics at the hospitals said.

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

"There came a moment when it simply no longer mattered," 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, if I had no children or partner then it would be easier just to be left in peace."

Instead of putting Bergmann on a mechanical ventilator, the clinic gave him morphine and kept him on the oxygen mask. He's since tested free of the infection, but not fully recovered. The head of the clinic, Thomas Voshaar, a German pulmonologist, has argued strongly against early intubation of COVID-19 patients. Doctors including Voshaar worry about the risk that ventilators will damage patients' lungs.

The 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 go into overdrive 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 the virus causes, have been compared to the Spanish flu pandemic of 1918-19, which killed 50 million people worldwide. Now as then, the disease is novel, severe and spreading rapidly, pushing the limits of the public health and medical knowledge required to tackle it.

When coronavirus cases started surging in Louisiana, doctors at the state's largest hospital system, Ochsner Health, saw an influx of people with signs of acute respiratory distress syndrome, or ARDS. Patients with ARDS have inflammation in the lungs which can cause them to struggle to breathe and take rapid short breaths.

"Initially we were intubating fairly quickly on these patients as they began to have more respiratory distress," said Robert Hart, the hospital system's chief medical officer. "Over time what we learned is trying not to do that."

Instead, Hart's hospital tried other forms of ventilation using masks or thin nasal tubes, as Voshaar did with his German patient. "We seem to be seeing better results," Hart said.

Other doctors painted a similar picture.

In Wuhan, where the novel coronavirus emerged, doctors at Tongji Hospital at the Huazhong University of Science and Technology said they initially turned quickly to intubation. Li Shusheng, head of the hospital's intensive care department, said a number of patients did not improve after ventilator treatment.

"The disease," he explained, "had changed their lungs beyond our imagination." His colleague Xu Shuyun, a doctor of respiratory medicine, said the hospital adapted by cutting back on intubation.

Luciano Gattinoni, a guest professor at the Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Göttingen in Germany, and a renowned expert in ventilators, was one of the first to raise questions about how they should be used to treat COVID-19.

"I realised as soon as I saw the first CT scan ... that this had nothing to do with what we had seen and done for the past 40 years," he told Reuters.

In a paper 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. Patients' lungs were working better than they would expect for ARDS, they wrote - they were more elastic. So, he said, mechanical ventilation should be given "with a lower pressure than the one we are used to."

Ventilating some COVID-19 sufferers as if they were standard patients with ARDS is not appropriate, he told Reuters. "It's like using a Ferrari to go to the shop next door, you press on the accelerator and you smash the window."

The Italians were swiftly followed by Cameron Kyle-Sidell, a New York physician who put out a talk on YouTube saying that by preparing to put patients on ventilators, hospitals in America were treating "the wrong disease." Ventilation, he feared, would lead to "a tremendous amount of harm to a great number of people in a very short time." This remains his view, he told Reuters this week.

When Spain's outbreak erupted in mid-March, many patients went straight onto ventilators because lung X-rays and other test results "scared us," said Delia Torres, a physician at the Hospital General Universitario de Alicante. They now focus more on breathing and a patient's overall condition than just X-rays and tests. And they intubate less. "If the patient can get better without it, then there's no need," she said.

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

Of the 36 acute COVID-19 patients on his ward in mid-April, Voshaar said, one had been intubated - a man with a serious neuro-muscular disorder - and he was the only patient to die. Another 31 had recovered.

Someone I know just died a few days ago. He was being sedated and they took him off the ventilator to see if he could breathe on his own. He died within hours.

41 years old.

[quote] Li Shusheng, head of the hospital's intensive care department, said a number of patients did not improve after ventilator treatment.

[quote] "The disease," he explained, "had changed their lungs beyond our imagination."

I find this part to be the most fascinating.

How in the fuck can this virus "change" someone's lungs???

In the other thread, it's noted that the virus also thickens your blood.

That's incredible. In a bad way, of course.

People are saying the disease resembles altitude sickness. We will learn a lot through this disease.

Cute Dr. Cameron was right.