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Medicine United States Technology

Researchers To Doctors: Stop Putting COVID-19 Patients On Invasive Ventilators (statnews.com) 126

Posted by BeauHD from the treatment-protocols dept.
Rei writes: A paper recently published by The American Society of Tropical Medicine and Hygiene adds further support to recent CDC guidelines for minimizing the use of invasive ventilators. As physicians had been voicing concern that doctors were being too eager to put patients on invasive ventilation and may be doing more harm than good, the investigators looked into outcomes of intubated patients vs. non-intubated patients experiencing hypoxia. Unlike with other forms of pneumonia, they found that COVID-19 patients were unusually damaged by invasive ventilation but also able to tolerate higher levels of anoxia -- to the point that one doctor recalls having to tell patients to get off their cellphones so that they could be intubated. The recommendation is that guidelines be adjusted to discourage invasive ventilation unless a patient is physically struggling to breathe, rather than relying strictly on oxygen levels; otherwise, the use of non-invasive ventilation, such as CPAP and BiPAP, should be encouraged. When invasive ventilation is used, oxygen levels should be minimized in order to reduce the risk of damaging healthy tissue.
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Researchers To Doctors: Stop Putting COVID-19 Patients On Invasive Ventilators More

Researchers To Doctors: Stop Putting COVID-19 Patients On Invasive Ventilators

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  • HMMM (Score:1, Insightful)

    by Kaenneth ( 82978 )

    after everyone bitching about Tesla only shipping cpap/bipap machines...

  • Not looking like giving oxygen even helps (Score:4, Interesting)

    by jwymanm ( 627857 ) on Wednesday April 22, 2020 @08:28PM (#59978142) Homepage
    Blood clotting seems to be the largest issue. People can be breathing normal and fine and be dead a few minutes later because of all the clots in their lungs/limbs. They are discussing prescribing blood thinners (something extremely dangerous but seems like necessary) to people even with small amounts of symptoms.
    • That and forcing the infection even deeper into the lungs.

      • Re:Not looking like giving oxygen even helps (Score:4, Informative)

        by rtb61 ( 674572 ) on Wednesday April 22, 2020 @11:58PM (#59978618) Homepage

        Well perhaps keeping their mouths lower than their lung to promote drainage and creating an atmosphere that best serves clearing their lungs and minimises the harms of infection, substance infused steams focusing on minimising the symptoms and being somewhat weakly antibiotic to avoid negative reactions. A slightly pressurised bag over the head, drawing in air, medically conditioning it and then exhausting and filtering it, larger bag better than smaller, with regard to air motion and steam generation, more stable an efficient and room for drainage. Let them look at a video monitor for mood stabilisation to promote positive release of sustaining and repairing bodily functions.

        • > Well perhaps keeping their mouths lower than their lung to promote drainage

          It's a wet sponge scenario - that is not going to work unfortunately.

    • Re: (Score:2)

      by Kokuyo ( 549451 )

      I'm on blood thinners. Have been for years, will be for the rest of my life... where do you get the idea that this is extremely dangerous?

      • Oh, I don't know, maybe in the fact that blood thinners are literally used to make it harder for blood to clot? Normally a good thing when prescribed to prevent clotting in veins, but a damn bad thing when you want blood flow to stop from injuries. That's why surgeries and major dental work all ask if you are on thinners, and will work with your doctor to either lower the dose or take you off temporarily so you don't bleed out and die if they can't induce clotting.

        So instead of lungs filling up with fluids

    • Blood clotting seems to be the largest issue.

      No it doesn't. It seems to be *a* issue but it's reported in a minuscule number of patients and is a comparatively tiny source of the mortality related to the virus.

      The Washington Post (I assume you base all your scientific knowledge on what you read in the media) did a story on it covering a small selection without any data or figures behind it, so there's no basis for considering it the largest issue, or even an issue worth targeting compared to many of the others.

      Blood clots in general don't kill people.

    • Re: (Score:2, Interesting)

      by Anonymous Coward

      Since very early on it's been clear from the stats that COVID-19 disproportionately affects people with cardiovascular issues. This is why it's far less deadly for children than the flu is, about as deadly for people in the 20 - 40 range, but increasingly significantly more deadly for older people.

      Nowadays a lot of first aid taught says not to even bother trying CPR on young children, a) because it's harder to do without doing more damage, and b) because the odds of kids having a cardiovascular issue is qui

  • Actually a very good thing (Score:4, Insightful)

    by emacs_abuser ( 140283 ) on Wednesday April 22, 2020 @08:29PM (#59978148)

    For those of us still alive, it looks like we learned something about treatment. This is very good news. I hope we find a way to eliminate the virus but until then I'll settle for treatment advances.
     

    • Re:Actually a very good thing (Score:5, Insightful)

      by phantomfive ( 622387 ) on Wednesday April 22, 2020 @08:41PM (#59978186) Journal

      For those of us still alive, it looks like we learned something about treatment.

      And for those who had any doubt, this is yet another reason why "flattening the curve" is a good idea: each month that passes the treatments get better.

      • Re:Actually a very good thing (Score:4, Interesting)

        by remoteshell ( 1299843 ) on Wednesday April 22, 2020 @09:33PM (#59978302)
        Strongly agree. You look like a beacon of reason on /. We've used distancing, quarantine and masks (look up plague masks for great visuals) for centuries. AFAICT, plagues have hit humans about ever 50-150 years since we have been able to write history. That's just long enough to forget previous lessons (2 generations). So, even before there was a Gaussian distribution, vaccines, or ventilators, these measures were both effective and intuitive.

        • AFAICT, plagues have hit humans about ever 50-150 years since we have been able to write history. That's just long enough to forget previous lessons

          Next up: why inflation is a bad thing.

      • Re: (Score:2)

        by gweihir ( 88907 )

        For those of us still alive, it looks like we learned something about treatment.

        And for those who had any doubt, this is yet another reason why "flattening the curve" is a good idea: each month that passes the treatments get better.

        Indeed. Very obvious, yet for some reason many people cannot even think _that_ far.

    • For those of us still alive, it looks like we learned something about treatment.

      Some of us learnt something about doctors more than about treatments. Here locally in Europe ventilation has always used only as a last resort after O2 therapy fails to raise blood O2 levels. It's almost like the article is implying that some doctors somewhere get trigger happy with ventilators (no doubt they do, medical science isn't universal and people are of different skills and opinions all the time).

      • It seems to me that doctors were putting peeps on ventilators when they couldn't get the O2 levels to the right number using other standard methods. Protocol is apparently is to then ventilate. TFA is saying that may not be the correct protocol.
        But yeah, I get that "trigger-happy doctors" is a better soundbite.

        As a bonus, I'll include a bit from one of the TFAs...

        What’s driving this reassessment is a baffling observation about Covid-19: Many patients have blood oxygen levels so low they should be dead. But they’re not gasping for air, their hearts aren’t racing, and their brains show no signs of blinking off from lack of oxygen.

        That is making critical care physicians suspect that blood levels of oxygen, which for decades have driven decisions about breathing support for patients with pneumonia and acute respiratory distress, might be misleading them about how to care for those with Covid-19.

    • Comment removed based on user account deletion

  • So, just... (Score:4, Funny)

    by nospam007 ( 722110 ) * on Wednesday April 22, 2020 @08:43PM (#59978190)

    ...because 80% of them die you want us to stop?

    • Re: (Score:3)

      by dgatwood ( 11270 )

      ...because 80% of them die you want us to stop?

      I know you're being facetious, but yeah, because only 20% of the people who they don't intubate die. :-) Okay, I'm exaggerating. I don't remember the actual numbers (I read about this last night and can't find the details right now), but it seems like it was something like half again more deaths for people intubated than not (after adjusting from severity of symptoms).

      The approach that seems to be most effective, from what I've read, is increasing the availability of oxygen without intubation [uchicagomedicine.org]. Specificall

      • Re: (Score:2)

        by ebyrob ( 165903 )

        face down.

        Didn't it used to be a really bad thing to lie down when you had pneumonia?

        Just what do they teach them in these medical schools these days?

  • to tell everybody we have enough ventilators when we don't. Last I heard we had about 1/50th the ventilators we'd need if we "let 'er rip" and reopen early like the right wing want to. This new guideline will reduce the use of ventilators, not eliminate it.

    I seriously doubt patients were being Intubated at a rate 50 times necessary.

    • Re:I'm worried right wing media will run with this (Score:4, Insightful)

      by cascadingstylesheet ( 140919 ) on Wednesday April 22, 2020 @10:34PM (#59978454) Journal

      to tell everybody we have enough ventilators when we don't. Last I heard we had about 1/50th the ventilators we'd need if we "let 'er rip" and reopen early like the right wing want to. This new guideline will reduce the use of ventilators, not eliminate it. I seriously doubt patients were being Intubated at a rate 50 times necessary.

      Or you could react with some humility. Even the "good" people haven't been right about everything through this. One day, masks are useless or even counter productive. The next day, they are ordering us to wear them. One day, every severe case needs a ventilator. The next day, oops, maybe not, maybe that's sometimes counter productive.

      Nobody in this doesn't have some egg on their face. WHO uncritically tweeted Chinese stuff about there being no person to person transmission in January. NYC mayor was telling everybody to not worry about this and go enjoy Chinese new year, and later still telling everyone not to worry and go get out on the town.

      Nobody in this doesn't have some egg on their face. Drop the political stuff about your opponents all being evil idiots. It's stupid at the best of times, and really stupid and offensive right now.

  • This reminds me of a story a guy named Aesop was telling me recently about a miller taking his donkey to the market.

  • ER Doc Here (Score:5, Informative)

    by lowLark ( 71034 ) on Wednesday April 22, 2020 @10:11PM (#59978402)
    Initially, we were being told to intubate early and avoid non-invasive ventilation like CPAP and BIPAP because it increased aerosolization of the virus, and because the volume of air pushed into the lung could be more precisely controlled, attempting to prevent lung damage. By late March [rebelem.com], many of us in the EM community were pushing back on guidance asking us to intubate hypoxic but otherwise healthy looking patients. In the interim, folks figured out [emcrit.org] ways to rig a viral filter on to the outflow of a bibap mask, decreasing the hospitals concerns about letting us use non-invasive.

    • Re: (Score:2)

      by bobby ( 109046 )

      Rats. We were doing so well speculating away here. The sobering of real information is bittersweet.

      Seriously,

      volume of air pushed into the lung could be more precisely controlled

      Makes great sense, but how do you know how much is the right amount? Do the ventilators carefully sense resistance, in case there's increasing inflammation / atelectesis and decreasing available alveoli volume?

      • Re:ER Doc Here (Score:4, Informative)

        by lowLark ( 71034 ) on Thursday April 23, 2020 @11:00AM (#59979964)
        Great question. When you intubate a patient, the tube that goes into the trachea has a balloon that inflates, which prevents air leak and creates a closed system. So the volume that the vent delivers is the volume that the lung gets. An individual taking a deep breath usually has a lung capacity of about 12ml/kg of ideal body weight. Prior to year 2000, that was the typical goal of adults on a vent. The vent does measure both volume and required pressure and getting to that volume took a peak pressure of about 50mmHg. In 2000 the ARDSNet [wikijournalclub.org] trial showed that using much smaller volumes (about 6ml/kg) allowed for lower pressures (around 25 mmHG) and caused much less lung damage. To make up for the lower respiratory volumes, the respiratory rate in increased so that the total volume/min stays the same. Bi-pap, by comparison, is much less precise. There is a lot of leak around the mask, a lot of the volume you are delivering goes into the “dead-space” of the mouth and nasopharynx, and the delivery pressure at the mouth is often very different from what the lung sees. That being said, most of the time we try to use bi-pap first, since intubation required deep sedation, and can lead to a lot of other complications

      • Re: (Score:3)

        by tlhIngan ( 30335 )

        Makes great sense, but how do you know how much is the right amount? Do the ventilators carefully sense resistance, in case there's increasing inflammation / atelectesis and decreasing available alveoli volume?

        Yes, they do. Ventilators have a tough job - they have to sense when the person wants to breathe, then force air in, sense when the person stops breathing in and stops forcing air in. Then they must carefully monitor the exhausted air to detect when the person wants to breathe again.

        You canoot do this

    • Re: (Score:2)

      by bobby ( 109046 )

      Oh, and thank you thank you!!! For being a Dr., for helping people, for posting here. Wish I could do something to help (besides running some folding @ home clients).

    • I have been sleeping with such a mask for a decade or so. Even with an outflow filter it still would leak at the face sealing.

      • Re: (Score:2)

        by lowLark ( 71034 )
        Thats true in cpap (continuous positive airway pressure). In the hospital, we usually use BiPap (biphasic positive airway pressure). The pressure is significantly decreased during expiration, to the leak of exhaled air is pretty low.
    • Comment removed based on user account deletion

      • Re:ER Doc Here (Score:4, Informative)

        by lowLark ( 71034 ) on Thursday April 23, 2020 @11:07AM (#59979988)
        If you have poor profusion in the place where you are measuring, it can definitely cause poor pulse-ox reading. When you are looking at a pulse-ox in a hospital setting, you can see something called the pleth wave [amperordirect.com] that shows the stregnth of the pulse in the measures area. If you have a weak pleth, we know the O2 reading is off and we need to move it to another area.
  • Why not just put them on oxygen instead of an artificial breathing machine if what they need is more oxygen due to tissue damage in their lungs but their breathing muscles and brain stem telling them to breathe work just fine?
    • Comment removed based on user account deletion
    • Not a doctor here but; You have to get the CO2 out as well as the O2 in so you need to have a certain volume of gas going in and out of the patient. If the patient's lung muscles aren't working (e.g. due to a too deep coma, anaesthesia etc.) then that gas won't go in and out so you need a ventilator . That's the bit of the general answer I understand. There's a specific answer above from an ER doctor about why they were [slashdot.org] being pushed to do it for covid-19 cases.

    • Re: (Score:2)

      by BECoole ( 558920 )

      They should be put in a hyperbaric chamber instead. That would avoid damaging the lungs and help with saturation.

  • What were the Italian machines? (Score:3)

    by spitzak ( 4019 ) on Wednesday April 22, 2020 @11:43PM (#59978584) Homepage

    In the videos (long ago it seems now...) from Italy during their crisis it seems they put the patients in cylindrical mylar tents over their faces and nothing in their mouths. What were these and did they work better or worse? They don't look like anything I see here.

  • You don't 'struggle to breathe' when short of oxygen. That's caused by an excess of carbon dioxide. So if the CO2 diffuses enough, the patient can still be dangerously low on O2, without showing distress. Buy a cheap oximeter for your finger and get used to your own readings - lower than 94% and you are in real trouble.

    • Yep. Someone even thought that your mod of "1" was overrated :)
      You win the Cassandra award for today.

  • Because admitting CPAP and BiPAP are also ventilators mean we have to concede Elon Musk was at least partially microscopically correct. Cant allow that.

  • Ventilators have become a politicized talking point and hospitals are able to bill massive charges to insurance companies for using ventilators while continuing to push the narrative that treating covid requires emergency services which are easily overwhelmed by capacity spikes but it's well known medically that the majority of respiratory issues associated with covid can be treated posturally without invasive ventilation, but there's no bonus billable procedure and no need for emergency care to push for mo

  • Hyperbarics is a much better solution to low O2 saturation.
    Now to get more of those machines....

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