Mechanical ventilators may cause more trauma than good in a significant number of COVID-1 9 cases, which is a conundrum for physicians used to treating severe hypoxia — low-pitched blood oxygen — with such machines. In some contingencies, COVID-1 9 patients have oxygen elevations that are so low-grade they’re considered “incompatible with life, ” more the patients have no shortness of breath or labored breathing. 1

The phenomenon has been dubbed “happy hypoxia, ” a period medically known as silent hypoxemia, in which COVID-1 9 patients may have blood-oxygen saturation levels as low as 50% — regular blood-oxygen saturation is 95% or higher.

“There is a mismatch[ between] what we see on the monitor and what the patient looks like in front of us, ” Dr. Reuben Strayer, an emergency physician at Maimonides Medical Center in New York City, told Science. 2

Typically, if a person has low-spirited oxygen saturation, they’ll be treated with breathing support in the form of incessant positive airway pressing, or CPAP, disguises, which are often used to treat severe sleep apnea. CPAP designs regulate the pressure and level of oxygen that reaches the lungs, 3 consuming mild air pressure to keep breathing airways open.

Bilevel positive airway pressing ventilators( BiPAP ), another noninvasive device to supply pressurized breeze into the airways, may also be used. If oxygen saturation doesn’t increase, or in cases of acute respiratory distress syndrome( ARDS ), a lung condition that’s common in severe COVID-1 9 cases, and which causes low-spirited blood oxygen and fluid buildup in the lungs, mechanical breathing is often recommended.

However, investigate is divulging that COVID-1 9 patients placed on ventilators often don’t survive, contributing professionals to suggest the machines are being overused and cases may do better with less invasive treatments.

Over 50% of Mechanically Ventilated COVID-1 9 Patients Die

“Mechanical ventilation is the main encouraging management for critically ill patients” infected with novel coronavirus 2019( COVID-1 9 ), are consistent with a February 2020 study published in The Lancet Respiratory Medicine. 4 Yet, it’s immediately become apparent that invasively ventilated COVID-1 9 patients often don’t make it, and have a very high case fatality rate of more than 50%. 5

The rehearse is widespread , nonetheless. In a speciman line of 1,300 critically ill patients admitted to intensive care unit( ICUs) in Lombardy, Italy, 88% received invasive ventilation, but the mortality rate was still 26%. 6

Further, in a JAMA study that included 5,700 cases hospitalized with COVID-1 9 in the New York City area between March 1, 2020, and April 4, 2020, mortality rates for those who received mechanical breathing arrayed from 76.4% to 97.2%, depending on age. 7

Similarly, in a study of 24 COVID-1 9 patients admitted to Seattle-area ICUs, 75% received mechanical ventilation and, overall, half of individual patients died between one and 18 daylights after being admitted. 8P TAGEND

There are many reasons why those on ventilators have a high risk of fatality, including being more severely ill to begin with. However, given the poor outcomes, some physicians are now trying to keep cases off of ventilators as much as possible by consuming less-invasive alternative measures.

“Contrary to the impression that if extremely ill patients with Covid-1 9 are treated with ventilators they will live and if they are not, they will die, the reality is far different, ” Dr. Muriel Gillick of Harvard Medical School told STAT news. 9

There are probabilities inherent to mechanical ventilation itself, including disability to the lung’s air sacs from high levels of oxygen and lung damage caused by the high pressure used by the machines. Long-term sedation from the intubation is another risk, one that’s difficult for some patients, extremely the elderly, to bounce back from.

In cases of ARDS, the lung’s air sacs may be filled with a yellowed fluid that has a “gummy” texture, becoming oxygen give from the lungs to the blood difficult, even with mechanical ventilation.

According to Gillick, “We need to ask, are we use ventilators in a way that establishes appreciation for other infections but not for this one? Instead of asking how do we ration a scarce resource[ ventilators ], we should be asking how do we best give this malady? ”1 0

Less Invasive Nasal Cannula May Work Better

In some subjects, there’s evidence that a far less invasive nasal cannula may be sufficient to help COVID-1 9 cases. In a study of COVID-1 9 patients in China, most of the critically ill cases received high-flow nasal cannula( HFNC) oxygen care as a first-line treatment, and it was sufficient in the majority of cases. 11

Although 41% did eventually involve more intensive breathing assist , noninvasive ventilation, such as BiPAP, was offered next and again succeeded in keeping most of the patients off mechanical ventilators. Eventually, only four of the 27 cases with severe acute respiratory downfall were intubated.

According to some physicians, COVID-1 9 patients expose symptoms more in line with altitude sickness than pneumonia, such as having low levels of carbon dioxide in the blood, despite low oxygen, announcing mechanical breathing into further question.

Speaking with STAT, Dr. Scott Weingart, a critical care physician in New York and multitude of the “EMCrit” podcast, said, “we’ve had a number of people who improved and get off CPAP or high-pitched flow[ nasal cannulas] who would have been tubed 100 out of 100 ages in the past.”

But, he said, automatically putting patients on mechanical ventilators “is really bad, ” adding “ … I see these patients do much, much worse on the ventilator … I would do everything in my dominance to avoid intubating patients.”1 2

Are There Two Forms of COVID-1 9 Renditions?

An April 2020 essay by Drs. Luciano Gattinoni and John Marini describes two different types of COVID-1 9 lectures, which they refer to as Type L and Type H. 13 In Type L, cases have “low lung elastance( high-pitched compliance ), lower lung weight as estimated by CT scan, and low-grade response to PEEP[ positive end-expiratory pressure ]. ” Many cases become stabilized at the current stage and do not deteriorate further.

However, in some cases manifestations closer to ARDS develop. This type of presentation is defined as Type H, and includes “high elastance( low-grade compliance ), higher lung force, and high PEEP response.”

Importantly, while one type benefits from mechanical ventilation, the other does not. Dr. Roger Seheult discusses this document, as well as the analogy of COVID-1 9 to high altitude pulmonary edema, or HAPE, in the MedCram video above, once again suggesting it may turn out that mechanical ventilators are inappropriate for a majority of patients.

‘Prevent the Vent’ Approach Yields Remarkable Results

Meanwhile, physicians at University of Chicago( UChicago) Medicine reported “truly remarkable” develops utilizing high-flow nasal cannulas in lieu of ventilators. 14 In fact, 24 COVID-1 9 patients who were in respiratory distress were given HFNCs instead of ventilators. All “fared extremely well, ” and only one required intubation 10 days later.

Dr. Michael O’Connor, administrator of critical care medicine, called the team’s success “truly remarkable. At one point, lands department had 137 COVID-1 9 cases, but only 27 are currently in ventilators. “The medical personnel has avoided mechanical ventilation on 40% of patients, and extubated 50% of those who needed ventilators, O’Connor said in a news release. “It’s a stupendous quantity, because in Italy, the number of extubations was much lower.”1 5

The team has also been mixing the use of HFNCs with prone positioning, another alternative treatment that’s shown promise for treating COVID-1 9. Lying in the prone( face down) berth, in which your dresser is down and your back is up, has been shown to improve outcomes in parties with severe ARDS, 16 and oxygenation tends to be significantly better among patients in the prone stance compared to the supine( face up) caste. 17

A study of critically ill COVID-1 9 cases in China’s Jiangsu Province recommended the use of awake prone positioning, which, the researchers memo, “showed significant effects in improving oxygenation and pulmonary heterogeneity.”1 8P TAGEND

It’s too been suggested that the physiological alters that occur with prone slotting may be even more favorable in spontaneously breathing patients than in those who are intubated.

A 2003 study encountered, in fact, that the prone arrange led to a rapid increase in partial pressure of oxygen, or PaO2, which is a measure of how well oxygen moves from the lungs to the blood, among cases with respiratory omission. 19 All of individual patients in the study were able to avoid mechanical ventilation.

Dr. Thomas Spiegel, medical director of UChicago Medicine’s emergency department, said, “The proning and the high-flow nasal cannulas mixed have brought patient oxygen levels from all over 40% to 80% and 90%, so it’s been mesmerizing and wonderful to see.”2 0

The UChicago Medicine team is using an approach they’ve dubbed “prevent the ventilate, ” which involves exploiting mechanical ventilation only as a last resort. “Avoiding intubation is key, ” Spiegel said. “Most of our colleagues around the city are not doing this, but I sure wish other ERs would take a look at this procedure closely.”2 1

Hyperbaric Oxygen Therapy May Prevent Mechanical Ventilation

Hyperbaric oxygen therapy( HBOT ) is another treatment adjunct being explored against severe COVID-1 9. It makes by render 100% oxygen in a pressurized chamber, which allows your body to assimilate oxygen instantly into your materials. Since there’s no airflow being coerced instantly into the lungs, it doesn’t cause the lung damage that mechanical breathing can.

Dr. Kelly Thibodeaux with Opelousas General Hospital in Louisiana, which has a hyperbaric hub, announced HBOT “a less invasive way to deliver oxygen that doesn’t compel lodging a tube down the trachea.”2 2

Thibodeaux and collaborators asked, “Once intubated, fatality advances exponentially.”2 3 They’ve been deploying off-label compassionate use of HBOT as an alternative for patients that would otherwise have necessitated ventilation, with promising causes. In a client streak of five patients, “dramatic improvement” was encountered with HBOT. According to the article 😛 TAGEND

“All the patients recovered without the need for mechanical breathing. Following HBOT, oxygen saturation increased, tachypnea[ rapid breathing] resolved and inflammatory markers came.

At the time of writing, three of the five cases ought to have exhausted from the hospital and two remain in stable condition … Most importantly, HBOT potentially avoided the need for mechanical ventilation.”2 4

Ongoing research will be needed to determine the best course of action for individual COVID-1 9 suits, but it appears that starting with the least invasive options is beneficial in the majority of cases, while an increase of specialists are advising against mechanical breathing whenever possible.

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