
UChicago doctors see ‘remarkable’ success using ventilator alternatives - 9nGQluzmnq3M
https://www.uchicagomedicine.org/forefront/coronavirus-disease-covid-19/uchicago-medicine-doctors-see-truly-remarkable-success-using-ventilator-alternatives-to-treat-covid19
======
DanielBMarkham
One of the most interesting parts of this press release, following it on other
boards, is the immediate "We already do that. Nothing new here."

That kind of reply would immediately lead me to think it was just a useless
release, but then I see people posting comments along the lines of "No, we
don't do that. In fact, we have a policy against doing that because of the
danger of aerosolization"

For my hacker/systems wonks, this a great example of group learning happening
world wide. I imagine there are many ICUs that do this, and many that forbid
it. In such an environment, releases like this aren't submarines or spam;
they're recurring prompts to administrators elsewhere that they might be
missing something important.

I hate to sound cold, but damn this is an interesting example of how
organizations learn. One commenter asked "I wonder how many of those hospitals
who forbid intubation are doing it to patients with good insurance"

For the record, as far as I know this is a horrible thing to suggest. But the
overall point, that large organizations have incentives that are many times
removed from the actual work being done, is a good one.

This kind of conversation facilitation across borders is what the internet was
supposed to be doing. I think this is the first time I've seen it working the
way we had hoped. What's especially interesting to me is that many of the
signals we look for in social forums, like "this is just a spam press
release", "nothing new to see", or "there's some ulterior motivation here"
voting up or down, etc., are actually counter-indicators and inhibitors of
overall progress.

~~~
joshgel
Even better would be randomized experimental data that this was better than an
alternative... 'It works' can mean lots of different things...

~~~
DanielBMarkham
It's an excellent point. Learning is not the same as science, and we need
randomized trials to actually be sure of anything.

Unfortunately, in the middle of a pandemic, that's not going to happen with
enough speed to prevent a lot of people dying.

The perfect can be the enemy of the good enough. We don't have to guess or
learn about the mass of an electron; that's been well-established through
great lab work. But not all decisions are like that. Many times the hardest
decisions are those you make with incomplete and contradictory information ...
and not making a decision is, in effect, making a decision. This is one of the
things that's so interesting here. If it were simple yes/no, what's science
and what's speculation, there wouldn't be much interesting learning or
decision-making happening.

~~~
gus_massa
> _Unfortunately, in the middle of a pandemic, that 's not going to happen
> with enough speed to prevent a lot of people dying._

How are you sure that this method is not worse than the ventilator method and
will kill even more people during the pandemic?

How many death did they get with this method? How many death would they had
got with the ventilator method?

~~~
ineedasername
This is "decision making under conditions of uncertainty." [0]

It's not that your questions are bad, it's that in practice medical
professionals have to operate without answers to them. Doing so involves
communication with peers about their own observations of what may work
better/worse, such as in this article. Double-blind randomized trials are not
the only source of actionable information: Case studies also form a
significant pillar of knowledge, especially pending results from more
systematic studies.

[0]
[https://link.springer.com/chapter/10.1007/978-1-4757-2068-6_...](https://link.springer.com/chapter/10.1007/978-1-4757-2068-6_3)

~~~
gus_massa
One of the lesson of the physics lab is that unless you have calibrated very
carefully all the equipment and experimental setup, you can't mix the
measurements of one day with the measurements of another day.

For example one day we have very weird results trying to compare two
measurements of the same day about something related with the speed of sound.
After a lot of time trying to understand the problem we notice that one
measurement was from 9am when the temperature was like 10°C(50°F) and the
other was from 1pm when the temperature was like 25°C(77°F). The following
days we tried to take all the measurements as close as possible.

The same applies to benchmarks in computers. A few days ago I got an
improvement for a program that reduced the runtime from 85s to 59s. Until I
noticed that one was with the notebook plugged in an the other with the
batteries. I tried again both with the notebook plugged in and the improvement
was only from 65s to 59s. Still a nice improvement but not fantastic.

Quoting again part of the original comment I'm repliying

> _Learning is not the same as science, and we need randomized trials to
> actually be sure of anything. Unfortunately, in the middle of a pandemic,
> that 's not going to happen with enough speed to prevent a lot of people
> dying. The perfect can be the enemy of the good enough._

Without a randomized control group it is very difficult to be sure if a small
improvement of the survival rate is real. So you can't learn if the new method
or the old method is better.

~~~
ineedasername
Yes, absolutely correct. We just don't always have time to wait: Doctors must
take action now. Knowing a majority of people that end up ventilators will die
means the balance of risk weighs at least a little more heavily towards novel
treatments than in less critical cases.

Case studies of those attempts are exactly the kind of data points that can
provide a great deal of information and hypothesis generation for more
systematic studies.

------
theobeers
One of the most active figures in this debate has been a New York doctor named
Cameron Kyle-Sidell. He frequently posts interesting sources on Twitter:

[https://twitter.com/cameronks](https://twitter.com/cameronks)

~~~
not_a_moth
Yes, rather absurdly, I learned about him like a month ago on ZeroHedge when
they started following him; he was brushed off for weeks, his message being,
"Look at patient behavior, this is not actually ARDS, our ventilator strategy
is probably wrong."

Crazy to think that so many doctors around the world, experts, and policy
makers didn't really question the fundamental nature of the disease, and
perhaps telling that it took an ER doctor in NYC posting on youtube for a
month to bring it proper attention.

~~~
fragmede
Dr Ignaz Semmelweis had this ludicrous theory, back in 1846, of “cadaverous
particles” causing high deaths in women who had just given birth. Despite
evidence that it _worked_ , he spent the rest of his life trying to get people
to listen. The doctors of the day were so threatened by the possibility that
they were the ones killing their patients that they rejected the practice.

We haven’t culturally evolved much further it seems. ”Wacky” ideas are
routinely rejected by mainstream science; eg ulcers being caused by germs
rather than stress, and can be cured as such. What societal changes need to
come about that this doctor _doesn 't_ have to make YouTube videos for a
month?

[https://www.npr.org/sections/health-
shots/2015/01/12/3756639...](https://www.npr.org/sections/health-
shots/2015/01/12/375663920/the-doctor-who-championed-hand-washing-and-saved-
women-s-lives)

~~~
beagle3
There’s a saying, “progress is made one funeral at a time”, especially in
science but also in other areas; smbc had a good comic about it too a whole
back (am in mobile and can’t find it now).

Linus Pauling famously and successfully used all his night to reject the idea
of quasicrystals. The Updated concept of crystals was adopted shortly after
his death; i can’t say I was able to track the history - there is an enormous
amount of whitewashing - but it seems initially everyone rejected
quasicrystals, but eventually people started to look at ahechtman’s evidence -
and accept it, except not publicly because the luminaries of the field led by
Pauling rejected it. And then Pauling’s funeral allowed the science to finally
advance.

~~~
ineedasername
When I studied computational linguistics, my professors told me that a great
deal of promising research on linguistics in the US had been similarly stifled
by Noam Chomsky and his adherents, the result being a relative stagnation in
"continental" linguistics compared to that seen in Europe.

------
reticular
I don't doubt that this works well but there is a good reason that other
hospitals are not using this approach. As the article mentions:

"This approach is not without risk, however. HFNCs blow air out, and convert
the COVID-19 virus into a fine spray in the air. To protect themselves from
the virus, staff must have proper personal protective equipment (PPE),
negative pressure patient rooms, and anterooms, which are rooms in front of
the patient rooms where staff can change in and out of their safety gear to
avoid contaminating others."

"UChicago Medicine’s Emergency Department recently doubled its number of
anterooms, thereby doubling its capacity to give ?high-flow nasal cannula to
patients. The main hospital also added negative pressure rooms on two floors,
making it safer and easier to take care of COVID-19 patients."

Not all hospitals have the ability to double the number of negative pressure
rooms or even provide needed PPE to all caregivers.

A ventilator on the other hand allows for a HEPA filter in-line that prevents
the spread of the disease within the hospital.

------
firasd
Related:

"The respiratory distress appears to include an important vascular insult that
potentially mandates a different treatment approach than customarily applied
for ARDS."
[https://twitter.com/jama_current/status/1253722428053823492](https://twitter.com/jama_current/status/1253722428053823492)

------
loeg
The article mentions 40% O2 sat to 80 or 90%; aren't the latter still really
low? I'm certainly no doctor, but wikipedia[1] claims "Prolonged hypoxia
induces neuronal cell death via apoptosis, resulting in a hypoxic brain
injury" and suggests that 80-85% is considered _severe_ and 86-90% moderate.

Granted, both are a hell of a lot better than 40%!

It adds, "Mild and moderate cerebral hypoxia generally has no impact beyond
the episode of hypoxia; on the other hand, _the outcome of severe cerebral
hypoxia will depend on the success of damage control, amount of brain tissue
deprived of oxygen, and the speed with which oxygen was restored._ "

So I guess my questions are:

* How does this stack up against an intubated ventilator, assuming one is available?

* My understanding is the patients needing respiratory support are often on ventilation for 1-2 weeks; how much damage would one expect from having severe hypoxia for that duration?

[1]:
[https://en.wikipedia.org/wiki/Cerebral_hypoxia](https://en.wikipedia.org/wiki/Cerebral_hypoxia)

~~~
tomohawk
Being on a ventilator is traumatic. So much so that they generally put you
under. Can you imagine waking up with a tube through your mouth and down your
throat forcing you to breathe? It happens and people panic and have to be
restrained. People get PTSD.

[https://www.hopkinsmedicine.org/news/media/releases/ptsd_com...](https://www.hopkinsmedicine.org/news/media/releases/ptsd_common_in_icu_survivors)

If you can get the O2 up to a livable level without a ventilator so that the
patient is supported enough to get well, that that is a good outcome.

~~~
polishTar
I suppose I’d rather risk the 1/4 chance of getting ptsd vs the guarantee of
moderate/severe brain injury if it was a choice

------
ineedasername
I wonder how they decide which patients would get the cannula instead of a
ventilator?

Otherwise, intubation w/ a ventilator generally requires some form of
sedation-- I wonder if that sedation has an impact on the body's ability to
fight back.

~~~
Izkata
By seeing what type of damage is being done to the lungs through CT scan or
X-Ray, according to this article on a similar topic from two weeks ago:
[https://www.webmd.com/lung/news/20200407/doctors-puzzle-
over...](https://www.webmd.com/lung/news/20200407/doctors-puzzle-over-
covid19-lung-problems)

More and more it's starting to look to me like we have two different novel
viruses going around.

~~~
ineedasername
Two viruses may be possible, but other diseases certainly can have similar
ranges of problems: The Flu might case different type of lung problems--
pneumonia, bronchitis, exacerbate asthma. Or it might hit your stomach, or
result in ear infections by allowing other opportunistic infections to fester,
or seizures. It may cause pericarditis or other heart problems, or strokes. So
it is not unreasonable to assume that Covid-19 might cause the same symptoms
through 2 different mechanisms.

------
DenisM
So about CPAP / BiPAP? If all one needs it to push air down the lungs a CPAP
can produce a lot of pressure. Anyone knows enough about it?

~~~
piannucci
First-- and I'm sure you weren't suggesting this, but I feel I need to
mention-- it's extremely dangerous to pressurize a person's lungs above the
surrounding environment[1]. Not to mention that pressurizing the inside of the
throat could pressurize the middle ear and blow out your eardrums.

Second, I'm not a physician, I'm a physicist. What follows is for curiosity's
sake.

I suspect that the goal is to maximally enrich the patient's airstream in
oxygen, whenever it is that they happen to breathe in. In a patient with
fluid-filled alveoli, the surface area available for diffusion of oxygen into
the bloodstream is greatly diminished. Additionally, the distance that oxygen
needs to diffuse before it reaches hemoglobin is increased: rather than just
the lining of alveoli and capillaries, it has to first dissolve into the fluid
gunk filling the space, then diffuse through the fluid, then pass through the
lining of the alveolus and capillary. To top it off, water doesn't have great
solubility for oxygen, and atmospheric air is mostly nitrogen anyways.

Each of these passive transport phenomena occurs at a rate that depends on the
gradient (roughly...) of available O2. This concentration is greatest in the
air, and lowest in the bloodstream adjacent to the alveoli, where hemoglobin
binds up oxygen. One way to increase the rate of dissolution and diffusion is
to increase the concentration gradient. That means enriching the airstream in
O2.

[1]
[https://en.wikipedia.org/wiki/Barotrauma#Pulmonary_barotraum...](https://en.wikipedia.org/wiki/Barotrauma#Pulmonary_barotrauma)

------
40four
Sounds like a promising strategy to manage patients, assuming the hospital has
the necessary negative pressure rooms, etc. Especially since ventilators don’t
even seem to be very effective. We’ve been seeing stories last few days that
the large majority (88%) of folks put on ventilators in NYC, end up dying.

~~~
maxerickson
Be careful with that number. It's 88% of the cases that had resolved after
~4.5-5 days, which was only 25% of the cases included in the study.

If there is some bias in the study population, the overall rate can change
quite a lot (for example, a possibility is that the weakest patients succumb
in that period, with stronger patients coming off the ventilators after a
longer period...).

------
mrfusion
I heard on Reddit that Medicare pays 3x more for intubation. Can anyone find a
source?

~~~
ceejayoz
It’s a far more complicated procedure, of course it pays more. A five year old
can install a nasal cannula.

~~~
1996
and it could be done at home, using an O2 cannister, that should be cheap even
for those paying out of pocket without medical insurance.

no wonder why the medical establishment would be opposed to a simple work
around that would remove the need for hospitalization or ICU

~~~
ceejayoz
These patients still need the care and monitoring you'd get in an ICU, and
there's zero indication the "medical establishment" is opposed to it - high-
flow oxygen is used regularly in hospitals in a variety of scenarios.

~~~
1996
define care and monitoring.

\- care, like taking the drugs they have been prescribed and regularly take at
home? Any family member can do that.

\- monitoring that the saturation does not fall too low... so that patients
can be intubated with a 90% risk of death? I'd rather opt out of that one.

To be clear, I'm talking about de-medicalizing covid: no ICU, no hospital.
Just O2 nasal canula at home.

It seems unimaginable, but a large number of in the world deal with no
hospital healthcare.

------
bobowzki
I'm an intensivist based in Sweden. From my perspective there is absolutely
nothing new in this article. We have been using HFC for years if not decades.

~~~
joshgel
Our* guidance has been HFNC only in negative pressure rooms because of the
aersolization risk.

We've converted a huge number of beds to negative pressure in order to
maximize use of HFNC. Anecdotally, I feel like it works, but would be great to
see a trial.

*major nyc health system

~~~
amluto
Is management of an HFNC patient simple enough that it could be done outside a
hospital? I’m imagining a converted stadium or similar area in which patients
use HFNC and everyone who isn’t a patient puts on serious PPE before entering
and takes it off only when they’re quite far away.

~~~
ceejayoz
Or staff it with recovered healthcare workers.

~~~
eternalny1
'No evidence' that recovering from Covid-19 gives people immunity, WHO says

[https://www.france24.com/en/20200425-no-evidence-that-
recove...](https://www.france24.com/en/20200425-no-evidence-that-recovering-
from-covid-19-gives-people-immunity-who-says)

~~~
ceejayoz
There was no evidence of human-to-human transmission early on, too.

“No evidence” is not “evidence against immunity”. It means we don’t know yet.

~~~
redis_mlc
> There was no evidence of human-to-human transmission early on, too.

I have two comments about that:

1) Like somebody else said, if you don't look, you won't find evidence, even
if it's there.

2) Wuhan officials were incentivized to say it wasn't contagious, ergo, no
lockdown needed.

However, it clearly was being transmitted to non-wet market patients in late
Nov./early Dec., and Disneyworld Shanghai was closed Jan. 24, so you have to
be wilfully blind to say it's not contagious.

~~~
ceejayoz
Yes, the WHO is not a spy organization. They rely in large part on cooperation
from member nations.

Sometimes that’s an issue, but it doesn’t mean they were lying when they said
they didn’t have the evidence yet.

------
forgetcolor
I wonder how this technique differs from CPAP. CPAP doesn't use pure O2, but
perhaps the pressures can be similar?

------
grizzles
Sound a lot like the devices people criticized Tesla for delivering.

~~~
redis_mlc
Yes, it turns out the Tesla devices were actually more practical than first
thought.

The caveats are:

1) Would US hospitals accept or recommend them?

2) If US hospitals accepted them, was there an acceptable solution to the
aerosolization problem? Wuhan hospitals were segregated into corona and non-
corona locations, so aerosolization wasn't a problem for other patients, but I
don't know if US hospital systems got that organized.

I highly recommend reading the Wuhan accounts and papers. They really moved
fast on improving their response, which the US totally ignored. Only now, Apr.
26, are we catching up to what they found in Jan./Feb. I doubt if it affected
the body count much, but time was wasted.

Instead HN wasted months on endless navel-gazing and "IFR vs. CFR" chatter.
Really a new low for HN.

------
agumonkey
Ha yes, the good old Louis Pouzin runcom #frenchtech

------
IlyaMoroshkin
With treatment so simple, we have effectively removed the healthcare system as
a bottleneck on the rest of society.

I think we can safely reopen fully now and treat any serious cases using our
existing healthcare systems in combination with this kind of new knowledge.

The longer we 'suppress the curve', when we are already far below hospital
system capacity, the more economic and social damage we cause unnecessarily.

~~~
mrfusion
Not sure why you’re being downvoted. Here’s an article that puts sources and
numbers on your thought:

[https://thehill.com/opinion/healthcare/494034-the-data-
are-i...](https://thehill.com/opinion/healthcare/494034-the-data-are-in-stop-
the-panic-and-end-the-total-isolation)

I’d be curious to hear counterpoints. I could be wrong. It does anyone think
this will go away with a long enough lockdown? Or is there any solution other
than herd immunity?

~~~
empath75
We don’t know if people have long term immunity.

~~~
mrfusion
If we didn’t have immunity it would be unlike any other respiratory virus
known to man. All other corona viruses have non-insignificant periods of
immunity.

Further Fauci himself says it’s very likely there is immunity:
[https://www.google.com/amp/s/www.newsweek.com/fauci-
really-c...](https://www.google.com/amp/s/www.newsweek.com/fauci-really-
confident-people-recover-coronavirus-become-immune-infection-1494612%3famp=1)

There was also a study performed on monkeys showing immunity:
[https://www.biorxiv.org/content/10.1101/2020.03.13.990226v1](https://www.biorxiv.org/content/10.1101/2020.03.13.990226v1)

