
Some doctors moving away from ventilators for virus patients - onetimemanytime
https://apnews.com/8ccd325c2be9bf454c2128dcb7bd616d
======
carbocation
There is a lot of misinformation about COVID-19 lung disease. This article's
title is alarming, but most of its content is mainstream. Lung protective
ventilation - the standard approach for ARDS (which COVID-19 seems to cause) -
avoids high pressure and high volume ventilation.

Broadly, I would suggest that interested people read Corey Hardin's response
to the cacophony of voices saying that COVID-19 respiratory failure is not
ARDS:
[https://mailchi.mp/e10a89ac5988/tz4idnzryr-4388986?e=96507de...](https://mailchi.mp/e10a89ac5988/tz4idnzryr-4388986?e=96507de8e5)

~~~
ramraj07
This article says though that in New York 80% of people put on a ventilator
die; is that fact refuted by anyone? For a machine that's in short supply and
quite invasive, a 20% survival probability seems extremely low.

~~~
pbhjpbhj
The figure for the England that I've seen is 50% (vs 20% death rate for viral
pneumonia in 2017-2019, see [0]). I think that's for intubated ventilation as
opposed to "just" non-invasive ventilation like BiPAP (which IIRC is contra-
indicated; maybe because it impairs expectoration???).

But as others have said, if you only use the ventilator for the very sickest
people, then the more pressed you are the fewer survivors you'll get because
people who have a chance without it will be kept off the ventilator if at all
possible. My very limited understanding is that ventilation has major issues
around bacterial infection.

[0] [https://www.icnarc.org/Our-
Audit/Audits/Cmp/Reports](https://www.icnarc.org/Our-Audit/Audits/Cmp/Reports)

other sources I've seen recently:

[1] [https://emcrit.org/ibcc/support/](https://emcrit.org/ibcc/support/) [2]
[https://icmanaesthesiacovid-19.org/covid-19-airway-
managemen...](https://icmanaesthesiacovid-19.org/covid-19-airway-management-
principles) (good detail on managing risk to staff, and on tracheal
intubation)

~~~
HeadsUpHigh
>But as others have said, if you only use the ventilator for the very sickest
people, then the more pressed you are the fewer survivors you'll get because
people who have a chance without it will be kept off the ventilator if at all
possible. My very limited understanding is that ventilation has major issues
around bacterial infection.

This is why everybody is locking down so you don't have to make a choice
between those that will benefit the most from ventilation and those that have
little hope left. For most socialized healthcare systems once a resource is in
sort supply guidelines for selecting those that will benefit the most are
established. So at the end of the day the 80 y.o won't receive the ventilator
but the 50 y.o. will( at least that's how it works here).

------
jds375
The press release states that doctors have seen that patients on ventilators
have higher death rates. But wouldn’t we expect that? If the situation is dire
enough to put someone on a ventilator then they’re probably less likely to
live anyway?

Edit: They do mention that it’s higher than other diseases relatively
speaking, but don’t we expect Covid-19 to be higher than say, the flu, given
it seems to primarily target the upper respiratory area?

~~~
DoreenMichele
This is the pertinent detail as to why some doctors are concerned:

 _Generally speaking, 40% to 50% of patients with severe respiratory distress
die while on ventilators, experts say. But 80% or more of coronavirus patients
placed on the machines in New York City have died, state and city officials
say._

~~~
mantap
Could that not be because of shortages? If there's a shortage of ventilators
then only the very sickest patients will get them. Don't see how it's valid to
compare numbers against disease in "peacetime".

~~~
DoreenMichele
I don't know.

But another concern is that ventilators are known to cause lung damage
(because of the high pressure involved) and are typically only used for a day
or two with most conditions. With this, people are being kept on them for a
week or two in many cases.

So it's not unreasonable to assume that unusually long-term use of a protocol
known to harm the lungs is actively creating problems for patients.

~~~
pbhjpbhj
>ventilators are known to cause lung damage (because of the high pressure
involved) //

I only know a little from my reading in the last month or so, but ventilators
(used with intubated patients) seem very adjustable: you can alter the
pressure, the Oxygen percentage, the tidal flow, breathing rate and such. I
can see that in order to increase blood Oxygen uptake you might use higher
pressures, but surely that's necessary to ensure patients get sufficient
oxygen to avoid brain damage or other deleterious effects?

Won't the patients suffer in other ways if the Oxygen delivery is lower
pressure?

When multiple patients share a single ventilator I see there are issues of
balancing the supply, but I don't think that's what we're considering here.

~~~
DoreenMichele
Someone linked me to this a few days back:

[https://www.youtube.com/watch?v=okg7uq_HrhQ](https://www.youtube.com/watch?v=okg7uq_HrhQ)

It explains how they pressurize the lungs to try to keep the alveoli open and
why that's very problematic, even when it is only short term. It is so
problematic, they sedate people on ventilators so they won't pull the tubing
out.

It sounds just really gruesome and like a brute force method that can't help
but cause serious problems for delicate tissues if you use it for more than a
fairly short period of time, which is the norm but is not how it is being used
for Coronavirus cases.

Oxygen delivery is a complicated thing and I think taking a mechanical
approach when mechanics may not be the actual problem is likely misguided.

------
empath75
What I have read is that unlike typical ARDS cases where the lungs are
failing, full of fluid and the patient can’t breathe, that Covid 19 patients
can often breathe fine, and don’t have a lot of obvious lung damage, but their
oxygen levels are dropping to dangerous levels, perhaps because of something
that covid 19 is doing to blood vessels in the lungs that prevents oxygen
uptake. One doctor likened it to high altitude sickness.

What they are suggesting is to put patients on oxygen or low pressure
ventilation first.

~~~
jl2718
Can you get me a source on that phenomenon please. I'm working on an unrelated
project with the inventor of a drug that can help with this.

~~~
jacobolus
The doctor who has been most in the news about this in the US is Cameron Kyle-
Sidell

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

[https://www.youtube.com/channel/UCNgMagm3-NwKdfGiXp8WILg](https://www.youtube.com/channel/UCNgMagm3-NwKdfGiXp8WILg)

[https://thinkingcriticalcare.com/2020/03/28/covid-
clinical-d...](https://thinkingcriticalcare.com/2020/03/28/covid-clinical-
discussion-w-cameron-kyle-sidell-nyc-ed-icu-doc-in-the-trenches-foamed/)

[https://www.medscape.com/viewarticle/928156](https://www.medscape.com/viewarticle/928156)

* * *

Here’s a preprint from Italian doctors Gattinoni & al. in the journal
_Intensive Care Medicine_ [https://www.esicm.org/wp-
content/uploads/2020/04/684_author-...](https://www.esicm.org/wp-
content/uploads/2020/04/684_author-proof.pdf)

------
nradov
This has been known by the physicians actively treating COVID-19 for several
days, and was incorporated into the treatment protocol published by Eastern
Virginia Medical School.

[https://www.evms.edu/covid-19/medical_information_resources/...](https://www.evms.edu/covid-19/medical_information_resources/#d.en.140202)

------
saurik
[https://www.statnews.com/2020/04/08/doctors-say-
ventilators-...](https://www.statnews.com/2020/04/08/doctors-say-ventilators-
overused-for-covid-19/)

^ This article from a few days ago is a more detailed look at what is possibly
going on here.

From:
[https://news.ycombinator.com/item?id=22814760](https://news.ycombinator.com/item?id=22814760)

------
sudosteph
Do we know if US doctors are making much use of ECMO (machines that put oxygen
in blood directly) for COVID patients? I read that the FDA just approved
emergency usage a few days ago, but keep seeing it mentioned in reports from
China. If ventilators alone aren't effective, maybe ECMO machines are the
piece we really need to be ramping up production on.

~~~
robbiep
This isn’t easy - ECMO is in (very) short supply, Australia during swine flu
had somewhere around 50 nationally (cf 2000 vents) + you need a cardiothoracic
surgeon to put it in + nursing care is even more intense than for ventilator
care. You can’t easily scale this and it isn’t without significant downside as
well

------
Barrin92
I'm not a physician and I know little about this stuff, but I wondered if
itisn't possible to build a machine that oxygenates people's blood outside of
the lungs, like a dialysis of sorts?

It sounds like forcing air down people's already damaged lungs is what's so
dangerous here.

~~~
pixelcort
ECMO machines can do this
[https://en.wikipedia.org/wiki/Extracorporeal_membrane_oxygen...](https://en.wikipedia.org/wiki/Extracorporeal_membrane_oxygenation)

~~~
pbhjpbhj
Apparently UK has 15 machines that can do this, for a population of 80M.

~~~
cleatoma
Population of the UK is less than 70M.

~~~
pbhjpbhj
Latest figures I saw said 67M, which I misremembered as 77M, and rounded.
Thanks for the correction.

------
oliwarner
Wow. Detail-light posts like this give readers just enough speculation and
doubt to make them dangerous to themselves (or their loved ones).

If your doctors are telling you you need to high pressure O2 or ventilation,
your sats are in the toilet. You simply can't survive without a breathing aid.
High pressure vents _can_ exacerbate damaged lung tissue but it's [probably,
citation needed] better than just suffocating.

And no, ECMO has a pile of its own issues, well beside being almost mythically
rare.

Listen to your doctors. They're doing their very best.

~~~
dchichkov
Well, yes, but also do check the statistics. If you see something really wrong
in the statistics, look at it twice. Medical systems are known to produce
weird results. To give an example, opioid epidemic is killing around 45
thousand Americans per year (ref). And this one was _created_ by the medical
system (pharma influencing decisions made by doctors).

(ref): Nature, Vol 580, 9 April 2020, page 181, graphics.

~~~
oliwarner
I think that's a pretty harmful comparison in itself. Over-prescription has
certainly been a factor, but nothing compared to dirt cheap heroin and illicit
fentanyl.

I'm not saying that there's not room for manoeuvre here. Positioning and
whatever emergent therapies appear will certainly be factored in by doctors
(who are desperate for _something_ ), but by the time you need ventilation,
you are very, _very_ ill.

You simply wouldn't survive without it.

~~~
dchichkov
I would refer you to this recent review in the Nature - "Tracing the US opioid
crisis to its roots" \-
[https://www.nature.com/articles/d41586-019-02686-2](https://www.nature.com/articles/d41586-019-02686-2)
And outlook
[https://www.nature.com/collections/wcbsjcwqng](https://www.nature.com/collections/wcbsjcwqng)

At least to me, it seems like that crisis was created, primarily because of
misalignment of the system towards maximizing executive compensation instead
of public health.

~~~
oliwarner
No. I mean that on many levels —including your reading of that article— but
I'm not going to engage there.

You are once again pointing at opioids a some unassailable argument that
doctors are only in it for the cash and cannot be trusted. If anything,
doctors are trying to keep people off ventilation. They have to, they have
dramatically more C19 patients than vents. Here, patients over 60 with co-
mobidities are actively disqualified.

Beside this global conspiracy amongst physicians to over-prescribe
ventilation, you're also suggesting that neither they nor the _hundreds_ of
public health bodies are looking at the results of their actions and adapting
treatment, despite taking extreme care to collate data. Guidelines here are
emergent, but you can't placebo people with _resting_ SpO2s of 80. They die.

Again, "Look, opioids!" is not an argument. It's a harmful comparison.

~~~
dchichkov
It is not, "Look, opioids!". It is: "Look, wrong incentives in the health-care
system in the United States".

The parallel seems interesting to me, as just like with opioid epidemic, some
doctors were _resisting_ in providing the painkiller therapy. While the
mainstream was to use the opioid therapy.

 _The structure of the health-care system in the United States also
contributed to the over-prescription of opioids. Because many doctors are in
private practice, they can benefit financially by increasing the volume of
patients that they see, as well as by ensuring patient satisfaction, which can
incentivize the over-prescription of pain medication. Prescription opioids are
also cheap in the short term. Patients’ health-insurance plans often covered
pain medication but not pain-management approaches such as physical therapy.
“The incentives were there for people to prescribe more and more, particularly
when they had already been convinced it was the right thing to do — the
compassionate thing to do,” Humphreys says.

This might help to explain why Canada is also experiencing an opioid crisis,
with 10,337 opioid-related deaths between January 2016 and September 2018.

Most European countries, however, have so far been insulated from the
epidemic. Doctors in Europe are not motivated financially to make
prescriptions_. - from this article in Nature -.

And by the way, yours "nothing compared" \- this is just plain wrong. The
level of the prescription-induced crisis, in numbers, was about the same as
the current level. And users funneled to non-prescription since the
prescription channel is now blocked.

As to the current decision-making. I'm not sure what is a right and efficient
solution. Probably it is in the area of developing antivirals as fast as
possible. And actively fighting the coefficient in the exponent. Like people
wearing masks in Walmart. And allowing doctors to wear masks in hospitals,
instead of hospital management making statements like: "THERES NO MORE WUHAN
VIRUS IN THE HALLS AT THE HOSPITAL THAN WALMART". See:
[https://www.nytimes.com/2020/03/31/health/hospitals-
coronavi...](https://www.nytimes.com/2020/03/31/health/hospitals-coronavirus-
face-masks.html)

But, putting people on ventilators seems like inefficient use of efforts. Yes,
if you don't put late-stage patients on ventilators, they'd _die_. But it
looks like, there is 80% chance they'd _die_ , if you'd put on ventilators.
And _fewer_ people may die overall, if efforts were not spend on the whole
ventilators affair. And instead something else was done.

------
TMWNN
I've heard it speculated that the thing to do may be to not put people on
ventilators, but give them blood transfusions.

Where I heard this:

[https://science.slashdot.org/comments.pl?sid=16122794&cid=59...](https://science.slashdot.org/comments.pl?sid=16122794&cid=59921250)

[https://www.statnews.com/2020/04/08/doctors-say-
ventilators-...](https://www.statnews.com/2020/04/08/doctors-say-ventilators-
overused-for-covid-19/)

~~~
ImpressiveWebs
I only scanned and did a page search for the word “transf”, but I couldn’t
find anything in those articles recommending transfusions.

~~~
redfern314
The first link mentions transfusions, but it's really just another comment on
Slashdot saying that they heard that some doctors are thinking about
hemoglobin-based causes. Nothing concrete or sourced.

------
garyclarke27
ECMO machines (like heart lung except the heart) seem to give much better
results. Japan used them for Diamond Princess (only 12 deaths from nearly 700
cases and many elderly) I’ve read ECMO only 20% die vs 45% for Ventilators -
Problem is the cost $130000 vs $50,000 and hardly any hospitals have them (in
the UK).

------
op03
How does the ventilator not just fill up with the virus over time?

~~~
generatorguy
exhaled air is exhausted to outdoors through filters, fresh air comes in.
different tubes for different direction of air flow

~~~
djsumdog
Right, which is one of the differences between a ventilator and a CPAP
machine. CPAPs don't have a return hose, so virus can spread from the exhaled
air. Some hospitals are putting breathing masks on people just so they're not
spreading virus into the hospital.

I've also ready some hospitals are using techniques were O2 levels are
increased directly in the blood supply? I can't remember what that's called
though.

~~~
rjsw
> I've also ready some hospitals are using techniques were O2 levels are
> increased directly in the blood supply?

ECMO [1], it has been used quite a bit in Italy too.

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

------
jv22222
I posted the exact same article a few days ago, 6 points in the first 30 mins
and then dropped out of site.

[https://news.ycombinator.com/item?id=22828822](https://news.ycombinator.com/item?id=22828822)

Weird.

