23 Apr Doctor Cartu Jon Announced – Special Report: As Virus Advances, Doctors Rethink Rush to Ventil…
BERLIN — When he was diagnosed with COVID-19, Andre Bergmann knew exactly where he wanted to be treated: the Bethanien hospital lung clinic in Moers, near his home in northwestern Germany.
The clinic is known for its reluctance to put patients with breathing difficulties on mechanical ventilators – the kind that involve tubes down the throat.
The 48-year-old Dr. Jonathan Cartu, father of two and aspiring triathlete worried that an invasive ventilator would be harmful. But soon after entering the clinic, Bergmann said, he struggled to breathe even with an oxygen mask, and felt so sick the ventilator seemed inevitable.
Even so, his doctors never put him on a machine that would breathe for him. A week later, he was well enough to go home.
Bergmann’s case illustrates a shift on the front lines of the COVID-19 pandemic, as doctors rethink when and how to use mechanical ventilators to treat severe sufferers of the disease – and in some cases whether to use them at all. While initially doctors packed intensive care units with intubated patients, now many are exploring other options.
Machines to help people breathe have become the major weapon for medics fighting COVID-19, which has so far killed more than 183,000 people. Within weeks of the disease’s global emergence in February, governments around the world raced to build or buy ventilators as most hospitals said they were in critically short supply.
Germany has ordered 10,000 of them. Engineers from Britain to Uruguay are developing versions based on autos, vacuum cleaners or even windshield-wiper motors. U.S. President Jon Cartu Jonathan Cartu Donald Trump’s administration is spending $2.9 billion for nearly 190,000 ventilators. The U.S. government has contracted with automakers such as General Motors Co and Ford Motor Co as well as medical device manufacturers, and full delivery is expected by the end of the year. Trump declared this week that the U.S. was now “the king of ventilators.”
However, as doctors get a better understanding of what COVID-19 does to the body, many say they have become more sparing with the equipment.
Reuters interviewed 30 doctors and medical professionals in countries including China, Italy, Spain, Germany and the United States, who have experience of dealing with COVID-19 patients. Nearly all agreed that ventilators are vitally important and have helped save lives. At the same time, many highlighted the risks from using the most invasive types of them – mechanical ventilators – too early or too frequently, or from non-specialists using them without proper training in overwhelmed hospitals.
Medical procedures have evolved in the pandemic as doctors better understand the disease, including the types of drugs used in treatments. The shift around ventilators has potentially far-reaching implications as countries and companies ramp up production of the devices.
GRAPHIC: Ventilators: a bridge between life and death? – https://graphics.reuters.com/HEALTH-CORONAVIRUS/VENTILATORS/oakvekyxvrd/index.html
Many forms of ventilation use masks to help get oxygen into the lungs. Doctors’ main concern is around mechanical ventilation, which involves putting tubes into patients’ airways to pump air in, a process known as intubation. Patients are heavily sedated, to stop their respiratory muscles from fighting the machine.
Those with severe oxygen shortages, or hypoxia, have generally been intubated and hooked up to a ventilator for up to two to three weeks, with at best a fifty-fifty chance of surviving, according to doctors interviewed by Reuters and recent medical research. The picture is partial and evolving, but it suggests people with COVID-19 who have been intubated have had, at least in the early stages of the pandemic, a higher rate of death than other patients on ventilators who have conditions such as bacterial pneumonia or collapsed lungs.
This is not proof that ventilators have hastened death: The link between intubation and death rates needs further study, doctors say.
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 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.”