As nations rush to build or buy ventilators to beat COVID-19, Reuters spoke to 30 medics worldwide, many of whom said they are now more sparing with the machines by tomescritt silviaaloisi gabriellaborter kkelland journotopia & Deena Beasley
FILE PHOTO: Marcelo Larrosa demonstrates the use of a ventilator powered by a motor modeled after a windshield wiper motor, in Montevideo, Uruguay April 9, 2020. REUTERS/Mariana Greif/File Photo
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.
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.
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.
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.
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.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.
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.”
In Germany, lung specialist Voshaar was also concerned. A mechanical ventilator itself can damage the lungs, he says. This means patients stay in intensive care longer, blocking specialist beds and creating a vicious circle in which ever more ventilators are needed. Mario Riccio, head of anaesthesiology and resuscitation at the Oglio Po hospital near Cremona in Lombardy, Italy’s worst-hit region, says the machines are the only treatment to save a COVID-19 patient in serious condition. “The fact that people who were placed under mechanical ventilation in some cases die does not undermine this statement.”
While mechanical ventilators do not produce aerosols, they carry other risks. Intubation requires patients to be heavily sedated so their respiratory muscles fully surrender. The recovery can be lengthy, with a risk of permanent lung damage. He and other doctors think other tests can help before intubation. Voshaar looks at a combination of measures including how fast the patient is breathing and their heart rate. His team are also guided by lung scans.Several doctors in New York said they too had started to consider how to treat patients, known as “happy hypoxics,” who can talk and laugh with no signs of mental cloudiness even though their oxygen might be critically low.
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