I love the point about ventilators being brought up. LOL! 3 major reasons we ended up being able to get ventilators to where we needed them: 1) other states that weren't experiencing peaks at the time sent ventilators to New York and New Orleans 2) as we worked through the situation with Covid-19 doctors began to become more familiar with what they were seeing and changed practice so that they didn't intubate as quickly and place patients on ventilators as we normaly would in other situations.
Article published April 8,2020 by Sharon Begley
With ventilators running out, doctors say the machines are overused for Covid-19
Even as hospitals and governors raise the alarm about a shortage of ventilators, some critical care physicians are questioning the widespread use of the breathing machines for Covid-19 patients, saying that large numbers of patients could instead be treated with less intensive respiratory support.
If the iconoclasts are right, putting coronavirus patients on ventilators could be of little benefit to many and even harmful to some.
What’s driving this reassessment is a baffling observation about Covid-19: Many patients have blood oxygen levels so low they should be dead. But they’re not gasping for air, their hearts aren’t racing, and their brains show no signs of blinking off from lack of oxygen.
That is making critical care physicians suspect that blood levels of oxygen, which for decades have driven decisions about breathing support for patients with pneumonia and acute respiratory distress, might be misleading them about how to care for those with Covid-19. In particular, more and more are concerned about the use of intubation and mechanical ventilators. They argue that more patients could receive simpler, noninvasive respiratory support, such as the breathing masks used in sleep apnea, at least to start with and maybe for the duration of the illness.
“I think we may indeed be able to support a subset of these patients” with less invasive breathing support, said Sohan Japa, an internal medicine physician at Boston’s Brigham and Women’s Hospital. “I think we have to be more nuanced about who we intubate.”
That would help relieve a shortage of ventilators so critical that states are scrambling to procure them and some hospitals are taking the unprecedented (and largely untested) step of using a single ventilator for more than one patient. And it would mean fewer Covid-19 patients, particularly elderly ones, would be at risk of suffering the long-term cognitive and physical effects of sedation and intubation while being on a ventilator.
None of this means that ventilators are not necessary in the Covid-19 crisis, or that hospitals are wrong to fear running out. But as doctors learn more about treating Covid-19, and question old dogma about blood oxygen and the need for ventilators they might be able to substitute simpler and more widely available devices.
An oxygen saturation rate below 93% (normal is 95% to 100%) has long been taken as a sign of potential hypoxia and impending organ damage. Before Covid-19, when the oxygen level dropped below this threshold, physicians supported their patients’ breathing with noninvasive devices such as continuous positive airway pressure (CPAP, the sleep apnea device) and bilevel positive airway pressure ventilators (BiPAP). Both work via a tube into a face mask.
In severe pneumonia or acute respiratory distress unrelated to Covid-19, or if the noninvasive devices don’t boost oxygen levels enough, critical care doctors turn to mechanical ventilators that push oxygen into the lungs at a preset rate and force: A physician threads a 10-inch plastic tube down a patient’s throat and into the lungs, attaches it to the ventilator, and administers heavy and long-lasting sedation so the patient can’t fight the sensation of being unable to breathe on his own.But because in some patients with Covid-19, blood-oxygen levels fall to hardly-ever-seen levels, into the 70s and even lower, physicians are intubating them sooner. “Data from China suggested that early intubation would keep Covid-19 patients’ heart, liver, and kidneys from failing due to hypoxia,” said a veteran emergency medicine physician. “This has been the whole thing driving decisions about breathing support: Knock them out and put them on a ventilator.”
To be sure, many physicians are starting simple. “Most hospitals, including ours, are using simpler, noninvasive strategies first,” including the apnea devices and even nasal cannulas, said Greg Martin, a critical care physician at Emory University School of Medicine and president-elect of the Society of Critical Care Medicine. (Nasal cannulas are tubes whose two prongs, held beneath the nostrils by elastic, deliconscious and] can participate in his care. But if the oxygen saturation gets too low you can achieve more oxygen delivery with a mechanical ventilator.”
The question is whether ICU physicians are moving patients to mechanical ventilators too quickly. “Almost the entire decision tree is driven by oxygen saturation levels,” said the emergency medicine physician, who asked not to be named so as not to appear to be criticizing colleagues.
That’s not unreasonable. In patients who are on ventilators due to non-Covid-19 pneumonia or acute respiratory distress, a blood oxygen level in the 80s can mean impending death, with no room to give noninvasive breathing support more time to work. Physicians are using their experience with ventilators in those situations to ver air to the nose.) “It doesn’t require sedation and the patient [remains conscious and] can participate in his care. But if the oxygen saturation gets too low you can achieve more oxygen delivery with a mechanical ventilator.”
The question is whether ICU physicians are moving patients to mechanical ventilators too quickly. “Almost the entire decision tree is driven by oxygen saturation levels,” said the emergency medicine physician, who asked not to be named so as not to appear to be criticizing colleagues.
That’s not unreasonable. In patients who are on ventilators due to non-Covid-19 pneumonia or acute respiratory distress, a blood oxygen level in the 80s can mean impending death, with no room to give noninvasive breathing support more time to work. Physicians are using their experience with ventilators in those situations to guide their care for Covid-19 patients.
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So now, for the arm chair google doctors out there, physicians are changing the way they are approaching mechanical ventilation with Covid-19 patients and trying very aggressive high flow oxygen therapy for longer periods of time with arterial blood gas results that we would have never "sat" on in the past with pneumonia from some other cause.
These patients now have what one nurse I know called arterial blood gas results incompatible to life and keeping them on high flow oxygen and setting other criteria before intubating. Another factor in the fact they haven't needed the number of ventilators they normally would need if they keep the standard of care the same as in the past.
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