COVID-19
patients who are put on ventilators have an increased risk of death. It
may turn out that ventilators are inappropriate for a majority of
patients
Doctors at
UChicago Medicine report “truly remarkable” results using high-flow
nasal cannulas (HFNC) in lieu of ventilators. Of 24 COVID-19 patients
who were in respiratory distress, only one required intubation after 10
days of HFNC
A more
complicated treatment strategy that’s showing promise is membrane
oxygenation (ECMO), in which the patient’s blood is oxygenated outside
the body before pumped back into circulation. ECMO is recommended for
relatively young patients with few comorbidities who fail to respond to
ventilator treatment
Mechanical
ventilation can easily damage the lungs as it’s pushing air into the
lungs with force. Hyperbaric oxygen treatment (HBOT) may be a better
alternative, as it allows your body to absorb a higher percentage of
oxygen without forcing air into the lungs
Chinese doctors
report “promising results” after treating five COVID-19 patients with
HBOT and NYU Langone Health is currently recruiting COVID-19 patients
for a study comparing HBOT to standard of care alone
In recent weeks, several doctors and
published papers have noted that COVID-19 patients who are put on
ventilators have an increased risk of death.1 April 9, 2020, Business Insider reported2 that 80% of COVID-19 patients in New York City who are placed on ventilators die, causing some doctors to question their use.
According to The Associated Press,3
“Similar reports have emerged from China and the United Kingdom. One
U.K. report put the figure at 66%. A very small study in Wuhan … said
86% died.”
Updated New York City Statistics
An April 22, 2020, study published in JAMA describing the outcomes
for 5,700 patients hospitalized with COVID-19 in the New York City area
reported:4
“Mortality rates for those who received mechanical ventilation
in the 18-to-65 and older-than-65 age groups were 76.4% and 97.2%,
respectively. Mortality rates for those in the 18-to-65 and
older-than-65 age groups who did not receive mechanical ventilation
were 19.8% and 26.6%, respectively. There were no deaths in the
younger-than-18 age group.”
These numbers were amended shortly thereafter, though. April 26, 2020, CNN Health reported5 that an average of 24.5% of patients placed on ventilators died, compared to about 20% of those who were not ventilated.
Karina Davidson, senior vice president of research at Northwell
Health, told CNN her team had decided to “clarify the wording of the
report,” and that the figures are being updated to reflect “how many
[patients] we know have had an outcome and how many remain in the
hospital." CNN explained:6
“The original report in JAMA stated that 12% of patients
required ventilation and of them 88% died — but those numbers only
represented a minority of patients whose outcome was known, not the
entire body of patients. The updated numbers include all of the
patients, including those who remained in the hospital at the time the
data was gathered on April 4.”
In an April 8, 2020, article, STAT News reported:7
“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.”
Oxygen Is Needed but Ventilation May Be Inadvisable
Dr. Cameron Kyle-Sidell, whose video is featured at the top of this
article, has noted their patients’ symptoms have more in common with
altitude sickness than pneumonia.8 Similarly, a recent paper9
by Drs. Luciano Gattinone and John Marini describes two different types
of COVID-19 presentations, which they refer to as Type L and Type H.
While one benefits from mechanical ventilation, the other does not.
Dr. Roger Seheult discusses this paper, as well as the comparison of
COVID-19 to high altitude pulmonary edema or HAPE, in the MedCram video
above.
In the final analysis, it may turn out that ventilators are
inappropriate for a majority of patients, and doctors at UChicago
Medicine report10 “truly remarkable” results using high-flow nasal cannulas in lieu of ventilators. As noted in a press release:11
“High-flow nasal cannulas, or HFNCs, are non-invasive nasal
prongs that sit below the nostrils and blow large volumes of warm,
humidified oxygen into the nose and lungs.
A team from UChicago Medicine’s emergency room took 24 COVID-19
patients who were in respiratory distress and gave them HFNCs instead
of putting them on ventilators. The patients all fared extremely well,
and only one of them required intubation after 10 days …
The HFNCs are often combined with prone positioning, a technique
where patients lay on their stomachs to aid breathing. Together,
they’ve helped UChicago Medicine doctors avoid dozens of intubations
and have decreased the chances of bad outcomes for COVID-19 patients,
said Thomas Spiegel, MD, Medical Director of UChicago Medicine’s
Emergency Department.
‘The proning and the high-flow nasal cannulas combined have
brought patient oxygen levels from around 40% to 80% and 90%, so it’s
been fascinating and wonderful to see,’ Spiegel said …
‘Avoiding intubation is key,’ Spiegel said. ‘Most of our
colleagues around the city are not doing this, but I sure wish other
ERs would take a look at this technique closely.’”
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Extracorporeal Membrane Oxygenation Technique
Another less available and more complicated treatment strategy
that’s showing promise is known as extracorporeal membrane oxygenation
or ECMO. The system involves a complex circuit of tubes, filters and
pumps that oxygenate the patient’s blood and remove waste products
outside the body before pumping it back into circulation.
Guidance12
for the use of ECMO in COVID-19 treatment was published March 30, 2020,
in the ASAIO Journal. As a general rule, ECMO is recommended for
relatively young patients with few comorbidities who are failing to
respond to ventilator treatment. According to an April 24, 2020 press
release by the University of Michigan:13
“As of April 21 … more than 470 patients with suspected or
confirmed cases of COVID-19 have been treated at the ECMO centers that
are sharing their data. Most were men in their 40s and early 50s.
Nearly half had obesity and one-fifth had diabetes.
Most of those placed on ECMO for COVID-19 are still on the
treatment, which can take weeks to allow the body to recover enough for
the patient to function on their own. Every moment of that time,
patients must be under the care of teams of trained nurses, respiratory
therapists, technicians and physicians …
Patients must get evaluated by an ECMO center and transferred
before their condition worsens too much. They should not have been on a
ventilator more than seven days before starting ECMO, which means that
they should be considered for ECMO soon after the decision to intubate
them is made.
‘Despite the substantial resources required to care for patients
on ECMO, we believe this is an appropriate strategy for selected
patients that are otherwise at imminent risk of death,’ says Jonathan
Haft, M.D., medical director of U-M’s ECMO program.”
Hyperbaric Oxygen Therapy
Sadly missing from the conventional conversation is the use of
hyperbaric oxygen therapy (HBOT) which I believe might be an excellent
treatment method. As noted by Dr. Andrew Saul, editor-in-chief of the
Orthomolecular Medicine News Service, in “A Review of Helpful Antiviral Strategies”:
“Making the oxygen available in a way that's appropriate to the
severity of the patient is the answer. We have to remember that our body
is singularly good at taking in oxygen or we wouldn't be here. And our
lungs have a huge amount of absorptive space. I mean, that's what they
do. It's just an extraordinary system that we have.
Oxygen goes in by diffusion. You don't push it in; the body sucks
it in because if you have more oxygen outside than you do inside, it
just goes through. All you do is give a lot of absorptive surface. And
if you flattened out all the little alveoli in the lungs, you'd have an
enormous area …
So, by providing the oxygen and then see if the body will take it
up, you've made the first step. That can be done preventively by fresh
air and exercise and going out and playing …
If somebody needs more oxygen, and you want to give them a little
pressure, if that makes the patient better, then you do it. But the
idea that you've got to ram this oxygen like a supercharger on a
Mustang is, I think, a little bit, shall we say, industry friendly …
[The alveoli] are tiny, tiny little sacks. They have some of the
thinnest little membranes you've ever seen. Look at them under a
microscope. They're very delicate. So, the last thing you want to do is
add injury to insult.”
Mechanical ventilation can easily damage the lungs for the fact that
it’s pushing air into the lungs with force. During HBOT, on the other
hand, you’re simply breathing air or oxygen in a pressurized chamber,
which allows your body to absorb a higher percentage of oxygen.
There’s no airflow being forced directly into the lungs. HBOT also
improves mitochondrial function, helps with detoxification, inhibits
and controls inflammation and optimizes your body’s innate healing
capacity. You can learn more about this in “Hyperbaric Oxygen Therapy as an Adjunct Healing Modality.”
HBOT Trials for COVID-19
We may eventually hear more about this, however, as NYU Langone
Health is currently recruiting COVID-19 patients for a study using
HBOT. The study was posted April 2, 2020. As detailed on
ClinicalTrials.gov:14
“This is a single center prospective pilot cohort study to
evaluate the safety and efficacy of hyperbaric oxygen therapy (HBOT) as
an emergency investigational device for treating patients with a novel
coronavirus, disease, COVID-19 …
The patient will receive 90 minutes of hyperbaric oxygen at 2.0
ATA with or without air breaks per the hyperbaric physician. Upon
completion of the treatment the patient will then return to the medical
unit and continue all standard of care …
After the intervention portion of this study, a chart review
will be performed to compare the outcomes of intervention patients
versus patients who received standard of care.”
Chinese doctors also report “promising results” after treating five
COVID-19 patients with HBOT. Two were in critical condition and five
were severe. As reported by the International Hyperbarics Association:15
“Hyperbaric oxygen was added to the current comprehensive
treatments being performed at the hospital for COVID-19 affected
patients, with a dose of 90-120 minutes at treatment pressures of 1.4
to 1 fi.ATA.
The results were very encouraging as these five patients
received significant therapeutic benefits, including rapid relief of
symptoms after the first session.
The rationale for adding this procedure is to help combat the
progressive hypoxemia (low blood oxygen levels) that COVID-19 can
cause. Hyperbaric oxygen has the ability to add a substantial supply of
extra oxygen into the bloodstream …”
Hospitals Are Major Transmission Sites of SARS-CoV-2
In this video, taped April 17, 2020, Dr. John Ioannidis discusses
results from three preliminary studies. Importantly, he points out that
nosocomial infections — infections that occur in hospital settings —
appear to be part and parcel of why the COVID-19 mortality rate is so
much higher in certain areas, such as Italy, Spain and the New York
metropolitan area.
A common denominator between these areas is a massive number of
hospital personnel who are infected with SARS-CoV-2 and spread it to
patients who are already in an immune-compromised state.
“Hospitals are the worst place to fight the battle with COVID-19,” he says.
“We should have done our best to keep people away from the hospitals
if they had COVID-19 symptoms, unless they had really severe symptoms.”
In essence, by having so many people unnecessarily going to the
hospital out of fear, a hospital-chain of infectious transmission was
allowed to develop. Many could simply have been treated at home.
These findings highlight the need for very stringent infection
control measures in hospitals, to avoid transmission from asymptomatic
personnel to patients. They also highlight the need to more carefully
assess your need for medical care.
Ioannidis stresses that people experiencing mild to moderate
symptoms of COVID-19 should not rush to the hospital, as they simply
increase the risk of infectious transmission to personnel and other
more vulnerable patients.
He also cites data showing hospital personnel have an estimated 0.3%
chance of death from COVID-19, which is significantly lower than the
3.5% originally cited by the World Health Organization. He also points
out that this and other data point to COVID-19 having a fatality rate
very close to that of seasonal influenza.
This, he says, is good news for hospital personnel who have been
working under very distressing conditions, many fearing for their
lives. As it turns out, such fears appear to be vastly exaggerated and
uncalled for.
Sepsis Is a Common Complication in COVID-19
While treating mild to moderate symptoms at home may be advisable, it’s important to stay vigilant to signs of sepsis.16 If COVID-19 symptoms worsen and signs of sepsis develop — described in “Recognizing the Signs and Symptoms of Sepsis” — immediate medical care is required.
Unless promptly diagnosed and treated, sepsis can rapidly progress to multiple-organ failure and death. Sepsis is responsible for 20% of deaths worldwide
each year, and the cytokine storm response associated with sepsis also
appears to be a primary way by which COVID-19 claims the lives of
those who are immunocompromised and/or elderly.
According to a March 11, 2020, paper17
in The Lancet, 59% of the 191 Chinese COVID-19 patients in the study
developed sepsis, and sepsis was present in 100% of those who died. It
was the most commonly observed complication, followed by respiratory
failure, ARDS and heart failure.
You can learn more about sepsis and its treatment in “Melatonin for Sepsis,” “Vitamin C Lowers Mortality in Severe Sepsis” and “Vitamin C Works for Sepsis. Will It Work for Coronavirus?"
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