A British ER consultant known only as ‘Dr. Al’ admitted on the BBC Radio 5 Live’s Stephen Nolan Show to a zero percent success record in getting sick COVID-19 patients off of ventilators.

“…A good 86% of the people are not going to survive anyway, so the ventilator is going to make a difference for 14% of the people who are that unwell. That’s the first thing.

The second thing is that once we put someone on the ventilator… like the current hospital that I am in right now, all the patients that we have put on the ventilator, none of them have come off the ventilator alive. Either they have died, or they are still on ventilators.

Subsequently, he discussed patients with comorbidities, and the choices that were offered to them by the hospital.

The choices are that: we can try and keep you on oxygen; we can offer you a ventilator, but we are pretty sure by looking at the situation – your chest x-ray, your blood results, the functions of your kidney and heart and everything – that you’re not going to survive the ventilator for more than twelve hours. So either ways, it is looking unlikely that you’re going to survive.

Lots of patients understand where we come from, what we’re offering. And the vast majority of them choose not to be on a ventilator, and choose to converse with their families instead.

There have been one or two patients that we have ventilated, but prior to putting them on a ventilator (because we have to sedate them before we put them on a ventilator), we’ve offered them to have a conversation with their family, because obviously people are not waking up from the ventilators. We have people dying on the ventilators. So we want to give them a chance to have a conversation with their families.

Clearly, Dr. Al is placing himself at enormous risk working on the frontlines of the pandemic and his courage and self-sacrifice are greatly to be commended. However, his institution’s failure to save ventilated patients should be a cause for concern.

In the UK, only 50% of patients admitted to critical care for whom outcomes are known survive. In the Intensive Care National Audit & Research Unit survey drawn up through 4 April 2020, of critical care 2249 patients in England, Wales and Northern Ireland, “346 patients had died, 344 patients were discharged alive from critical care and 1559 patients were last reported as still being in critical care”.

Critical Approaches

Physicians in other jurisdictions are beginning to question whether treating patients with COVID-19 pneumonia using Acute Respiratory Distress Syndrome (ARDS) protocols is actually counter-productive. At issue is the use of respiratory therapy protocols for a disease that is presenting more like High Altitude Pulmonary Edema (HAPE) than ARDS in patients.

HAPE is a form of pulmonary edema affecting mountaineers who have failed to acclimatise correctly to high altitudes, and is the major cause of death related to high-altitude exposure. Symptoms of HAPE include some combination of shortness of breath at rest, cough, weakness, and congestion or chest tightness. Genetic factors and prior instances of HAPE are known risk factors, with males being at greater risk of developing the disease than females.1

In a letter to the American Journal of Respiratory and Critical Care Medicine on March 30, and in an editorial accepted for publication in Intensive Care Medicine, Luciano Gattinoni, MD, of the Medical University of Göttingen in Germany argues that protocol-driven ventilator use for patients with COVID-19 could be “doing more harm than good”.

Dr. Gattinoni noted that COVID-19 patients in intensive care units in northern Italy had an atypical ARDS presentation with severe hypoxemia and well-preserved lung gas volume. He and his colleagues suggested that instead of high positive end-expiratory pressure (PEEP), physicians should consider the lowest possible PEEP and gentle ventilation – practicing patience to “buy time with minimum additional damage.”

Specifically, they took issue with guidelines from a panel of experts put together by the Surviving Sepsis Campaign, published in Intensive Care Medicine on 28 March 2020, which provided the following guidance:

Currently there are no studies addressing mechanical ventilation strategies in COVID-19 patients. However, the panel of experts believes that mechanically ventilated patients with COVID-19 should be managed similarly to other patients with acute respiratory failure in the ICU.

To Dr. Gattinoni, this failed to take into account the distinctive characteristics of pneumonia in COVID-19 patients.

“Yet, COVID-19 pneumonia, despite falling in most of the circumstances under the Berlin definition of ARDS, is a specific disease, whose distinctive features are severe hypoxemia often associated with near normal respiratory system compliance,” Dr. Gattinoni and colleagues wrote, noting that this was true for more than half of the 150 patients he and his colleagues had assessed, and that several other colleagues in Northern Italy reported similar findings. “This remarkable combination is almost never seen in severe ARDS.”

Cameron Kyle-Sidell, a New York critical care doctor was also similarly surprised by how the COVID-19 patients he was encountering were presenting with symptoms not characteristic of ARDS:

When I initially started treating patients, I was under the impression, as most people were, that I was going to be treating acute respiratory distress syndrome (ARDS), similar in substance to AIDS, which I saw as a fellow. And as I start to treat these patients, I witnessed things that are just unusual. And I’m sure doctors around the country are experiencing this.

On his channel on Youtube, the doctor explained the differences in greater detail.

COVID-19 lung disease, as far as I can see, is not a pneumonia and should not be treated as one. Rather it appears … as some kind of viral induced disease, most resembling high altitude sickness. It is as if tens of thousands of my fellow New Yorkers are on a plane at 30,000 feet and the cabin pressure is slowly being let out. These patients are slowly being starved of oxygen.

I have seen patients dependent on oxygen take off their oxygen and quickly progress through a state of anxiety and emotional distress and eventually get blue in the face, and while they look like patients absolutely on the brink of death they do not look like patients dying of pneumonia.

I have never been a mountain climber, and I do not know the conditions at base camp below the highest peaks in the world, but I suspect that the patients I’m seeing in front of me look most like as if a person was dropped off on the top of Mount Everest without time to acclimate.

I don’t know the final answer of this disease but I’m quite sure that a ventilator is not it. That is not to say that we don’t need ventilators: we absolutely need them. They are the only way at this time that we were able to give a little more oxygen to patients who need it, but when we treat people with ARDS, we typically use ventilators to treat what’s called respiratory failure. That is, we use the ventilator to do the work that the patient’s muscles can no longer do, because they’re too tired to do it. These patients’ muscles work fine.

I fear that we are … using a false paradigm to treat a new disease, that the method that we program the ventilator – one based on a notion of respiratory failure as opposed to oxygen failure – that this method (and there are a great many number of methods we can use with the ventilator) but this method being widely adopted at this very moment in every hospital in the country, which aims to increase pressure on the lungs in order to open them up, is actually doing more harm than good, and that the pressure we are providing to lungs, we may be providing to lungs that cannot stand it, that cannot take it, and that the ‘ARDS’ that we are seeing – that the whole world is seeing – may be nothing more than lung injury caused by the ventilator.

Returning to the Gattinoni study, preliminary results from their substantially revised treatment plan, which is now freely available online, appear to be very positive.

While not willing to name the hospitals at this time, he said that one center in Europe has had a 0% mortality rate among COVID-19 patients in the intensive care unit when using this approach, compared with a 60% mortality rate at a nearby hospital using a protocol-driven approach.

So, for Dr. Gattinoni, the approach of sticking strictly to prescribed protocols may also be hindering doctors from responding appropriately to the disease phenotypes observed. His team believes that the patterns at patient presentation depend on interaction between “three sets of factors”:

1) disease severity, host response, physiological reserve and comorbidities;

2) ventilatory responsiveness of the patient to hypoxemia; and

3) time elapsed between disease onset and hospitalization.

The two primary phenotypes which his team have identified have contrasting characteristics, with Type L (low elastance, low ventilator perfusion ratio, low lung weight, and low recruitability) and Type H (high elastance, high right-to-left shunt, high lung weight, and high recruitability).

“Given this conceptual model, it follows that the respiratory treatment offered to Type L and Type H patients must be different,” Dr. Gattinoni said.

Patients may transition between phenotypes as their disease evolves.

The doctors recommend treating Type L and Type H patients differently initially, and having a response that pays more attention to their latest signs than to following treatment protocols.

Clap for our Carers

Meanwhile, back in the UK, there is an extensive public relations campaign being waged in support of the National Health Service. Under the ‘Clap for our Carers’ campaign, Brits take to their doorsteps and balconies at 8pm on Thursdays to show their appreciation for the tremendous self-sacrifice of frontline medical staff.

Of course, it does the public no favours if journalists become cheerleaders, and fail to ask the hard questions of NHS consultants and senior leaders about the effectiveness of the treatments and procedures being deployed. Otherwise, we are no wiser than the First World War generation that failed to criticise deeply flawed military tactics for fear of looking unpatriotic.

Constructive criticism may well prove more important to the NHS than our applause.

Author: David McHutchon

Picture Inodayahospitals / CC BY-SA

Footnotes

  1. As an aside, we might note the relatively low death rates in countries with a particularly high average altitude, such as Nepal, Bhutan, Tajikistan, Kyrgyzstan and Lesotho, and largely native populations. On the other hand, Andorra has a very high rate of confirmed cases/population, although its crude CFR, at least at this stage, is lower than neighbouring Spain and France. Whether the influence of acclimatisation to high-altitude on COVID-19 symptoms is worth considering further, I will leave to others to decide.
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