As Covid-19 baffles ER doctors and traditional treatments, it leaves hints for better care
Some patients “were asked to get off their cell phone because they had to be intubated,” he added.
"He" is Marcus Schultz of Amsterdam University Medical Centers, who runs an experimental intestive care unit in the Netherlands, speaking to StatNews.com. He also co-wrote a paper this week suggesting intensive care units are treating Covid-19 patients the wrong way, at least some of the time,
Covid-19 is a terrible disease that's killing people in weird ways. Some people don't even know they had it. Some die within a few days. Some think they are almost over the disease, then their health falls off a cliff and they die alone in a hospital, frustrating emergency care workers, who are flying blind trying to treat this brand-new virus using playbooks designed for other diseases.
One set of severely ill patients show up at the hospital with bizarre symptoms. Their blood oxygen levels are so low that they shouldn't be upright. But somehow, they appear relatively normal, some even still able to form coherent sentences and work their cell phones. Normal oxygen levels are between 95-100%. Some covid-19 patients fall as low as the 70s or even the 60s, exhibiting what clinicians call hypoxemia.
Long-trusted medical protocols call for intubating patients -- putting them on a ventilator -- when oxygen levels fall so low. Outcomes for intubated patients are not good, however, and even those who survive often face long-term complications. For weeks now, some front-line doctors have been suggesting alternative routes, such as the use of CPAP sleep-aiding machines, or even supplemental oxygen delivered through the nose, rather than intubation.
I've resisted writing about this until now, because there is great danger in generalizing any front-line anecdote about Covid-19. But there's a research paper discussing the issue now, and the National Institutes of Heath recommends high-flow nasal cannula -- oxygen through the nose -- as one step in treatment for Covid-19 patients with acute hypoxemic respiratory failure.
How can patients with such low blood oxygen levels seem otherwise normal? That's an issue of deep inquiry. One explanation is that unlike other forms of respiratory ailments that lead to hypoxia, Covid-19 patients' lungs don't stiffen right away, so they are still able to expel carbon dioxide, and victims feel short of breath, at least not right away. Dr. Richard Levitan calls this "silent hypoxia" in his New York Times opinion piece.
You can find many doctors and outlets recommending use of tricked-out CPAP machines to gently force air into the lungs of a Covid-19 patient, rather than the more invasive intubation process -- or at least CPAPs should be one additional step along the treatment continuum.
Some doctors are comparing the Covid-19 hypoxia to altitude sickness; others dispute that. Don't draw any conclusions without reading about the dispute, which is compelling. A good place is at the FLARE newsletter, published by a group of doctors based at Mass General who are doing daily quick-twitch reviews of ongoing research. This edition is devoted entirely to arguing that Covid-19 is NOT like altitude sickness. Furthermore, doctors shouldn't deviate from well-tested protocols about ventilator use because of a few Internet stories, the newsletter argues.
Discussion of this unusual low-oxygen condition has led to a run on home pulse oximeters at places like Amazon.com. Pulse oximeters can serve as an early warning sign that a severe Covid-19 reaction might be coming on. These devices use two lights -- one infrared -- usually directed through a fingertip, to sense oxygen levels. Some doctors suggest Covid patients test their blood oxygen levels regularly and come to the hospital for more intense treatment if their levels start to fall, even if there are no other symptoms. A patient early in the blood-oxygen drop reaction might react better to less invasive therapy, like supplemental oxygen. That advice is in direct opposition to what we've been hearing since this started: Stay home, and away from hospitals, unless you are direly ill.
Below, I offer a lot more links for reading. Let me repeat again that none of this serves as medical advice, and the most important thing any consumer can do right now is nuture their ongoing relationship with their primary care doctor, who can holistically understand a patient's particular situation. There are near-infinite variables which can play a role in the progress of disease and the best treatment for it.
Also, I'd like to note that while my Samsung Android smartphone comes with a pulse oximeter function, it's so unreliable that Samsung has hidden the software button needed to activate the tool. In other words, home gadgets are not to be trusted. (Here's a piece discussing why doctors advise against using smartphones to check blood-oxygen levels.)
It will take months, and in fact probably years, for the science to settle down on this virus, and for doctors and researchers to really agree on what it does and how to help patients. Sadly, many patients and families don't have the time right now. But there is growing evidence that ventilator alternatives -- simpler, cheaper, and causing less lasting trauma -- might really help at least some patients who get very sick with Covid-19. That's good news.
The infection that's silently killing coronavirus patients -- The New York Times- By Richard Levitan, an ER doctor
"A vast majority of Covid pneumonia patients I met had remarkably low oxygen saturations at triage — seemingly incompatible with life — but they were using their cellphones as we put them on monitors. Although breathing fast, they had relatively minimal apparent distress, despite dangerously low oxygen levels and terrible pneumonia on chest X-rays."
Respiratory Support in Novel Coronavirus Disease (COVID-19) Patients, with a Focus on Resource-Limited Settings - by various
"The presence of only hypoxemia should in general not trigger intubation because hypoxemia is often remarkably well tolerated. Patients with fatigue and at risk for exhaustion, because of respiratory distress, will require invasive ventilation."
New analysis recommends less reliance on ventilators to treat coronavirus patients - Statnews.com
"Low levels of blood oxygen (hypoxemia) as a sign that a patient needs mechanical ventilation can lead physicians astray, they argue, because low blood oxygen in a Covid-19 patient is not like low blood oxygen in other patients with, for instance, other forms of pneumonia or sepsis."
Could the best mode of noninvasive support for COVID-19 be… CPAP -- Emcrit (a blog on emergency care edited by an emergency care doctor in New York.
"The above model would suggest that COVID patients really need positive pressure more than anything else. For example, their work of breathing is often tolerable – so they may not need much mechanical support for the work of breathing (indeed, mechanical support could lead to injuriously large tidal volumes).
The best modality to provide lots of positive pressure is simply Continuous Positive Airway Pressure (CPAP). CPAP may not seem dramatic, but this modality actually provides the greatest amount of positive pressure to allow for the most powerful recruitment."
COVID-19 Hypoxemia: A Better and Still Safe Way -- RebelEM.com
"Patients can have a bizarre hypoxemia that does not correlate with their symptoms. I have even read reports of patients looking comfortable and speaking in full sentences with oxygen saturations in the 40 – 80% range. There are also more traditional patients in respiratory distress with similar oxygen saturations. This is a situation where we cannot treat a patient based solely on a number – pulse oximetry may not be a reliable marker of respiratory compromise."
Doctors say ventilators are overused- Statnews.com
“It’s hard to switch tracks when the train is going a million miles an hour,” said Kyle-Sidell, who works at a New York City hospital. “This may be an entirely new disease,” making ventilator protocols developed for other conditions less than ideal.