Some are asking now, can we prevent the ventilation of some patients and increase the chances of hospitalization for living people?
“In many ways, it’s unlike anything we’ve seen before,” said Dr. James Downar, an intensive care and palliative care specialist from a dedicated Ottawa Hospital intensive care unit, on Thursday. to seriously ill COVID-19 patients. The unit was full on Thursday.
The pandemic virus appears not only to affect the lungs, making them stiff and inflamed, but also to other parts of the body, including the heart. It is not clear if it is a direct effect of the virus on the heart that causes heart failure in some cases, or if it is because the virus plays with the body’s clotting system, increasing the risk of clots blood.
It is different in another way too: in a phenomenon reported in the United States, as well as in Italy and, now, in Canada, some patients with severe COVID-19 arrive at the hospital with levels of blood oxygen so low that they should be out of breath, unable to speak in full sentences, disoriented and barely conscious.
Except that they are in no way in distress, or very little in distress. They are talking. They are lucid. It is not the classic acute respiratory distress syndrome that doctors are used to seeing, and that most guidelines recommend that doctors treat it as such. A Brooklyn intensive care doctor compared it to altitude sickness and urged colleagues to pay attention to who is ventilated and how. The problem is that the pressure can damage the lungs and that some patients could be treated safely with less aggressive means – oxygen masks or tubes in the nose.
With some Ottawa patients, “we give them all the oxygen we can give them without putting them on a respirator, and they are very alert and talking,” said Downar. In certain situations, people are overturned on their stomachs while lying down to improve gas exchange.
This is not the classic acute respiratory distress syndrome that doctors are used to seeing
While the vast majority, about 80% of infections, are mild, the COVID-19 virus can cause pneumonia, which interferes with the ability of oxygen to enter the lungs and into the bloodstream. Currently, approximately 6% of confirmed cases in Canada have been admitted to the intensive care unit.
A ventilator does two things: it provides oxygen as well as pressure to open the alveoli, the air sacs in the lungs to bring in oxygen and carbon dioxide. Although it can potentially save lives, it can worsen lung damage.
The strategy, at this time, is not to rush to intubate, said Downar, who led the writing of a “triage protocol” in Ontario if hospitals are forced to ration beds and ventilators. intensive care. “Unless someone seems to fail or their oxygen level is really at this life-changing critical level, we may be able to hesitate,” said Downar.
“But let me be clear here: these are always the exceptions. The majority fail… They have to put a tube (their throat) and put on a breathing apparatus to help them breathe. “
It is not known what proportion will be discharged alive.
A study published this week in the Journal of the American Medical Association implicated 1,591 people infected with the pandemic virus admitted to the ICU in the Lombardy region of Italy between February 20 and March 18. A high proportion – 88% – required mechanical ventilation. As of March 25, 26% of intensive care patients had died, 16% had left and 58% were still in intensive care. The median age was 62; 82% were men.
Prime Minister Boris Johnson remained in an intensive care unit on Thursday, where his condition is reported to continue to improve. The 55-year-old man is not on a fan; according to a spokesperson, he receives standard oxygen therapy.
People who to have been broken down to describe the experience as horrible beyond belief.
The person is sedated so that they are calm. “Sometimes you have to relax the respiratory muscles so that they can open their mouths and accept that the tube is inserted,” said Dr. John Granton, head of the respiratory division at the University Health Network – Sinai Health System in Toronto. “If they are extremely sick, we have to catch their breath completely, and so we calm them down completely,” which means a medically induced coma.
“We don’t allow them to wake up from this anesthesia until their lungs are healed. And then once they’re cured, or if they’re not that sick, we can allow them to be reasonably conscious, “said Granton.
If it happened to me, that’s what I wouldn’t want to look like at the end
With a tube in the throat, however, they cannot speak. They must communicate using a board or moving their lips. “We have become expert lip readers in the intensive care unit,” said Granton.
Based on experience with H1N1 and SARS, it can sometimes take several weeks or even a month or more for people to recover to the point where they can be “released” from the machines. For some with an important underlying condition, such as chronic obstructive pulmonary disease, there is a risk that they will never come off.
If nothing else, said Granton, the pandemic should force conversations such as, “If this happens to me, that’s what I wouldn’t want to look like in the end.”
As hospitals are closed to COVID-19, families are not allowed inside intensive care. Normally, they are at the bedside. “We are trying to update them over the phone, we are trying to do Facetime,” said Downar. “Having to see a seriously ill family member via video call and having your questions answered by someone who wears a face mask … that is not how we like to do it. But it’s better than nothing. “
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