Limited data on ventilator use for COVID-19 patients: respiratory therapist

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Vicki Kap’s family believed she had a cold, but within two days of arriving at the hospital, she was placed on a ventilator and died of COVID-19.

Daughter Jody Brouwer said 75-year-old Kap started having difficulty breathing before being taken by ambulance to a hospital in Sarnia, Ontario, where she would spend a week before dying on the unit intensive care.

“Mom didn’t want to be on a fan for more than four days if she made no progress,” said Brouwer, adding that her parents had end-of-life conversations because her father had stage bowel cancer. four and was presumed to have the virus.

“We were told with my mom that she would wear a respirator for the rest of her life, that she could never go home, that she would go to a nursing home if she kept her under ventilator for month. “

Kap’s heart was in distress before her death on March 29, three days after she would have celebrated her 54th wedding anniversary with husband Frank, said Brouwer. She was the only caretaker of her husband at their home while he was waiting to go to a hospice.

She believes her parents contracted the virus after having coffee with friends who returned from Portugal in early March. The friends were asymptomatic at the time, but later fell ill.

Brouwer’s uncle and his wife from nearby Strathroy had traveled with the couple and also fell ill, one of eight relatives and friends who contracted the virus, said Brouwer.

His uncle, Martin Postma, died two days before his mother and was also on a fan, said his wife.

Mieke Postma said her family decided to remove her husband from the ventilator after nine days because they feared his quality of life would be poor if he survived.

“He hasn’t really shown much improvement during this period. If anything, it got worse with her completely failing kidneys, “said Postma, adding that her husband’s heart was also affected.

Kap had minor chronic obstructive pulmonary disease but was otherwise healthy, said Brouwer, who has questions about what is learned about the use of ventilators.

Doctors around the world have little limited study data. Much of the research includes patients still on respirators, with no information on long-term outcomes for those who might survive.

Kap ended up in the hospital after his nephew, Jeff Cain, spoke to him on the phone and realized that his breathing was difficult.

Cain, who is a former respiratory therapist, said he had placed a small device called a pulse oximeter outside of Kap’s home so that she could place it on her finger to measure the level of oxygen saturation in her blood and go to the hospital if the level was too high. low.

Cain said both of his parents were also diagnosed with COVID-19 and that they are recovering well.

“I know a gentleman from the same community who came out of the fan this week,” he said.

“My mom asked,” Is this automatically a death sentence? I said, “No, it depends on what’s going on. »»

Thomas Piraino, a respiratory therapist from the intensive care unit at St. Michael’s Hospital in Toronto, said that patients are put on respirators after they develop a lung injury called acute respiratory distress syndrome.

People with a condition like chronic obstructive pulmonary disease, like Kap, have reduced air flow to the lungs and may receive non-invasive oxygen therapy depending on the severity of COVID- 19 upon arrival at the hospital, said Piraino, who oversees the integration of clinical research and the practice of mechanical ventilation at St. Michael’s.

“They could be at an early stage where when you insert the tube, the lungs are very conforming, like a balloon that can inflate very well. Or they may be at a stage where they have much stiffer lungs and it is more difficult to ventilate them, “he said.

By then, the lungs may look like a hardened sponge, preventing oxygen from flowing to the air sacs called air sacs and making breathing impossible, said Piraino. A medical coma is induced at this point before a tube is inserted into a patient’s trachea so that a ventilator can supply oxygen and resume breathing.

“As to why (the virus) gets to this point, it is a number of components and we are still trying to learn it because it has only been around for a few months. “

Small studies around the world show mixed results on the survival rates of COVID-19 patients. They include limited data and involve patients who are still on the machines, so it is unclear whether they will survive or what their long-term outcome or quality of life will be if they start breathing on their own.

For example, a study published recently in the Journal of the American Medical Association on 1,591 patients in hospitals in Lombardy, Italy, showed that 68% of them were placed under a ventilator and 26% of them have passed away.

He said 58% of the patients were on ventilators when the nearly five-week study was completed on March 25.

“Every study that is published right now is in the middle of it all, so it’s useful to see where people are, but that doesn’t really give us an overview,” said Piraino, adding that the concerns range from whether the patients should have been ventilated earlier or whether the intubation took place too early.

“Most people who use a fan take it out. With COVID, we just don’t know. “

Mortality rates for studies so far have ranged from 26% to 70%, he said.

Dr. Michael Curry, an emergency room doctor at Delta Hospital in the Vancouver area, said he saw studies showing death rates as high as 80%, depending on the data used.

“Fans can save lives for some people who will die without a fan,” he said. “A ventilator can give them time for the body to fight the infection and they can do well after the ventilator stops. But for a lot of people who put on a fan, they’re never going to detach from it, at least not alive. “

Curry said that Canada has about seven or eight respirators per 100,000 people and that there is no shortage of respiratory equipment, which requires a large staff of doctors, nurses and respiratory therapists.

“What will happen in the future, we don’t know. But we have seen in countries like Spain and Italy that there could be dramatic demand for ventilators if we do not get this disease under control quickly, “he said.

The federal government has announced plans to order 30,000 fans.

This Canadian Press report was first published on April 15, 2020

Camille Bains, The Canadian Press

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