“Standard treatment cannot be applied to a non-standard disease,” said Luciano Gattinoni, a world-renowned Italian intensive care specialist.
He was referring to the current protocol for machines used to push oxygen into the lungs of critically ill patients with COVID-19, the disease caused by the new coronavirus.
Gattinoni, professor in the Department of Anesthesiology and Intensive Care at the Medical University of Göttingen in Germany, became known in the early 1980s for placing patients with certain respiratory problems on their stomachs , to improve their oxygenation. The technique was first ridiculed before being widely adopted.
When the coronavirus pandemic broke out in Italy, many emergency departments immediately placed patients with COVID-19 with alarming oxygen levels in mechanical ventilators, a standard practice for a condition known as acute respiratory disease syndrome (ARDS).
But in an article published this week in the journal Intensive Care Medicine, Gattinoni and colleagues wrote that COVID-19 appears to diverge significantly from normal ARDS, and that the usual recommended use of high-pressure ventilators that work for standard respiratory distress may actually harm some COVID- patients. 19.
COVID-19 patients, like those with ARDS, have lower-than-normal oxygen levels in their blood, which causes breathing problems. In ARDS, the lungs lose their elasticity. But in many cases of COVID-19, the lungs remain elastic and people can continue to breathe for a while despite the low oxygen levels.
This “remarkable combination is almost never seen in severe ARDS,” he writes, adding that patients with normal looking lungs but low oxygen levels are at risk for lung damage to ventilators, where pressure air damages the thin air sacs that exchange oxygen with the blood.
In Gattinoni’s study, only 20-30% of patients fully met the stringent ARDS criteria.
Different types of patients requiring differentiated types of treatment are better identified by computed tomography, says Gattinoni. But if CT scans aren’t available, doctors can indirectly assess a patient’s needs based on “surrogate” measures of lung stiffness, for example, and other factors.
With standard ARDS treatment, says Gattinoni, people are put on a ventilator sometimes too late or too early, with a set ventilator pressure too high, causing damage.
Marco Garrone, an emergency doctor at Mauriziano Hospital in Turin, Italy, calls Gattinoni’s diary “a game changer”. He said he was making it clear what he and his colleagues have been living in the emergency room since the pandemic exploded in northern Italy in late February.
“We started with a unique attitude, which has not paid off,” said Garrone of the practice of putting patients on immediate ventilation to see their condition deteriorate. “Now we are trying to delay the intubation as much as possible. “
Factors such as the person’s overall health before taking COVID-19, or how sick they are when they arrive at the hospital, could also affect an individual’s health.
Oxygen without force
Garrone says his emergency department now starts with non-invasive ventilation – different ways to get oxygen into the lungs of patients without force, like a mask or a nasal cannula. This helps people in the early stages of the disease to inhale enough oxygen without damaging their lungs.
Doctors in New York State and elsewhere have expressed similar concerns about putting patients too early on ventilation and too high pressure. Many have started to delay their use, after New York authorities have reported an 80% death rate for people who use respirators.
However, the chief of intensive care at the University Health Network in Toronto and Mount Sinai Hospital cautioned against any firm conclusions drawn from Gattinoni’s article.
Niall Ferguson, who also runs the Toronto General Hospital site, also said that without data to confirm it, the 80% rate in New York is anecdotal and seems “extreme”.
“It’s mostly a theory”
Ferguson, who calls Luciano Gattinoni “The EF Hutton of Critical Care – When Gattinoni Speaks, People Listen”, recalling an announcement from a once famous brokerage firm, was one of the editors of Gattinoni’s article at Intensive Care Medicine.
His comments on COVID-19 “sparked much discussion in the medical community and on Twitter,” said Ferguson. “But I think it’s important to recognize that this is mainly a theory at this point. “
With many IC units operating near full capacity, he says, doctors have no time to randomize patients to one treatment protocol or another to study the effectiveness of each.
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The Journal of American Medical Association (JAMA) released a study earlier this month on the mortality rate of patients on COVID-19 on ventilation in the Italian region of Lombardy most affected. He actually showed a relatively low ventilation mortality rate, 26%, but Ferguson and Garrone both rejected his results because many patients were still ventilated when the data were collected and may have died afterwards.
Garrone said it is when intensive care units are overwhelmed that the risk of improper use of ventilators is greatest.
“It was a constant flood”
“Everyone’s talking about COVID as a tsunami, but a tsunami is a passing wave. Here in Italy, it’s a constant flood, “he said. “ICU doctors in Italy are familiar with ventilation. But there were so many of these patients that they leaked from the ICU to the emergency room. And that’s where we started to break them down. “
3. I had to show more courage not to intubate the patients. I think we should avoid intubation if possible. I have already been a proponent of early intubation to ensure safe and non-emerging conditions of intubation. My perspective changes.
Ferguson agrees that the use of ventilators is becoming an issue with physicians, trained in a crisis, who are less experienced with the devices.
But he said that the IC community of doctors with whom he is in contact is well aware that the treatment of COVID-19 patients must be individualized, which was the main point of Gattinoni.
Laura Duggan, anesthesiologist at the Ottawa Hospital, told the Written for Emergency and Critical Care podcast that, like many critical care physicians, she wanted to intubate low oxygen patients immediately, but that she was “happy to see this pendulum rocking little” to understand what else can be done.
“I think there is a balance to be struck between finding something simple and broadly applicable versus trying to further personalize things for each patient,” said Ferguson.