Ventilators no panacea
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Back in the dark ages, when I was doing respiratory intensive care, superinfection was a big, big problem. The risk of infection increased with the time of mechanical ventilation.
The other thing that people aren't talking about is that keeping an endotracheal tube in for a long time has its own attendant complications (vocal cord injury, etc). After about 5 days on a ventilator, we started asking the question: "Do you see this person not needing a ventilator in 48 hours?"
If the answer was "No," we would start talking about tracheostomy.
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I’d seen the UK results that 1/3 survive.
I wonder what the survival rate is of people who need ventilators and don’t get them?
Only non-witches get due process.
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I’d seen the UK results that 1/3 survive.
I wonder what the survival rate is of people who need ventilators and don’t get them?
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@jon-nyc said in Ventilators no panacea:
I wonder what the survival rate is of people who need ventilators and don’t get them?
Probably about zero, if I had to guess.
Good point.
I don’t believe the public has a real understanding of vents. Cuomo made it the number 1 thing as if it was the most important matter of life and death. Vents consume lots of healthcare resources and I’m not sure if it puts them more at risk. I’m sure we would all want a vent for our loved ones but it is expensive use of reources, with low odds and could but additional stress on the system.
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I don’t believe the public has a real understanding of vents. Cuomo made it the number 1 thing as if it was the most important matter of life and death. Vents consume lots of healthcare resources and I’m not sure if it puts them more at risk. I’m sure we would all want a vent for our loved ones but it is expensive use of reources, with low odds and could but additional stress on the system.
@Loki said in Ventilators no panacea:
I don’t believe the public has a real understanding of vents. Cuomo made it the number 1 thing as if it was the most important matter of life and death. Vents consume lots of healthcare resources and I’m not sure if it puts them more at risk. I’m sure we would all want a vent for our loved ones but it is expensive use of reources, with low odds and could but additional stress on the system.
Yeah.
Low odds, but ⅓ or ¼ are not horrible.
If your loved one was on the edge of needing a ventilator, and you were told "Hey, Loki, there's only a 25% chance s/he'll survive," would you take that chance?
I would.
25% is better than zero.
I don’t believe the public has a real understanding of vents.
Exactly. This is a big deal. It is a major commitment and toss of the dice. Ventilation after surgery is not a big deal, in fact it's common after some procedures. Ventilation with a short, self-limited disease (pneumonia) is the same.
This is not short, and not necessarily self-limited. It's not a cure, it's support.
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Yes. It would be (ahem) yuge.
However, the complications of administering chloroquine are dwarfed by the complications of putting an endotracheal tube in someone and keeping it there for two weeks.
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Yes. It would be (ahem) yuge.
However, the complications of administering chloroquine are dwarfed by the complications of putting an endotracheal tube in someone and keeping it there for two weeks.
@George-K it seems to me that part of the problem is that we are waiting too long to administer treatments to individuals? There are a lot of patients such as Jodi’s husband where the symptoms are severe flu-like but not quite serious enough to justify hospitalization and treatment. The majority of the time ( like in Mr. Jodi’s case) it works itself out, but in a significant number of cases it turns ugly quickly. Okay one minute and drowning the next. Maybe the treatments need to be more focused earlier on? Help them before they need intubation?
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And just how in the sugar are you going to do that?
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I’d seen the UK results that 1/3 survive.
I wonder what the survival rate is of people who need ventilators and don’t get them?
@jon-nyc said in Ventilators no panacea:
I’d seen the UK results that 1/3 survive.
I wonder what the survival rate is of people who need ventilators and don’t get them?
https://www.cnn.com/2020/04/22/health/coronavirus-ventilator-patients-die/index.html
One out of ten in this series:
Overall, about 20% of Covid-19 patients treated at Northwell Health died, and 88% of those placed on ventilators died, according to the study. A ventilator is a device that forces air into the lungs of patients who cannot breathe on their own because of severe pneumonia or acute respiratory distress syndrome.
Other, smaller reports have indicated that patients who need ventilation are unlikely to survive.
Just 12% of the patients in the study needed ventilators, Dr. Safiya Richardson at the Feinstein Institutes for Medical Research, Northwell Health, and colleagues found.
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This conversation is a prime example of why EMRs are not going to tell us the things that were envisioned. Data is not always reliable data, and there are SO DAMN MANY variables that go into making up these statistics. Loki's comment about not venting after a certain age for instance. There's no EMR in the world that takes into account local protocols like that, at least not in terms of sharing data.
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@Jolly said in Ventilators no panacea:
And just how in the sugar are you going to do that?
Jolly, at the time I made that post, most of the non-hospitalized ill were being told to take OTC drugs for symptom relief but generally weren't being given many of the drugs that were later included in clinical trials.
Of course, I think the results of most of these clinical trials are going to depend a lot on how money the pharmaceutical manufacturers stand to make...
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THe 88% number from NYC was premature.
Headlines from articles by theWashington Post, The Hill, CNN, the New York Post, Bloomberg, and others suggested that nearly 90 percent of patients with a case of coronavirus severe enough to require a ventilator died. The basis for these claims is a study published in the Journal of the American Medical Association, a peer-reviewed medical journal, on Wednesday. The study examined 5,700 patients who had been hospitalized due to coronavirus in New York City between March 1 and April 4. It analyzes a number of factors—age, sex, underlying health issues—to explore how patients in different groups fared with coronavirus. But the finding that led to a flurry of articles and tweets was that “Mortality for those requiring mechanical ventilation was 88.1%.”
However, this statistic doesn’t tell the whole story. Of the 5,700 patients included in the study, 3,066 cases were not yet resolved. As the doctors behind the paper wrote: “The absence of data on patients who remained hospitalized at the final study date may have biased the findings, including the high mortality rate of patients who received mechanical ventilation older than age 65 years.” While reporting on the study often included this caveat, the headlines and tweets did not.
The authors also cautioned that “this study reported mortality rates only for patients with definite outcomes (discharge or death), and longer-term study may find different mortality rates as different segments of the population are infected.”
One of the paper’s authors, Dr. Mangala Narasimhan, told The Dispatch Fact Check that across the hospital system the ventilator mortality rate is currently in the high 60 percent range. “It will continue to drop a little,” said Dr. Narasimhan. “I think it will be in the 50-60 percent mark.”
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'Truly remarkable' success using ventilator alternatives
Doctors at the University of Chicago Medicine are seeing “truly remarkable” results using high-flow nasal cannulas rather than ventilators and intubation to treat some COVID-19 patients.
High-flow nasal cannulas, or HFNCs, are non-invasive nasal prongs that sit below the nostrils and blow large volumes of warm, humidified oxygen into the nose and lungs.
A team from UChicago Medicine’s emergency room took dozens of COVID-19 patients who were in respiratory distress and gave them HFNCs instead of putting them on ventilators. The patients all fared extremely well, and only one of them required intubation after 10 days.
“The success we’ve had has been truly remarkable,” said Michael O’Connor, MD, UChicago Medicine’s Director of Critical Care Medicine.
The HFNCs are often combined with prone positioning, a technique where patients lay on their stomachs to aid breathing. Together, they’ve helped UChicago Medicine doctors avoid dozens of intubations and have decreased the chances of bad outcomes for COVID-19 patients, said Thomas Spiegel, MD, Medical Director of UChicago Medicine’s Emergency Department.
“The proning and the high-flow nasal cannulas combined have brought patient oxygen levels from around 40% to 80% and 90%, so it’s been fascinating and wonderful to see,” Spiegel said.Mechanical ventilation – the most common treatment for these patients thus far – involves inserting a breathing tube into the windpipe so a ventilator can pump air into the lungs. Using a ventilator or intubation as a last resort – an approach UChicago Medicine teams call “prevent the vent” – helps get COVID-19 patients out of the hospital intensive care unit and prevents harmful side effects caused by ventilators, such as lung injuries.
“Avoiding intubation is key,” Spiegel said. “Most of our colleagues around the city are not doing this, but I sure wish other ERs would take a look at this technique closely.”
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'Truly remarkable' success using ventilator alternatives
Doctors at the University of Chicago Medicine are seeing “truly remarkable” results using high-flow nasal cannulas rather than ventilators and intubation to treat some COVID-19 patients.
High-flow nasal cannulas, or HFNCs, are non-invasive nasal prongs that sit below the nostrils and blow large volumes of warm, humidified oxygen into the nose and lungs.
A team from UChicago Medicine’s emergency room took dozens of COVID-19 patients who were in respiratory distress and gave them HFNCs instead of putting them on ventilators. The patients all fared extremely well, and only one of them required intubation after 10 days.
“The success we’ve had has been truly remarkable,” said Michael O’Connor, MD, UChicago Medicine’s Director of Critical Care Medicine.
The HFNCs are often combined with prone positioning, a technique where patients lay on their stomachs to aid breathing. Together, they’ve helped UChicago Medicine doctors avoid dozens of intubations and have decreased the chances of bad outcomes for COVID-19 patients, said Thomas Spiegel, MD, Medical Director of UChicago Medicine’s Emergency Department.
“The proning and the high-flow nasal cannulas combined have brought patient oxygen levels from around 40% to 80% and 90%, so it’s been fascinating and wonderful to see,” Spiegel said.Mechanical ventilation – the most common treatment for these patients thus far – involves inserting a breathing tube into the windpipe so a ventilator can pump air into the lungs. Using a ventilator or intubation as a last resort – an approach UChicago Medicine teams call “prevent the vent” – helps get COVID-19 patients out of the hospital intensive care unit and prevents harmful side effects caused by ventilators, such as lung injuries.
“Avoiding intubation is key,” Spiegel said. “Most of our colleagues around the city are not doing this, but I sure wish other ERs would take a look at this technique closely.”
@George-K Why won’t other hospitals try it?
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@George-K Why won’t other hospitals try it?
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@LuFins-Dad it's my understanding that they are.
@George-K said in Ventilators no panacea:
@LuFins-Dad it's my understanding that they are.
From the article:
“ Most of our colleagues around the city are not doing this, but I sure wish other ERs would take a look at this technique closely.” -
@George-K said in Ventilators no panacea:
@LuFins-Dad it's my understanding that they are.
From the article:
“ Most of our colleagues around the city are not doing this, but I sure wish other ERs would take a look at this technique closely.”@LuFins-Dad this thinking has been going around for a while:
From April: https://www.businessinsider.com/ventilator-high-flow-oxygen-coronavirus-patients-ards-dying-2020-4?op=1
Initially, the Brooklyn hospital was racing to put patients on ventilators early on. Now it's relying more on high-flow oxygen therapy, in which oxygen is delivered into the lungs of patients through the nose.
Brooklyn Dr. Cameron Kyle-Sidell was among those who started questioning using the established ARDS protocol to treat patients, with many put on ventilators and not surviving.
Anumber of front-line doctors adopted a protocol to deliver high-flow oxygen through a tube or mask for long periods of time and using so-called “proning” — moving patients off their backs.
“We started having patients go to their left side or their right side and suddenly the oxygenation went up, and we’re able to reverse the hypoxemia and prevent the intubation,” Farcy said.
