USA TODAY International Edition
Regimen suggests serious illness
Some doctors question Trump’s progress report
President Donald Trump has received oxygen and has begun a course of steroids. Doctors said patients for whom that’s the case often spend several days in the hospital in the best- case scenario.
At a news conference Sunday morning, one of the physicians treating the president said he had begun a course of the steroid dexamethasone Saturday after a drop in his oxygen levels. The president will receive that “for the time being,” Dr. Sean Dooley said.
The president’s physician, Navy Cmdr. Sean Conley, said that if Trump continued to look and feel well, “our hope is that we can plan for a discharge as early as ( Monday) to the White House, where he can continue his treatment course.”
That would not be the typical plan for most COVID- 19 patients who have
required oxygen and have been placed on steroids, said doctors who care for patients with the illness.
“I will say that I’ve never started someone with COVID- 19 on steroids and then thought I’d be discharging the patient home the next day,” said Russell Buhr, a professor of pulmonary and critical care medicine at the University of California- Los Angeles.
Oxygen is typically given to patients when the level of oxygen saturation in their blood is below 92%, he said.
“Generally, once a patient is on oxygen, they stay in the hospital for four or five days, if everything goes well,” said J. Randall Curtis, a professor of pulmonary and critical care medicine at the University of Washington School of Medicine in Seattle.
“If a patient is off oxygen and then goes back on oxygen, that would suggest they’ve gotten a little bit worse. If they’ve started on dexamethasone, that suggests to me he’s gotten a little bit worse,” Curtis said. “If he’s requiring oxygen, then he has COVID pneumonia.”
Though that might sound dire, it simply means there is an infection in the lung causing inflammation in the alveoli, the tiny air sacs in the lungs that transfer oxygen from the lungs to the bloodstream. COVID- 19 pneumonia can range from mild to dangerously severe.
In Curtis’ experience treating more than 100 COVID- 19 patients in Seattle, people who require oxygen and get dexamethasone “would generally have some abnormality on their chest X- ray. Typically, it’s what we call the ‘ ground glass’ pattern that’s seen with COVID pneumonia,” he said. The ground glass pattern refers to a hazy white area in a lung X- ray or CT scan showing infection or inflammation. Typical lung tissue shows up as gray.
A patient with mild pneumonia and on oxygen could recover within two to five days and return home, Curtis said. But it could also go the other way.
“The concern is that in that window of time, it’s still possible that the pneumonia would continue to get worse,” he said. “Unfortunately, we don’t have any great ways of stopping that. Dexamethasone helps a little bit. Remdesivir helps a little but only a little.”
Dexamethasone treatment generally indicates more severe disease, they said. Recommendations for dexamethasone are that it be given to patients who require supplemental oxygen or who are on ventilation, Buhr said. It is not typically given prophylactically as an early defense against such an inflammatory response.
“The reason we don’t is that steroids are not totally benign. They increase your risk of other infections, and they increase your risks of delirium,” he said.
“The Infectious Diseases Society of America’s guidelines for steroids in COVID- 19 patients say that they should always be given to people with critical illness,” said George Rutherford, a professor of epidemiology at the University of California School of Medicine. “You don’t want to give steroids if they’re not needed.”
Dexamethasone is a steroid given to tamp down an overactive immune response in the body. This comes when the virus provokes an immune response that sends cells into the lungs to clean up the damage, which causes inflammation.
“That inflammation in and of itself can make it more difficult for oxygen to pass from the lung into the bloodstream” and tends to occur later in the course of the disease, Buhr said, and the inflammatory reaction can break down the lung tissue itself, “like a forest fire generating its own fuel.”
Though he didn’t want to play armchair physician to the president, Buhr said, the treatments reported by the president’s doctors and the rosy picture given in Sunday’s news conference “don’t line up.”