Majority in hospital need intubation
One Brooklyn critical care doctor has likened it to altitude sickness and is urging his colleagues to be cautious about who is being ventilated, and how. The concern is that the pressure may be harming lungs, and that some patients could be more safely treated with less aggressive means — oxygen masks or tubes in the nose.
With some Ottawa patients, “we’re giving them all the oxygen we can give them without putting them on a breathing machine, and they’re wide awake and talking,” Downar said. In some situations, people are being flipped onto their stomachs, into the prone position, to improve gas exchanges.
While the vast majority, some 80 per cent of infections, are mild, the COVID-19 virus can cause pneumonia, which interferes with the ability of oxygen to get in through the lungs, and into the bloodstream. Currently, about six per cent of confirmed cases in Canada have required admission to an ICU.
A ventilator does two things: it provides oxygen as well as pressure to open up the alveoli, the air sacs in the lungs to get oxygen in, and carbon dioxide out. While potentially life saving, it can worsen lung injury.
The strategy, for now, is not to rush to intubate, said Downar, who led the drafting of an Ontario “triage protocol” if hospitals are forced to ration ICU beds and ventilators. “Unless somebody seems to be failing, or their oxygen level is truly at this critical life-changing level, we can maybe hesitate,” Downar said.
“But let me be explicitly clear here: These are still the exceptions. The majority are failing … They need to have a tube put down (their throats) and put on a breathing machine to help them breathe.”
It’s not clear what proportion will be discharged alive.
A study published this week in the Journal of the American Medical Association involved 1,591 people infected with the pandemic virus admitted to ICUS in the Lombardy region of Italy between Feb. 20 and March 18. A high proportion — 88 per cent — required mechanical ventilation. As of March 25, 26 per cent of the ICU patients had died, 16 per cent had been discharged, and 58 per cent were still in the ICU. The median age was 62; 82 per cent were men.
British Prime Minister Boris Johnson was transferred out of ICU Friday, after his condition improved. The 55-year-old had spent three days there, where he had received standard oxygen therapy, but had not been on a ventilator, a spokesman said.
People who have been ventilated describe the experience as awful beyond belief.
The person is sedated, so that they’re calm. “Sometimes you have to relax the breathing muscles so they’re able to open their mouth and accept the tube being inserted,” said Dr. John Granton, head of the division of respirology at Toronto’s University Health Network-sinai Health System. “If they’re incredibly sick we need to take over their breathing completely, and so we fully sedate them,” meaning a medically induced coma.
“We don’t allow them to wake up from that anaesthetic until their lungs have healed. And then once they’ve healed, or if they’re not that sick, we can allow them to be reasonably aware,” Granton said.
With a tube down their throat, however, they can’t speak. They have to communicate by using a board, or moving their lips. “We’ve become expert lip readers in the intensive care unit,” Granton said.
From the experience with H1N1 and SARS, it can sometimes take several weeks, or a month or more, for people to recover to the point they can be “liberated” from the machines. For some with a significant underlying condition, like chronic obstructive pulmonary disease, there’s a risk they may never come off.
If nothing else, Granton said, the pandemic should be forcing conversations such as, “If this ever happened to me, this is what I would not want to look like at the end.”
With hospitals in COVID-19 lockdown, families aren’t allowed inside the ICU. Normally, they’re at the bedside. “We’re trying to update them by phone, we’re trying to do Facetime,” Downar said. “To have to see a critically ill family member through a video call and have your questions answered by somebody wearing a face mask ... it’s not the way we like to do things. But it’s better than nothing.”