Ma­jor­ity in hos­pi­tal need in­tu­ba­tion

Vancouver Sun - - PAN­DEMIC -

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.”

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