Early treatment may be a life-saver for patients
Covid-19 has been described as a ‘silent killer’ for its ability to damage the lungs without the patient even realising. Here, Plaid Cymru leader Adam Price explains why early and effective treatment could be the answer to reducing the burden on the NHS..
SPEED has turned out to be the great global dividing line between success and failure in the fight against Covid-19.
Those countries that did “move quickly”, in those ringing words of the WHO’s Mike Ryan on the day the pandemic was declared, implementing social distancing and a policy of mass test and trace early have kept their death rates to a minimum.
But there’s a third dimension to the triple early principle that worked so well in Asia that has so far largely been overlooked – not just “early diagnosis” and “early isolation”, but crucially, “early treatment”.
If treating early has worked elsewhere, are patients here presenting too late? A case notes review in Aneurin Bevan University Health Board has been looking into this and is due to be completed by the end of this week.
Many Covid-19 patients seem to exhibit a form of what some have described as “happy hypoxia” before they are hospitalised.
Their lungs remain “compliant” which in non-technical terms means they’re not yet stiff or painful, and they may not even feel short of breath.
But their oxygen levels are often already well below 90% saturation levels. Hypoxia is known to stimulate inflammation (the Cytokine Storm as it’s come to be known) and can lead to irreversible lung damage as patients try and compensate by breathing harder, again often without knowing that they’re doing so.
It’s this phenomenon that has led some to dub the novel coronavirus a “silent killer”, as people do not realise how ill they are until too late.
Many of those in hospital already have quite severe lung injury by the time they present, with a high proportion of these going on to develop acute respiratory failure.
Mechanical ventilation and intubation proves necessary for these patients, but has very poor prognosis for many (86% mortality quoted in one prominent international study) despite the heroic efforts of intensive care teams.
This has led some to question whether the policy of asking patients with only mild symptoms to simply isolate at home and wait until symptoms worsen before seeking medical support may be worsening their chances of survival.
A number of published studies from China and Italy have concluded that early treatment, before the onset of severe symptoms, may provide the best chance to lower mortality rates.
Giving supplemental oxygen through a variety of non-invasive methods (for example CPAP) and even asking patients to sleep on their front seems to have good results if applied early.
Early intervention also has the added benefit, according to doctors in Hong Kong, of improving the long-term outcomes of those that recover as the virus has less time to wreak havoc on the body.
Early identification of hypoxia, in particular, seems critically important. Beginning to test all those with symptoms again will help, but we need to monitor them closely too.
In Germany, for example, everyone who tests positive gets a daily check-up call – anyone who doesn’t answer gets visited by an ambulance.
A number of hospitals around the world are using pulse oximeters to measure oxygen levels remotely even among those with mild symptoms.
The Royal Berkshire Hospital in Reading, for example, has created a virtual ward for patients sent home with an oximeter.
Methods like these allow patients to be fast-tracked for earlier noninvasive intervention, which could even be done in the home as shown in Italy and Germany.
A CPAP device and a pulse oximeter made in Wales and designed specifically with Covid-19 in mind are waiting to be green-lighted by the MHRA regulatory body for temporary use once the Welsh Government signals its support.
The question of ‘patient pathways’ hasn’t figured much in the wider national policy debate to date.
Attention has focused more on how to prevent the level of infection from overwhelming the NHS (field hospitals, ventilators etc.) than how we treat and triage the already infected.
But if the ultimate aim is saving lives then the question of when to intervene is every bit as important.
The Aneurin Bevan study has involved looking at the case notes of a 100 people that were admitted to local hospitals with Covid-19.
The focus of the study has been working out whether earlier intervention might lead to improved outcomes and what the implications might be for service delivery and/or communication with the public eg. the initiation of CPAP at an early enough stage of the disease to prevent the need for mechanical ventilation.
One of the emerging hypotheses that is being tested is whether new shortness of breath might be an indication of needing to seek medical help.
Agility as ever is key. The European Centre for Disease Prevention and Control reported that “early supportive therapy, where healthcare capacity exists, can improve outcomes” almost four weeks go on April 23.
My colleague Rhun ap Iorwerth raised the need for earlier medical intervention with the Health Minister at the end of March.
If clinicians’ evidence from within the Welsh NHS now suggests we need to change our approach, then we must act quickly, and even independently if necessary, if there is no consensus yet among the other UK Chief Medical Officers.
The “greatest error is not to move” as Mike Ryan has said. Let’s not make that mistake again.