As emergency and intensive care doctors around the globe work frantically to save the lives of people gravely ill with COVID-19, one of the world’s foremost critical care experts is warning against what he calls the misuse and overuse of mechanical ventilators.
“A standard treatment cannot be applied to an un-standard disease,” said Luciano Gattinoni, a world-renowned Italian intensive care specialist.
He was referring to the current protocol for the machines used to push oxygen into the lungs of patients gravely ill with COVID-19, the disease caused by the novel coronavirus.
Gattinoni, a professor in the department of anesthesiology and intensive care at the Medical University of Göttingen in Germany, gained renown in the early 1980s for placing patients with certain respiratory problems in prone position, on their stomachs, to improve their oxygenation. The technique was first met with ridicule before being widely adopted.
At the outbreak of the coronavirus pandemic in Italy, many emergency departments were immediately placing COVID-19 patients with alarmingly low levels of oxygen on mechanical ventilators, a standard practice for a condition known as Acute Respiratory Distress Syndrome (ARDS).
But in a paper published this week in the journal Intensive Care Medicine, Gattinoni and colleagues wrote that COVID-19 appears to diverge in key ways from normal ARDS, and that the usual recommended use of ventilators at high pressure that works for standard respiratory distress cases may actually harm some COVID-19 patients.
COVID-19 patients, like those suffering from ARDS, have below-normal levels of oxygen in their blood, which leads to breathing problems. In ARDS cases, the lungs lose their elasticity. But in many cases of COVID-19, the lungs remain elastic and people are able to continue breathing for some time despite the low oxygen levels.
This “remarkable combination is almost never seen in severe ARDS,” he writes, adding that patients with normal looking lungs but low oxygen are at risk of lung injury from the ventilators, where pressure from the air damages the thin air sacs that exchange oxygen with the blood.
In Gattinoni’s study, only 20 to 30 per cent of patients fully fit the severe ARDS criteria.
Different types of patients requiring differentiated types of treatment are best identified by CT scan, says Gattinoni. But if CT scans are not available, doctors can indirectly gauge a patient’s needs based on “surrogate” measurements of lung stiffness, for instance, and other factors.
With the standard ARDS treatment, Gattinoni says, people are put on a ventilator sometimes too late, or too early, with the ventilator’s pressure set too high, causing damage.
Marco Garrone, an emergency doctor at the Mauriziano Hospital in Turin, Italy, calls Gattinoni’s paper “a game changer.” He said it states clearly what he and his colleagues have been experiencing in the emergency room since the pandemic exploded in northern Italy in late February.
“We started with a one-size-fits-all attitude, which didn’t pay off,” Garrone said of the practice of putting patients on ventilators right away, only to see their conditions deteriorate. “Now we try to delay intubation as much as possible.”
Factors such as the overall health of the person before catching COVID-19, or how sick they are by the time they arrive in hospital, could also affect how well a person fares.
Oxygen without force
Garrone says his emergency department now begins with non-invasive ventilation — different ways of getting oxygen into patients’ lungs without force, such as a mask or a nasal cannula. This helps people in the early stages of the disease to inhale enough oxygen without damaging their lungs.
Doctors in New York state and elsewhere have voiced similar concerns about putting patients on ventilators too soon and with the pressure too high. Many have begun to delay their use, after New York authorities reported a death rate of 80 per cent for people who go on ventilators.
However, the head of critical care at Toronto’s University Health Network and Mount Sinai Hospital, cautions against drawing any firm conclusions from Gattinoni’s paper.
Niall Ferguson, who is also site-lead at Toronto General Hospital, also says with no data to back it up, the 80 per cent rate in New York is anecdotal and seems “extreme.”
‘It’s mostly a theory’
Ferguson, who calls Luciano Gattinoni “the E.F. Hutton of intensive care — when Gattinoni talks, people listen,” recalling a once-famous brokerage firm ad, was one of the editors of Gattinoni’s paper at Intensive Care Medicine.
His observations about COVID-19 “have generated a lot of discussion in the medical community and on Twitter,” Ferguson said. “But I think it’s important to recognize that it’s mostly a theory at this point.”
With many IC units operating near capacity, he says, doctors do not have the time to randomize patients to one treatment protocol or another in order to study the effectiveness of each.
The Journal of American Medical Association (JAMA) published one study earlier this month on the death rate of COVID-19 patients on ventilators in the hardest-hit Italian region of Lombardy. It actually showed a relatively low death rate on ventilators, 26 per cent, but Ferguson and Garrone both dismissed its results because many patients were still on ventilators when the data was collected and may have died after.
Garrone said it’s when ICU units get overwhelmed that the risk of misuse of ventilators is highest.
‘It’s been a constant flood’
“Everyone talks about COVID as being a tsunami, but a tsunami is a wave that passes. Here in Italy, it’s been a constant flood,” he said. “ICU physicians in Italy are well-versed with ventilation. But these patients were so overwhelming in numbers that they trickled out of the ICU into the emergency department. And that’s where we began to ventilate them.”
3.I have had to become braver about not intubating patients. I think we should avoid intubation if at all possible. I have previously been an advocate of intubating early to ensure safe, non-emergent intubating conditions. My perspective is shifting.
Ferguson agrees that the use of ventilators becomes an issue with doctors, pulled into a crisis situation, who are less experienced with the devices.
But he said the IC community of doctors he’s in touch with are well aware that treatment of COVID-19 patients needs to be individualized, which was Gattinoni’s main point.
Laura Duggan, an anesthesiologist at the Ottawa Hospital, told the Emcrit podcast for emergency and critical care doctors that, like many ICU doctors, she looked to intubate patients with low oxygen right away, but that she’s “happy to see that pendulum swinging back a bit” to figuring out what else can be done.
“I think there is a balance to be had between finding something that’s simple and widely applicable versus trying to still personalize things for each patient,” said Ferguson.