As health officials around the world push
to get more ventilators to treat coronavirus patients, some doctors are
moving away from using the breathing machines when they can.
The reason: Some hospitals have reported unusually high
death rates for coronavirus patients on ventilators, and some doctors
worry that the machines could be harming certain patients.
Generally speaking, 40% to 50% of patients with severe
respiratory distress die while on ventilators, experts say. But 80% or
more of coronavirus patients placed on the machines in New York City
have died, state and city officials say.
Higher-than-normal death rates also have been reported
elsewhere in the U.S., said Dr. Albert Rizzo, the American Lung
Association’s chief medical officer.
Similar reports have emerged from China and the United
Kingdom. One U.K. report put the figure at 66%. A very small study in
Wuhan, the Chinese city where the disease first emerged, said 86% died.
The reason is not clear. It may have to do with what kind of
shape the patients were in before they were infected. Or it could be
related to how sick they had become by the time they were put on the
machines, some experts said.
But some health professionals have wondered whether the
breathing machines might actually make matters worse in certain
patients, perhaps by igniting or worsening a harmful immune system
reaction.
That’s speculation. But experts do say ventilators can be
damaging to a patient over time, as high-pressure oxygen is forced into
the tiny air sacs in a patient’s lungs.
“We know that mechanical ventilation is not benign,” said
Dr. Eddy Fan, an expert on respiratory treatment at Toronto General
Hospital. “One of the most important findings in the last few decades is
that medical ventilation can worsen lung injury — so we have to be
careful how we use it.”
The dangers can be eased by limiting the amount of pressure and the size of breaths delivered by the machine, Fan said.
But some doctors say they’re trying to keep patients off
ventilators as long as possible, and turning to other techniques
instead.
Only a few weeks ago in New York City, coronavirus patients
who came in quite sick were routinely placed on ventilators to keep them
breathing, said Dr. Joseph Habboushe, an emergency medicine doctor who
works in Manhattan hospitals.
But increasingly, physicians are trying other measures
first. One is having patients lie in different positions — including on
their stomachs — to allow different parts of the lung to aerate better.
Another is giving patients more oxygen through nose tubes or other
devices. Some doctors are experimenting with adding nitric oxide to the
mix, to help improve blood flow and oxygen to the least damaged parts of
the lungs.
“If we’re able to make them better without intubating them,
they are more likely to have a better outcome — we think,” said
Habboushe.
He said those decisions are separate from worries that there
are not enough ventilators available. But that is a concern as well,
Habboushe added.
There are widespread reports that coronavirus patients tend
to be on ventilators much longer than other kinds of patients, said Dr.
William Schaffner, an infectious diseases expert at Vanderbilt
University.
Experts say that patients with bacterial pneumonia, for
example, may be on a ventilator for no more than a day or two. But it’s
been common for coronavirus patients to have been on a ventilator “seven
days, 10 days, 15 days, and they’re passing away,” said New York Gov.
Andrew Cuomo, when asked about ventilator death rates during a news
briefing on Wednesday.
That’s one reason for worries that ventilators could grow in
short supply. Experts worry that as the cases mount, doctors will be
forced to make terrible decisions about who lives and who dies because
they won’t have enough machines for every patient who needs one.
New York State Health Commissioner Dr. Howard Zucker said
Wednesday that officials are looking into other possible therapies that
can be given earlier, but added “that’s all experimental.”
The new virus is a member of the coronavirus family that can
cause colds or more serious illnesses. Health officials say it spreads
mainly from droplets when an infected person coughs or sneezes. There is
no proven drug treatment or vaccine against it.
Experts think most people who are infected suffer nothing
worse than unpleasant but mild illnesses that may include fever and
coughing.
But roughly 20% — many of them older adults or people
weakened by chronic conditions — can grow much sicker. They can have
trouble breathing and suffer chest pain. Their lungs can become
inflamed, causing a dangerous condition called acute respiratory
distress syndrome. An estimated 3% to 4% may need ventilators.
“The ventilator is not therapeutic. It’s a supportive
measure while we wait for the patient’s body to recover,” said Dr. Roger
Alvarez, a lung specialist with the University of Miami Health System
in Florida.
Zachary Shemtob said he was “absolutely terrified” when he
was told his 44-year-old husband, David, needed to be put on a
ventilator at NYU Langone last month after becoming infected with the
virus.
“Needing to be ventilated might mean never getting off the ventilator,” he said.
Shemtob said the hospital did not give any percentages on
survival, but he got the impression it was essentially a coin flip. He
looked up the rates only after his husband was breathing on his own six
days later.
“A coin flip was generous it seems,” he said.
But Shemtob noted cases vary. His husband is relatively young.
“David is living proof that they can really save lives, and how incredibly important they are,” Shemtob said.
https://www.modernhealthcare.com/safety-quality/some-doctors-moving-away-ventilators-virus-patients
No comments:
Post a Comment
Note: Only a member of this blog may post a comment.