COVID-19: Revisiting ventilator protocol

Across the nation, government leaders and hospital systems have voiced the urgent need for more ventilators to meet the challenge of the increasing number of critically ill patients with COVID-19. But, with emerging evidence showing a significant percentage of patients with the disease dying on ventilators, some health experts are now wondering whether ventilation is really the best treatment strategy.

According to some frontline clinicians, ventilators may be doing more harm than good.

"We're not sure how much help ventilators are going to be. They may help keep somebody alive in the short term. We're not sure if it's going to help keep someone alive in the long term,” Tiffany Osborn, MD, professor of surgery, Washington University, St. Louis, MO, who has been caring for patients with COVID-19 at Barnes-Jewish Hospital, told NPR.

She added: "[T]he ventilator itself can do damage to the lung tissue based on how much pressure is required to help oxygen get processed by the lungs.”

Of note, patients with COVID-19 often require high levels of pressure and oxygen due to the severity of lung inflammation characteristic of the disease. In addition to lung damage, patients on ventilators are at increased risks for ventilator-associated pneumonia, as well as long-term, adverse cognitive and physical health effects secondary to sedation and intubation.

Why ventilators?

If ventilators aren’t providing the best outcomes for patients with COVID-19, why are healthcare workers clamoring for the equipment? Some physicians have suggested it’s because ventilators have been successful in the treatment of other common forms of pneumonia. What’s now becoming clear, however, is that coronavirus-related pneumonia is another beast entirely.

"[With common forms of pneumonia we] treat patients for several days, and then we get the antibiotics into the body and the patient recovers. Unfortunately with this COVID-associated pneumonia, there are no treatments that we know work for sure,” Negin Hajizadeh, MD, associate professor of medicine and a pulmonary critical care physician, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Long Island, NY, told NPR.

But, some physicians contend that the key to effective COVID-19 treatment may lie in the nuances of the disease itself. A number of critical care specialists have observed that many patients with COVID-19 have extremely low blood oxygen levels—yet, interestingly, they are not struggling for air, their hearts aren’t racing, and their brains show no signs of oxygen deprivation. This observation has led physicians to suspect that blood levels of oxygen—which has long driven decision-making about breathing support for patients with pneumonia and respiratory distress—might be misleading them about how to best care for those with COVID-19.

They contend that a large proportion of hospitalized patients with the respiratory illness may actually receive greater benefit from treatment with less invasive respiratory support alternatives—such as breathing masks used for sleep apnea and nasal cannulas—than with ventilatory therapy.

Commenting on the possibility of using less invasive breathing support for critically ill patients with COVID-19, Sohan Japa, MD, internal medicine physician, Boston’s Brigham and Women’s Hospital, Boston, MA, told Stat News: “I think we may indeed be able to support a subset of these patients…I think we have to be more nuanced about who we intubate.”

Changing gears

This shift in therapeutic strategy would help alleviate the shortage of ventilators and would reduce the risks of ventilator-associated adverse effects among patients. But, such a wide and abrupt change in protocol may be easier said than done, and there are a number of other risk factors to consider. One major problem is the danger CPAP and other positive-pressure machines pose to healthcare workers. Such devices can propel aerosolized particles into the air. Although the intubation for ventilators can also aerosolize virus particles, the machine is a contained system thereafter.

“If we had unlimited supply of protective equipment and if we had a better understanding of what this virus actually does in terms of aerosolizing, and if we had more negative pressure rooms, then we would be able to use more [of the noninvasive breathing support devices],” ICU physician and pulmonologist Lakshman Swamy, MD, Boston Medical Center, told Stat News.

Nevertheless, with countless patient lives at risk, healthcare systems are starting with small changes.

“Most hospitals, including ours, are using simpler, noninvasive strategies first,” such as apnea devices and nasal cannulas, Dr. Greg Martin—professor of medicine and a critical care physician at Emory University School of Medicine, Atlanta, GA, and president-elect of the Society of Critical Care Medicine—told Stat News. “But if the oxygen saturation gets too low you can achieve more oxygen delivery with a mechanical ventilator.”