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-> Coronavirus Health Questions
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amother
OP
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 Fri, May 01 2020, 11:04 am
I don’t want to derail the beautiful thread about the perspective of a wonderful frum nurse.
I want to discuss the use of ventilators in patients who are breathing normally and feel fine despite low blood oxygen levels.
| Quote: | | The patients don’t believe me when I say they need to be intubated, and soon. Their blood oxygen levels are dropping to dangerous levels, in spite of maximum noninvasive support, and yet they often feel ok. They are scared of being intubated, and ask if we can avoid it, what they can do to push it off. I am scared for them too. I don’t want to tell them that this conversation we are having, it may very well be the last conversation they will ever have. I don’t want them to push off intubation, because then they will die for sure. |
There is the speculation that ventilators are doing more damage than helping.
https://www.statnews.com/2020/.....d-19/
https://www.webmd.com/lung/new.....blems
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tweety1
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Fri, May 01 2020, 11:19 am
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Yes! There's a new study that ventilators are not good for covid patients. It's only one of the things they keep on changing abt covid. That's the scary part that they know so little abt the disease.
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ra_mom
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Fri, May 01 2020, 11:32 am
I watched a remote doctor's conference on Sunday with discussions on this. From what I remember they discussed that at the beginning they thought people needed ventilators and intubation and have since realized that this is not a regular respiratory disease, presents differently, and they can see that they can push off invasive measures longer and try to keep many patients on oxygen instead.
We have kept our sick relative at home for a month with oxygen concentrator, doctor visits, medication, constant labs and tests BH.
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amother
Coffee
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Fri, May 01 2020, 11:36 am
I should have started this thread so thanks OP.
I'm another red on the eschayas thread. I'll repost my post here.
There is one point that does concern me.
I heard from a Director of a big hospital in the Bronx.
My mother was his patient. She needed a blood transfusion and he felt it will be safer if she goes to a local hospital for it.
Once she was there the local hospital wanted to intubate her.
Her doctor from the Bronx was in touch with the doctor at the local hospital and he begged them not to intubate.
He told them that he covers a Covid floor in his hospital and he sees first hand that the vents kill.
The local hospital did not listen.
My mother succumbed to Covid after 10 days kidney failure and all.
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Amarante
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Fri, May 01 2020, 12:14 pm
There are so many things that they don't know about Covid - and they are constantly learning and refining treatments, protocol etc.
It is one of many reasons that I am doing everything possible to avoid becoming infected and avoid infecting others because the longer I can avoid contracting this disease, the better treatment is possible.
I am not a medical professional but am so grateful that the best minds are working on all kinds of tests and treatment experiments. I don't think a "cure" or a vaccine is around the corner and I think that there will be another wave or waves until a vaccine is widely available, but I think the chances of survival and/or surviving without serious complications are better than they were in the beginning and will continue to be better as more is learned.
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eschaya
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Fri, May 01 2020, 5:20 pm
Ventilators do not kill. They are saving lives. When people's oxygen saturations drop to emergent levels, vital organs in the body start to die, such as the heart, lungs, brain, kidneys, etc. With ventilators, we have the ability to provide 100% oxygen at high pressures or in precise amounts and sizes and pressures and times that we can tailor to the needs of the patient.
That being said, different modes of ventilation have very different results. In the beginning of this pandemic, the medical community was typically using a mode of ventilation with high pressures and low tidal volumes, which has long been the standard of treatment for ARDS (acute respiratory distress syndrome). The covid lungs on CT/xray looked remarkably like typical ARDS ("ground glass opacities") and it fit the official definition of ARDS (Berlin criteria). Because this is a new disease, we have to do the best we can based on what we know, all the while attempting to gather and generate new data. After a little while, we began to realize that while covid lungs look remarkably like ARDS and even fit the definition, there were some pieces that were not typical for ARDS (such as normal lung compliance, while in typical ARDS you see decreased compliance). And it seems like the standard ventilatory practices used for ARDS are actually less helpful in covid lungs. So we have changed our practice and are using lower pressures, at least initially, unless the patient needs it. (Higher pressures help push oxygen into the bloodstream, so if a patient is not oxygenating well even on 100% oxygen, one strategy is to increase the pressure and we often see improved oxygenation).
So NO, ventilators are not killing people. Covid is. But there is truth that we have had to alter our practices to use different forms of ventilation than we initially were using once we realized that the high tidal volume/low PEEP strategy is possibly leading to worse outcomes.
We do everything we can to avoid intubation. We are placing patients on high flow nasal cannula on 100% oxygen with very high flow rates. In a percentage of patients, this is enough to get them through the worst part of the disease. In many others though, it is not enough and they start to desaturate (ie, have low oxygen levels) even on the maximum amount of noninvasive support. At this point, if we don't intubate them they will for sure start the dying process. If we do intubate them, they have a chance of living (~50% in my ICU).
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amother
Coffee
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Fri, May 01 2020, 5:23 pm
| eschaya wrote: | Ventilators do not kill. They are saving lives. When people's oxygen saturations drop to emergent levels, vital organs in the body start to die, such as the heart, lungs, brain, kidneys, etc. With ventilators, we have the ability to provide 100% oxygen at high pressures or in precise amounts and sizes and pressures and times that we can tailor to the needs of the patient.
That being said, different modes of ventilation have very different results. In the beginning of this pandemic, the medical community was typically using a mode of ventilation with high pressures and low tidal volumes, which has long been the standard of treatment for ARDS (acute respiratory distress syndrome). The covid lungs on CT/xray looked remarkably like typical ARDS ("ground glass opacities") and it fit the official definition of ARDS (Berlin criteria). Because this is a new disease, we have to do the best we can based on what we know, all the while attempting to gather and generate new data. After a little while, we began to realize that while covid lungs look remarkably like ARDS and even fit the definition, there were some pieces that were not typical for ARDS (such as normal lung compliance, while in typical ARDS you see decreased compliance). And it seems like the standard ventilatory practices used for ARDS are actually less helpful in covid lungs. So we have changed our practice and are using lower pressures, at least initially, unless the patient needs it. (Higher pressures help push oxygen into the bloodstream, so if a patient is not oxygenating well even on 100% oxygen, one strategy is to increase the pressure and we often see improved oxygenation).
So NO, ventilators are not killing people. Covid is. But there is truth that we have had to alter our practices to use different forms of ventilation than we initially were using once we realized that the high tidal volume/low PEEP strategy is possibly leading to worse outcomes.
We do everything we can to avoid intubation. We are placing patients on high flow nasal cannula on 100% oxygen with very high flow rates. In a percentage of patients, this is enough to get them through the worst part of the disease. In many others though, it is not enough and they start to desaturate (ie, have low oxygen levels) even on the maximum amount of noninvasive support. At this point, if we don't intubate them they will for sure start the dying process. If we do intubate them, they have a chance of living (~50% in my ICU). |
This. Thanks!!
I have tears in my eyes reading this because a similar protocol to this is what the doctor was begging the local hospital to do.
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ra_mom
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Fri, May 01 2020, 5:31 pm
Unfortunately the high pressure of ventilators is killing patients. 
Please watch these.
This is a quick overview.
https://m.youtube.com/watch?v=Elgct0nOcKY
This is a collaboration of doctors from all over trying to figure this out and their experiences. If you have the time, it is worth the hour and a half, even if you don't get through all of it.
https://youtu.be/dTGpWDIzEPQ
Doctors started off treating the way they treat acute respiratory distress syndrome. But started to realize that the respiratory issues seem to be mirroring decompression pulmanary sickness more and needs to be treated differently.
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tp3
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Fri, May 01 2020, 6:17 pm
| eschaya wrote: | Ventilators do not kill. They are saving lives. When people's oxygen saturations drop to emergent levels, vital organs in the body start to die, such as the heart, lungs, brain, kidneys, etc. With ventilators, we have the ability to provide 100% oxygen at high pressures or in precise amounts and sizes and pressures and times that we can tailor to the needs of the patient.
That being said, different modes of ventilation have very different results. In the beginning of this pandemic, the medical community was typically using a mode of ventilation with high pressures and low tidal volumes, which has long been the standard of treatment for ARDS (acute respiratory distress syndrome). The covid lungs on CT/xray looked remarkably like typical ARDS ("ground glass opacities") and it fit the official definition of ARDS (Berlin criteria). Because this is a new disease, we have to do the best we can based on what we know, all the while attempting to gather and generate new data. After a little while, we began to realize that while covid lungs look remarkably like ARDS and even fit the definition, there were some pieces that were not typical for ARDS (such as normal lung compliance, while in typical ARDS you see decreased compliance). And it seems like the standard ventilatory practices used for ARDS are actually less helpful in covid lungs. So we have changed our practice and are using lower pressures, at least initially, unless the patient needs it. (Higher pressures help push oxygen into the bloodstream, so if a patient is not oxygenating well even on 100% oxygen, one strategy is to increase the pressure and we often see improved oxygenation).
So NO, ventilators are not killing people. Covid is. But there is truth that we have had to alter our practices to use different forms of ventilation than we initially were using once we realized that the high tidal volume/low PEEP strategy is possibly leading to worse outcomes.
We do everything we can to avoid intubation. We are placing patients on high flow nasal cannula on 100% oxygen with very high flow rates. In a percentage of patients, this is enough to get them through the worst part of the disease. In many others though, it is not enough and they start to desaturate (ie, have low oxygen levels) even on the maximum amount of noninvasive support. At this point, if we don't intubate them they will for sure start the dying process. If we do intubate them, they have a chance of living (~50% in my ICU). |
I would love to know which hospital is lucky enough to have such a wonderful devoted caring skilled nurse!
Thank you for what you do!
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octopus
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Fri, May 01 2020, 6:31 pm
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With the 50/50 outcome vs the 80/20 outcome it sounds like mt. Sinai.
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youngishbear
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Fri, May 01 2020, 6:49 pm
It's both horrifying and fascinating to watch the scientific process unfold in real time.
Horrifying because people have died because we didn't have the information and resources we needed to save them.
Fascinating because the more experience we have with this disease, the more we can begin to understand it, and move forward in the fight against it. BeH
Kudos to all on the front lines who have the presence of mind for observing and tracking patterns.
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amother
Beige
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Sat, May 02 2020, 3:50 pm
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amother
Coffee
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Sat, May 02 2020, 9:39 pm
CPAP was what the doctor (from the Bronx) thought was a better option for my mother.
This was April 1'st. Exactly a month ago.
I'm happy the medical world is making progress and everyone is slowly coming on the same page and at the same time I'm heartbroken that so many people I know, my mother one of them, were the ones that perished in order for this information to become known.
I wonder, why didn't Italy come up with this?
Why, when the pandemic came to the USA much later than in Italy, did we even think that vents are the absolute solution?
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eschaya
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Sat, May 02 2020, 10:18 pm
So 1st if all, CPAP can be given to patients while on a ventilator, and we are using this mode with some patients. It's not the vent that's harmful to lungs, but some of the modes used on a ventilator that can damage the lungs.
The use of noninvasive cpap/bipap is a big issue in covid patients. I totally agree that we could potentially prevent some intubations with cpap/bipap. The problem is that it aerosolizes the virus and puts the healthcare providers in the room at high risk. This is why many hospitals have decided not to use cpap/bipap for covid patients. Many hospitals are instead using high flow nasal cannula (which this particular physician mentions in his article, that his hospital ran out of those).
I am torn about the decision many hospitals have made to protect their employees. We have taken out a potential tool from our arsenal that can be beneficial for patients. On the other hand, you can't put all doctors and nurses and respiratory therapists at risk, both for their own sake and because you need them to treat other patients. On the same note, we have been told to protect ourselves 1st and not run into a patient room unprotected. So if a patient codes, or is in distress, or falls, we 1st don our PPE meticulously, and only them rush into the room. Chayechay Kodmin. Its halacha, not just a nice suggestion from our administration.
So agree that cpap can be helpful in many patients. We are using gentler vent modes (including cpap) and high flow nasal cannula in this vein, once we recognized that the standard ards treatment is not beneficial in covid. Most hospitals are avoiding cpap/bipap machines because of the risk it poses to everyone else.
Keep in mind that even with our updated protocols for respiratory and vent management (as well as ever changing drug and med regimens) , still >50% of ICU covid patients are dying. So it's not like all the people who died did so because of mismanagement or poor treatment. Most would have died anyway. This is a horrible mageifa.
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amother
Coffee
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Sat, May 02 2020, 10:29 pm
| eschaya wrote: | So 1st if all, CPAP can be given to patients while on a ventilator, and we are using this mode with some patients. It's not the vent that's harmful to lungs, but some of the modes used on a ventilator that can damage the lungs.
The use of noninvasive cpap/bipap is a big issue in covid patients. I totally agree that we could potentially prevent some intubations with cpap/bipap. The problem is that it aerosolizes the virus and puts the healthcare providers in the room at high risk. This is why many hospitals have decided not to use cpap/bipap for covid patients. Many hospitals are instead using high flow nasal cannula (which this particular physician mentions in his article, that his hospital ran out of those).
I am torn about the decision many hospitals have made to protect their employees. We have taken out a potential tool from our arsenal that can be beneficial for patients. On the other hand, you can't put all doctors and nurses and respiratory therapists at risk, both for their own sake and because you need them to treat other patients. On the same note, we have been told to protect ourselves 1st and not run into a patient room unprotected. So if a patient codes, or is in distress, or falls, we 1st don our PPE meticulously, and only them rush into the room. Chayechay Kodmin. Its halacha, not just a nice suggestion from our administration.
So agree that cpap can be helpful in many patients. We are using gentler vent modes (including cpap) and high flow nasal cannula in this vein, once we recognized that the standard ards treatment is not beneficial in covid. Most hospitals are avoiding cpap/bipap machines because of the risk it poses to everyone else.
Keep in mind that even with our updated protocols for respiratory and vent management (as well as ever changing drug and med regimens) , still >50% of ICU covid patients are dying. So it's not like all the people who died did so because of mismanagement or poor treatment. Most would have died anyway. This is a horrible mageifa. |
I think with time a solution will be found.
I hope you dont for one second think that, although my mother passed away, I blame a specific nurse or doctor.
Just the opposite. I have tears in my eyes reading your posts and I can't comprehend the risk you are prone to every day for the sake of saving lives.
Please take a virtual hug from me.
It's just painful to watch this process of finding the right treatment unveil.
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amother
Wheat
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Sat, May 02 2020, 10:33 pm
| eschaya wrote: | So 1st if all, CPAP can be given to patients while on a ventilator, and we are using this mode with some patients. It's not the vent that's harmful to lungs, but some of the modes used on a ventilator that can damage the lungs.
The use of noninvasive cpap/bipap is a big issue in covid patients. I totally agree that we could potentially prevent some intubations with cpap/bipap. The problem is that it aerosolizes the virus and puts the healthcare providers in the room at high risk. This is why many hospitals have decided not to use cpap/bipap for covid patients. Many hospitals are instead using high flow nasal cannula (which this particular physician mentions in his article, that his hospital ran out of those).
I am torn about the decision many hospitals have made to protect their employees. We have taken out a potential tool from our arsenal that can be beneficial for patients. On the other hand, you can't put all doctors and nurses and respiratory therapists at risk, both for their own sake and because you need them to treat other patients. On the same note, we have been told to protect ourselves 1st and not run into a patient room unprotected. So if a patient codes, or is in distress, or falls, we 1st don our PPE meticulously, and only them rush into the room. Chayechay Kodmin. Its halacha, not just a nice suggestion from our administration.
So agree that cpap can be helpful in many patients. We are using gentler vent modes (including cpap) and high flow nasal cannula in this vein, once we recognized that the standard ards treatment is not beneficial in covid. Most hospitals are avoiding cpap/bipap machines because of the risk it poses to everyone else.
Keep in mind that even with our updated protocols for respiratory and vent management (as well as ever changing drug and med regimens) , still >50% of ICU covid patients are dying. So it's not like all the people who died did so because of mismanagement or poor treatment. Most would have died anyway. This is a horrible mageifa. |
Thank you so much for taking the time to explain. Can you tell me more about aerosolization? Why does this pose greater risk to providers wearing proper ppe than when they are in a room with a covid patient breathing regularly?
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boots
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Sun, May 03 2020, 12:30 am
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Can patients be discharged and ues cpap machines at home?
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amother
Jade
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Sun, May 03 2020, 1:34 am
| octopus wrote: | | With the 50/50 outcome vs the 80/20 outcome it sounds like mt. Sinai. |
The 80/20 was in cases with a known outcome. It was fault reporting because it did not take into consideration the patients who were still receiving treatment in the hospital. Just want to clarify that.
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PinkFridge
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Sun, May 03 2020, 9:33 am
| amother [ Coffee ] wrote: | I think with time a solution will be found.
I hope you dont for one second think that, although my mother passed away, I blame a specific nurse or doctor.
Just the opposite. I have tears in my eyes reading your posts and I can't comprehend the risk you are prone to every day for the sake of saving lives.
Please take a virtual hug from me.
It's just painful to watch this process of finding the right treatment unveil. |
OP, this post especially must be a tremendous aliya for your mother's neshama. Hamakom yenachem eschem b'soch she'ar aveilei Tziyon VYrushalayim.
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