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 The clinic is known for its reluctance to put patients with
breathing difficulties on mechanical ventilators - the kind that
involve tubes down the throat.
The 48-year-old physician, father of two and aspiring triathlete
worried that an invasive ventilator would be harmful. But soon after
entering the clinic, Bergmann said, he struggled to breathe even
with an oxygen mask, and felt so sick the ventilator seemed
inevitable.
Even so, his doctors never put him on a machine that would breathe
for him. A week later, he was well enough to go home.
Bergmann's case illustrates a shift on the front lines of the
COVID-19 pandemic, as doctors rethink when and how to use mechanical
ventilators to treat severe sufferers of the disease - and in some
cases whether to use them at all. While initially doctors packed
intensive care units with intubated patients, now many are exploring
other options.
Machines to help people breathe have become the major weapon for
medics fighting COVID-19, which has so far killed more than 183,000
people. Within weeks of the disease's global emergence in February,
governments around the world raced to build or buy ventilators as
most hospitals said they were in critically short supply.
Germany has ordered 10,000 of them. Engineers from Britain to
Uruguay are developing versions based on autos, vacuum cleaners or
even windshield-wiper motors. U.S. President Donald Trump's
administration is spending $2.9 billion for nearly 190,000
ventilators. The U.S. government has contracted with automakers such
as General Motors Co and Ford Motor Co as well as medical device
manufacturers, and full delivery is expected by the end of the year.
Trump declared this week that the U.S. was now "the king of
ventilators."
However, as doctors get a better understanding of what COVID-19 does
to the body, many say they have become more sparing with the
equipment.
Reuters interviewed 30 doctors and medical professionals in
countries including China, Italy, Spain, Germany and the United
States, who have experience of dealing with COVID-19 patients.
Nearly all agreed that ventilators are vitally important and have
helped save lives. At the same time, many highlighted the risks from
using the most invasive types of them - mechanical ventilators - too
early or too frequently, or from non-specialists using them without
proper training in overwhelmed hospitals.
Medical procedures have evolved in the pandemic as doctors better
understand the disease, including the types of drugs used in
treatments. The shift around ventilators has potentially
far-reaching implications as countries and companies ramp up
production of the devices.
GRAPHIC: Ventilators: a bridge between life and death? -
https://graphics.reuters.com/HEALTH-CORONAVIRUS/VENTILATORS/
oakvekyxvrd/index.html
"BETTER RESULTS"
Many forms of ventilation use masks to help get oxygen into the
lungs. Doctors' main concern is around mechanical ventilation, which
involves putting tubes into patients' airways to pump air in, a
process known as intubation. Patients are heavily sedated, to stop
their respiratory muscles from fighting the machine.
Those with severe oxygen shortages, or hypoxia, have generally been
intubated and hooked up to a ventilator for up to two to three
weeks, with at best a fifty-fifty chance of surviving, according to
doctors interviewed by Reuters and recent medical research. The
picture is partial and evolving, but it suggests people with
COVID-19 who have been intubated have had, at least in the early
stages of the pandemic, a higher rate of death than other patients
on ventilators who have conditions such as bacterial pneumonia or
collapsed lungs.
This is not proof that ventilators have hastened death: The link
between intubation and death rates needs further study, doctors say.
In China, 86% of 22 COVID-19 patients didn't survive invasive
ventilation at an intensive care unit in Wuhan, the city where the
pandemic began, according to a study published in The Lancet in
February. Normally, the paper said, patients with severe breathing
problems have a 50% chance of survival. A recent British study found
two-thirds of COVID-19 patients put on mechanical ventilators ended
up dying anyway, and a New York study found 88% of 320 mechanically
ventilated COVID-19 patients had died.
More recently, none of the eight patients who went on ventilators at
the Abu Dhabi hospital had died as of April 9, a doctor there told
Reuters. And one ICU doctor at Emory University Hospital in Atlanta
said he had had a "good" week when almost half the COVID-19 patients
were successfully taken off the ventilator, when he had expected
more to die.
The experiences can vary dramatically. The average time a COVID-19
patient spent on a ventilator at Scripps Health's five hospitals in
California's San Diego County was just over a week, compared with
two weeks at the Hadassah Ein Kerem Medical Center in Jerusalem and
three at the Universiti Malaya Medical Centre in the Malaysian
capital Kuala Lumpur, medics at the hospitals said.
In Germany, as patient Bergmann struggled to breathe, he said he was
getting too desperate to care.
"There came a moment when it simply no longer mattered," he told
Reuters. "At one point I was so exhausted that I asked my doctor if
I was going to get better. I was saying, if I had no children or
partner then it would be easier just to be left in peace."
Instead of putting Bergmann on a mechanical ventilator, the clinic
gave him morphine and kept him on the oxygen mask. He's since tested
free of the infection, but not fully recovered. The head of the
clinic, Thomas Voshaar, a German pulmonologist, has argued strongly
against early intubation of COVID-19 patients. Doctors including
Voshaar worry about the risk that ventilators will damage patients'
lungs.
The doctors interviewed by Reuters agreed that mechanical
ventilators are crucial life-saving devices, especially in severe
cases when patients suddenly deteriorate. This happens to some when
their immune systems go into overdrive in what is known as a
"cytokine storm" of inflammation that can cause dangerously high
blood pressure, lung damage and eventual organ failure.
The new coronavirus and COVID-19, the disease the virus causes, have
been compared to the Spanish flu pandemic of 1918-19, which killed
50 million people worldwide. Now as then, the disease is novel,
severe and spreading rapidly, pushing the limits of the public
health and medical knowledge required to tackle it.
When coronavirus cases started surging in Louisiana, doctors at the
state's largest hospital system, Ochsner Health, saw an influx of
people with signs of acute respiratory distress syndrome, or ARDS.
Patients with ARDS have inflammation in the lungs which can cause
them to struggle to breathe and take rapid short breaths.
"Initially we were intubating fairly quickly on these patients as
they began to have more respiratory distress," said Robert Hart, the
hospital system's chief medical officer. "Over time what we learned
is trying not to do that."
Instead, Hart's hospital tried other forms of ventilation using
masks or thin nasal tubes, as Voshaar did with his German patient.
"We seem to be seeing better results," Hart said.
CHANGED LUNGS
Other doctors painted a similar picture.
In Wuhan, where the novel coronavirus emerged, doctors at Tongji
Hospital at the Huazhong University of Science and Technology said
they initially turned quickly to intubation. Li Shusheng, head of
the hospital's intensive care department, said a number of patients
did not improve after ventilator treatment.
"The disease," he explained, "had changed their lungs beyond our
imagination." His colleague Xu Shuyun, a doctor of respiratory
medicine, said the hospital adapted by cutting back on intubation.
Luciano Gattinoni, a guest professor at the Department of
Anaesthesiology, Emergency and Intensive Care Medicine, University
of Göttingen in Germany, and a renowned expert in ventilators, was
one of the first to raise questions about how they should be used to
treat COVID-19.
"I realised as soon as I saw the first CT scan ... that this had
nothing to do with what we had seen and done for the past 40 years,"
he told Reuters.
In a paper published by the American Thoracic Society on March 30,
Gattinoni and other Italian doctors wrote that COVID-19 does not
lead to "typical" respiratory problems. Patients' lungs were working
better than they would expect for ARDS, they wrote - they were more
elastic. So, he said, mechanical ventilation should be given "with a
lower pressure than the one we are used to."
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Ventilating some COVID-19 sufferers as if they were standard
patients with ARDS is not appropriate, he told Reuters. "It's like
using a Ferrari to go to the shop next door, you press on the
accelerator and you smash the window."
The Italians were swiftly followed by Cameron Kyle-Sidell, a New
York physician who put out a talk on YouTube saying that by
preparing to put patients on ventilators, hospitals in America were
treating "the wrong disease." Ventilation, he feared, would lead to
"a tremendous amount of harm to a great number of people in a very
short time." This remains his view, he told Reuters this week.
When Spain's outbreak erupted in mid-March, many patients went
straight onto ventilators because lung X-rays and other test results
"scared us," said Delia Torres, a physician at the Hospital General
Universitario de Alicante. They now focus more on breathing and a
patient's overall condition than just X-rays and tests. And they
intubate less. "If the patient can get better without it, then
there's no need," she said.
In Germany, lung specialist Voshaar was also concerned. A mechanical
ventilator itself can damage the lungs, he says. This means patients
stay in intensive care longer, blocking specialist beds and creating
a vicious circle in which ever more ventilators are needed.
Of the 36 acute COVID-19 patients on his ward in mid-April, Voshaar
said, one had been intubated - a man with a serious neuro-muscular
disorder - and he was the only patient to die. Another 31 had
recovered.
"IRON LUNGS"
Some doctors cautioned that the impression that the rush to
ventilate is harmful may be partly due to the sheer numbers of
patients in today's pandemic.
People working in intensive care units know that the mortality rate
of ARDS patients who are intubated is around 40%, said Thierry
Fumeaux, head of an ICU in Nyon, Switzerland, and president of the
Swiss Intensive Care Medicine Society. That is high, but may be
acceptable in normal times, when there are three or four patients in
a unit and one of them doesn't make it.
"When you have 20 patients or more, this becomes very evident," said
Fumeaux. "So you have this feeling - and I've heard this a lot -
that ventilation kills the patient." That's not the case, he said.
"No, it's not the ventilation that kills the patient, it's the lung
disease."
Mario Riccio, head of anaesthesiology and resuscitation at the Oglio
Po hospital near Cremona in Lombardy, Italy's worst-hit region, says
the machines are the only treatment to save a COVID-19 patient in
serious condition. "The fact that people who were placed under
mechanical ventilation in some cases die does not undermine this
statement."
Originally nicknamed "iron lungs" when introduced in the 1920s and
1930s, mechanical ventilators are sometimes also called respirators.
They use pressure to blow air - or a mixture of gases such as oxygen
and air - into the lungs.
They can be set to exhale it, too, effectively taking over a
patient's entire breathing process when their lungs fail. The aim is
to give the body enough time to fight off an infection to be able to
breathe independently and recover.
Some patients need them because they're losing the strength to
breathe, said Yoram Weiss, director of Hadassah Ein Kerem Medical
Center in Jerusalem. "It is very important to ventilate them before
they collapse." At his hospital, 24 of 223 people with COVID-19 had
been put on ventilators by April 13. Of those, four had died and
three had come off the machines.
AEROSOLS
Simpler forms of ventilation - face masks for example - are easier
to administer. But respirator masks can release micro-droplets known
as aerosols which may spread infection. Some doctors said they
avoided the masks, at least at first, because of that risk.
While mechanical ventilators do not produce aerosols, they carry
other risks. Intubation requires patients to be heavily sedated so
their respiratory muscles fully surrender. The recovery can be
lengthy, with a risk of permanent lung damage.
Now that the initial wave of COVID-19 cases has peaked in many
countries, doctors have time to examine other ways of managing the
disease and are fine-tuning their approach.
Voshaar, the German lung specialist, said some doctors were
approaching COVID-19 lung problems as they would other forms of
pneumonia. In a healthy patient, oxygen saturation - a measure of
how much oxygen the haemoglobin in the blood contains - is around
96% of the maximum amount the blood can hold. When doctors check
patients and see lower levels, indicating hypoxia, Voshaar said,
they can overreact and race to intubate.
"We lung doctors see this all the time," Voshaar told Reuters. "We
see 80% and still do nothing and let them breathe spontaneously. The
patient doesn't feel great, but he can eat and drink and sit on the
side of his bed."
He and other doctors think other tests can help before intubation.
Voshaar looks at a combination of measures including how fast the
patient is breathing and their heart rate. His team are also guided
by lung scans.
"HAPPY HYPOXICS"
Several doctors in New York said they too had started to consider
how to treat patients, known as "happy hypoxics," who can talk and
laugh with no signs of mental cloudiness even though their oxygen
might be critically low.
Rather than rushing to intubate, doctors say they now look for other
ways to boost the patients' oxygen. One method, known as "proning,"
is telling or helping patients to roll over and lie on their fronts,
said Scott Weingart, head of emergency critical care at Stony Brook
University Medical Center on Long Island.
"If patients are left in one position in bed, they tend to
desaturate, they lose the oxygen in their blood," Weingart said.
Lying on the front shifts any fluid in the lungs to the front and
frees up the back of the lungs to expand better. "The position
changes have radically impressive effects on the patient's oxygen
saturations."
Weingart does recommend intubating a communicative patient with low
oxygen levels if they start to lose mental clarity, if they
experience a cytokine storm or if they start to really struggle to
breathe. He feels there are enough ventilators for such patients at
his hospital.
But for happy hypoxics, "I still don't want these patients on
ventilators, because I think it's hurting them, not helping them."
QUALITY, SKILL
As governments in the United States and elsewhere are scrambling to
raise output of ventilators, some doctors worry the fast-built
machines may not be up to snuff.
Doctors in Spain wrote to their local government to complain that
ventilators it had bought were designed for use in ambulances, not
intensive care units, and some were of poor quality. In the UK, the
government has cancelled an order for thousands of units of a simple
model because more sophisticated devices are needed.
More important, many doctors say, is that the additional machines
will need highly trained and experienced operators.
"It's not just about running out of ventilators, it's running out of
expertise," said David Hill, a pulmonology and critical care
physician in Waterbury, Connecticut, who attends at Waterbury
Hospital.
Long-term ventilation management is complex, but Hill said some U.S.
hospitals were trying to bring non-critical care physicians up to
speed fast with webinars or even tip sheets. "That is a recipe for
bad outcomes."
"We intensivists don't ventilate by protocol," said Hill. "We may
choose initial settings," he said, "but we adjust those settings.
It's complicated."
(Escritt reported from Berlin, Aloisi from Milan, Beasley from Los
Angeles, Borter from New York and Kelland from London. Additional
reporting: Alexander Cornwell in Abu Dhabi, Panu Wongcha-um in
Bangkok, Maayan Lubell in Jerusalem, A. Ananthalakshmi and Rozanna
Latif in Kuala Lumpur, Kristina Cooke in Los Angeles, Sonya Dowsett
in Madrid, Jonathan Allen and Nicholas Brown in New York, John Mair
in Sydney, Costas Pitas in London, David Shepardson in Washington
DC, Brenda Goh in Wuhan and John Miller in; Zurich. Writing by
Andrew RC Marshall and Kate Kelland; Edited by Sara Ledwith and
Jason Szep)
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