When to use ventilators in COVID-19 cases? Some Miami doctors rethink their approach
Dr. David Farcy was in the midst of a discussion about treatment with a severely ill COVID-19 patient at Mount Sinai Medical Center in Miami Beach when he realized something unusual.
The patient’s blood oxygen level was in the 70% to 80% range — so low that he shouldn’t have been able to carry out a conversation, said Farcy, the hospital’s director of emergency medicine. The normal, healthy range is 98% or higher.
“This patient is talking to me in full sentences,” Farcy said. “He’s like, ‘Hey Doc, I don’t feel too good. My chest hurts, but I really want to go home.’ ”
Six weeks ago, Farcy said he or any other emergency medicine doctor in the country would have rushed to intubate the patient, putting him on a ventilator that would breathe for him in the hope that he would be able to recover from the illness caused by the novel coronavirus. But in recent weeks, propelled by online discussion in the medical community and a letter by a highly influential critical care doctor, some emergency medicine physicians have started rethinking the traditional way of treating acute respiratory distress syndrome, or ARDS., which can occur in severe cases of COVID-19.
Instead of automatically putting patients on ventilators, doctors are sometimes trying a method of helping patients breathe that involves placing them on their sides or bellies, and administering oxygen.
And though some prominent doctors have remained skeptical about the approach, saying there isn’t enough evidence that it works, others are trying it.
In the case of his recent patient, Farcy decided to see if the new approach would help. He told the patient to lie on his side while receiving oxygen, a posture that changes the way air and blood flows through the lungs. And the patient improved. His blood oxygen — the amount of oxygen present in the bloodstream, an important indicator of health — rose.
“This disease is not something we’ve ever seen, and not just as in, this is a new, novel disease, but this disease has challenged medical theories that I’ve been lecturing [about] for years,” Farcy said. “Until I saw it with my own eyes, I could not believe what I was seeing.”
The traditional approach to treating ARDS is to give supplemental oxygen, which can come in many forms, to anyone who has an oxygen blood rate below 90%, Farcy said. If they get into the 60s or 70s, he said, there is a rush to intubate to stave off death.
At Jackson Health System, Miami’s public hospital, Dr. Jeff Scott said his thinking about when to resort to ventilators with COVID-19 patients started to shift in early April, when he read a March 30 letter to the editor in the American Journal of Respiratory and Critical Care Medicine.
The letter, which had been circulating in online emergency medicine communities and was written by an Italian anesthesiologist named Luciano Gattinoni, relayed findings from researchers in Germany and Italy who said many patients were presenting with lung conditions not like those typically seen in those suffering from acute respiratory distress.
“[The letter] said we’re doing this wrong,” Scott said. “We should not be intubating everyone like China. We’re looking at a complicated disease that has two different presentations.”
Some patients with the disease had more elastic lungs than those typically seen in ARDS patients, which are stiffer. Patients with the more flexible lungs are the ones doctors are starting to think should be treated differently.
Scott said the new way of thinking has “caught fire” among many emergency medicine doctors.
“The paradigm in the last 10 days, two weeks, is don’t intubate unless absolutely necessary,” Scott said. “At every hospital, the ventilator needs are going down.”
Hospitalization data collected by Miami-Dade County shows that the number of patients on ventilators has remained relatively stable despite an increase in patient volume.
Farcy said he knows that firsthand: “In the past six weeks, I’ve significantly reduced the number of intubations I’ve done.”
‘Awake pronation’
Both Farcy and Scott said they have shifted to a new approach for some patients who would have normally been placed into a drug-induced coma and put on a ventilator. Now, they’re directing them to lie on their sides or stomachs while receiving high-flow oxygen.
In the case of Farcy’s patient, the improvement came quickly once they started the alternate treatment.
“We look at the monitor 20 minutes later and his oxygenation is 88 percent,” Farcy said. “His [breathing rate] is down to 30, 31. He’s like, ‘Hey, I feel better Doc.’ ”
Twenty minutes later, Farcy said he told the patient to lie face down. The oxygen rate rose to 99%, Farcy said., and his breathing rate went down further, a sign of less trouble getting oxygen into the bloodstream through the lungs.
“It’s called awake pronation,” Farcy said, of the treatment method. “The patient is breathing on their own.”
Scott said doctors at Jackson Health System have taken the same approach, laying patients on their bellies and asking them to play games or watch Netflix on their phones while treatment occurs.
It’s not simply that intubating any patient causes higher risk for them. Some doctors are also raising questions about whether ventilators can, in some of the cases of this new disease, actually worsen the illness by spreading it through the lungs.
Farcy also raised the possibility of “barotrauma,” or physical damage to the lungs caused by mechanical ventilation.
“At this moment in time, I think the entire medical society is working on every potential pathway,” said Farcy, who is optimistic that the different treatment can help more people. “I don’t think we have a clear understanding of this disease. ... Now that patients are surviving, we don’t have that noose around our neck. Now we can give it a little bit more time. And that’s key.”
The new method of treating COVID-19 patients has not escaped criticism from some doctors who say there isn’t enough data to justify restructuring the traditional way of treating acute respiratory distress syndrome.
Dr. Corey C. Hardin, of Massachusetts General Hospital, told The New York Times this week that the letter to the editor from the Italian anesthesiologist is being “misinterpreted” and that doctors shouldn’t yet deviate from traditional treatment protocols because they reduce mortality.
Hardin said that the renowned Boston hospital is using an early intubation strategy. Of the hospital’s first 66 patients, he added, a third of them have been successfully removed from ventilators.
“I’m arguing for evidence-based medicine, which is something we all purported to agree with before this outbreak hit,” Hardin told the Times.
Farcy said he agreed that randomized trials would be the best evidence, “but sometimes in medicine, we don’t have time.”
“I call it the parachute theory,” Farcy said. “Nobody has ever done a double randomized trial on a parachute. Nobody has ever said, ‘We’ll throw you out of the plane and see if your parachute works.’ ”
As part of the discussion about what works best, both Scott and Farcy raised concerns about the rate of survival for patients on ventilators. They said they can still decide to intubate a patient later, and the thinking now is more about how to avoid getting to that point.
“The risk is that a patient could crash” if they aren’t on a ventilator, Scott said. “Right now, the benefit [delaying intubation] outweighs the risk.”
An additional factor: As the two Miami doctors try to learn about the disease as they treat it, they’re seeing the average length of stay of COVID-19 patients in their hospitals’ intensive care units drop, though no one is sure why.
At Jackson Health System, the average length of stay for an intensive care unit patient has dropped from 27 days on March 20 to 11 days as of April 14, according to the hospital’s internal data. Jackson officials attributed the decrease to more efficient treatment, but did not specify what that means.
Farcy said Mount Sinai has also seen a shortening in its average length of stay for COVID-19 patients and attributed some of that to less ventilator usage. Once intubated, patients can stay on ventilators for two weeks or longer, Farcy said, while patients who avoid intubation can recover after three to five days.
Farcy said the quest to understand the novel coronavirus has a personal meaning for him.
“I’ve been spending every hour of my day focusing on this,” he said. “I’m not just a doctor in Miami Beach. I’m also a resident. This is for me, my family. It’s part of helping and hoping to find a cure, so I don’t lose another friend.”
This story was originally published April 15, 2020 at 1:44 PM.
