“STOP following protocols - follow the physiology” message from doctor’s fighting COVID-19
Updated: Jul 23, 2020
Stony Brook, NY – Anecdotal experience from physicians working with COVID-19 patients worldwide are finding that intubation may not be the best choice.
Some patients may be unnecessarily being intubated, according to a New York emergency medicine physician.
“The problem with (intubation), when you think it through, is all of us, to some extent or another, have locked into our collective subconscious the ARDS-net experience, and the gradual upping of PEEP as a response to hypoxemia -- sometimes even not so gradual, sometimes rapid,” said Scott Weingart, an emergency medicine physician at Stony Brook Medicine Hospital, Stony Brook, NY.
The acute respiratory distress syndrome (ARDS) approach might not be the best protocol, according to some physicians, who feel that the virus is resembling high-altitude pulmonary edema (HAPE) in some patients, and should not be treated like ARDS.
According to an article published in Medscape, Dr. Luciano Gattinoni of the Medical University of Göttingen in Germany, and his colleagues believe protocol-driven ventilator use for patients with COVID-19 could be doing more harm than good.
In a letter to the editor published in the American Journal of Respiratory and Critical Care Medicine on March 30, and in an editorial accepted for publication in Intensive Care Medicine, Gattinoni noted that COVID-19 patients in intensive care units in northern Italy had an atypical ARDS presentation with severe hypoxemia and well-preserved lung gas volume. Instead of high positive end-expiratory pressure (PEEP), physicians should consider the lowest possible PEEP and gentle ventilation-practicing patience to “buy time with minimum additional damage,” according to the letters and article published in Medscape.
Dr. Cameron Kyle-Sidell, a physician trained in emergency medicine and critical care and practicing at Maimonides Medical Center in Brooklyn, NY., agreed with the high-altitude concept.
“This is not to say that the pathophysiology underlying it is similar, but clinically they look a lot more like high-altitude sickness than they do pneumonia,” Kyle-Sidell said in a Medscape interview.
In a recent webinar, Weingart said physicians have been receiving input from physicians worldwide – including those from Italy and China, who dealt with the virus head-on.
Intubation too soon can cause issues and less favorable results for patients with COVID-19.
“What could happen to these ‘happy hypoxemic’ patients who are intubated early, is that due to that hypoxemia, they may work their way up the PEEP scale and actually a lot of the ALI (acute lung injury) may actually be iatrogenic (illness caused by medical examination or treatment),” Weingart said.
If you take a normal person and have them on a PEEP of 20 with mechanical mandatory breaths above that, that might be injurious levels of intubation for these patients with already damaged lungs.
As referred to many times, this virus is unprecedented – and may require physicians to think outside the typical protocol for treating COVID-19.
"This is a kind of disease in which you don't have to follow the protocol – you have to follow the physiology," Gattinoni said. "Unfortunately, many, many doctors around the world cannot think outside the protocol."
Physicians throughout the country – including those in Italy -- feel many COVID-19 patients can avoid or delay intubation and be at less risk for iatrogenesis, Weingart said.
While not willing to name the hospitals at this time, Gattinoni said one center in Europe has had a 0% mortality rate among COVID-19 patients in the intensive care unit when using this approach, compared with a 60% mortality rate at a nearby hospital using a protocol-driven approach. They have also seen indications of lower blood pressure and better mental status, when patients are not intubated, according to Gattinoni’s comments in the Medscape article.
Getting health institutions on board with this way of treating COVID-19 is a challenge, according to Kyle-Sidell.
“We are desperate now in the sense that everything we are doing does not seem to be working,” Kyle-Sidell said in an interview on Medscape. “So we've reached a point that most other diseases have not reached, where many physicians are willing to try anything that may help because so little seems to be helping.”
Most COVID-19 patients are started on nasal cannulas, Weingart said.
Non-rebreathers combined with surgical masks have been helping, as well, Weingart said.
“The last thing we are just about to start instituting is a trial of CPAP,” Weingart said, citing the “remarkable” success rate Italian physicians have had using helmet-based CPAPs. Companies are making (helmets) in the US as we speak.”
Weingart cited comfort and lower aerosolization as just two benefits of the helmet-based ventilation.
Another huge benefit of the helmet-based method is the ability for a COVID-19, based on Italian experience, is patients can change positions easily.
“These patients can do exactly what they do in bed at night, which is self-position,” Weingart said. “It’s not the same misery of an intubated patient proning procedure, which is dangerous and requires a huge amount of work.”
The helmet-based ventilation requires less hands-on needs from medical staff, and is more comfortable for the patient, while sedation, intubation, and proning are difficult for the patient and require more staff monitoring.
Webinar on Avoiding Intubation and Initial Ventilation in COVID19 with Dr. Weingart.