COVID-19 Excessive Invasive Intubation

Several news articles indicate that invasive intubation ventilators were often used without good results. The articles indicate that the approach was found problematic and many doctors “stepped away from doing this”. The primary problems involved premature use of invasive intubated ventilation, excessive long-term PEEP pressures above 10 cmH2O, and other protocols that, although “standardized”, did not fit the physiologic condition of the patient. It appears that most US hospitals began increased use of non-invasive ventilation and other improved protocols by May 2020. By June 2020, many protocol improvements included use of steroids to further minimize invasive ventilation use.

 And Germany’s agrees:… It seems that using a BiPAP was the obvious first choice over invasive intubation ventilation approaches. Why did doctors have to figure this out over time?

“Only a few weeks ago in New York City, coronavirus patients who came in quite sick were routinely placed on ventilators to keep them breathing, said Dr. Joseph Habboushe, an emergency medicine doctor who works in Manhattan hospitals.

But increasingly, physicians are trying other measures first. One is having patients lie in different positions — including on their stomachs — to allow different parts of the lung to aerate better.”

What about STANDING UP and WALKING AROUND when you just want to lay in bed? When I’m sick, the more I just lay in bed, the sicker I get. Chris Cuomo of CNN (love him or hate him) has said he is keeping as active as possible.

Could it be that over zealous use of ventilators is the greatest cause of death? Read the article.

This video, being a bit dated from Mar 31, 2020, provides important background information and is a call for action to reduce damage from improper ventilator use including that of over-pressure and premature use.

John Whyte, MD, MPH, Chief Medical Officer of WebMD interviews Dr. Cameron Kyle-Sidell, MD.

Stanley Chera – President Trumps New York Friend

In an anecdotal case, the president’s friend called him and said he was going to the hospital. The next day he was in a coma. Was it a medically induced coma typically performed prior to intubation? Was the president’s friend, Stanley Chera, pre-maturely intubated and lost? Somehow he went from talking with the president to a coma in 1 day. Listen to the next 4 minutes to understand the context of that case. Stanley Chera died April 11, 2020.

New York has more ventilators deployed than anybody: 13,000 deployed and 1000’s more in stockpiles to spare! That’s enough to kill 6,500 people every 8 to 10 days given that the chances of surviving “recommended ARDS protocols” invasive intubation ventilation is about 50%. Better protocols are needed. Keep reading.

But would an investor or administrator setting policy or anyone working in a hospital really code someone incorrectly to increase revenue or do anything so low as to put a patient at risk for the sake of money? While the nurses and doctors who are bedside tend to be very patient-focused, the administrators, investors, politicians, treatment policy makers, and others who are far removed from the bedside can have negative impacts on the judgement of those bedside. The bedside providers can sometimes become jaded, stressed, and even succumb to temptations and frustrations that result unfavorably. Exasperated front-line workers perceiving bad practice policies (real, perceived, or corrupt) at the administration level can sometimes sadly reach a point of thinking “… it, I don’t care anymore”.

If respiratory assistance is needed, supplemental oxygen, then BiPAP would be, by far, a first resort. Only in an extreme case would an invasive ventilator be the very undesirable last resort choice. But it was NOT the first choice of hospitals during the COVID19 epidemic. Yet a paper from 2010 demonstrates BiPAP effectiveness. Some doctors avoid BiPAP because the mask can leak when not fitted properly resulting in a risk to medical staff and this is balanced against the knowledge that using invasive intubation ventilation results in death nearly 50% per earlier articles. But there are solutions to minimize risk of virus containing aerosols to medical staff.

As for aerosols containing virus:

1) Employ a dual-limb ventilator with filters placed at the ventilator outlets.
2) Using negative pressure isolation rooms for patients, and gloves, gowns and masks for caregivers
3) Keep in mind that the early estimates of Infection Fatality Rate (IFR) of 3% were incorrect. As of June 2020, CDC models are based on a 0.4% IFR. This means that any escaping virus is not as threatening to health-care workers as once thought, reducing the incentive for medical professionals to prematurely intubate in order to contain aerosols from patients that could cause infection of health-care workers.

Solutions exist for IGel and CPAP as well.

Somewhat related is the inflation of death statistics. The federal state or local governments should not want increased death statistics. How would inflating the death count statistics help?

This is what could be done instead of premature intubation.

Dr. Gattinoni – 706 Publications, 37,055 Citations.

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, Luciano Gattinoni, MD, of the Medical University of Göttingen in Germany and colleagues make the case that protocol-driven ventilator use for patients with COVID-19 could be doing more harm than good.

Dr. Gattinoni noted that COVID-19 patients in ICUs in northern Italy had an atypical ARDS presentation with severe hypoxemia and well-preserved lung gas volume. He and colleagues suggested that 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.”

As of May 2020, Dr. Gattinoni has 706 Publications, 130,243 Reads, and 37,055 Citations.

“After considering that, all we can do ventilating these patients is “buying time” with minimum additional damage: the lowest possible PEEP and gentle ventilation. We need to be patient.” [while the immune system responds to the virus].