Ventilating COVID Patients

This is a topic I am to do some more research on. But early on in the COVID pandemic, the death rate was quite high. By the time the pandemic reached my work, the death rate had dropped significantly dropped but was still too high. Some estimates had a drop in the death rate by about 85% from March and April to October and November. What was the reason for this drop?

Many experts say it was ventilators. More specifically, it was a positive pressure. Severe COVID seems to cause blood clots. It also causes ARDS, COVID pneumonia, and pulmonary fibrosis. Their lungs get yucky and stiff. And, so it is believed, positive pressure pounds on these fragile lungs, making them worse.

And I don't know the exact mechanisms for how this happens. And, quite frankly, I am not sure the greatest COVID experts do either. Before COVID, if someone's saturations hung in the low 80s, we would be quit to think intubation. So, this is why I think you saw more ventilated COVID patients in the beginning. The theory developed that perhaps this was doing more harm than good. 

By the time the pandemic hit my area and my hospital, we were told to accept low oxygen levels. You put them on high flow nasal cannula, maybe add a non-rebreather if necessary, and be very patient with them. So, patients, we would usually consider incubating we now were very patient with them. 

And COVID is so unusual. You have a patient whose sats are the maybe high 80s and low 90s most of the day. But in the morning, that patient will get up to use the bathroom. And their sats may drop into the 70s. And, for some reason, it takes a long, long time for their sats to come back up. But, rather than panic and intubate, we wait. Usually, after an hour or so, the sats increase, and you relax a bit. 

But, when the sats drop like that, you have to enter the patient's room. I mean, at least I do if I can. I check the patient's nose to make sure the cannula is not blocked. You make sure your equipment is working properly. You make sure the saturation probe is connected right. Sometimes I have found simple problems to fix. But, most often, the problem is inside the patient's lungs. And you can't fix that, at least not as fast as you would want. 

So, you are patient. However, there comes that time when you have to make a decision. The patient's sats remain low. They stay low. The patient starts to experience symptoms. The x-ray is getting worse. You have no choice but to make a decision. 

Here your doctor will approach the patient. In the past, the decision must have been quick to intubate. Now, with what we know today. We know there is a poor outcome for patients with COVID placed on ventilators. One person told me it is 1 life out of 10. And that person who lives still does not have a good quality of life. He/she may require long-term, assisted living. That person is also still at risk for COVID complications, such as blood clots, PEs, heart attacks, and strokes. Why is this? No one knows for sure. Although, one theory that has around been that COVID causes little blood clots. That is why one of the treatments is heparin. 

Anyway, now the doctor talks to the patient—the doctor talks to the family. The option of hospice is talked about. The other option is a ventilator. Option one allows you to talk and communicate before you die. Option two means you will be deeply sedated before you die. And, yes, there is always hope. The reason we intubate anyone is to give that person a chance. 

Yes, we still ventilate COVID patients. But only as a last resort. The outcomes do not seem to be good. I just want to add that I still have a lot of learning to do about this COVID thing. As I learn more, I will be sure to share it with you. As you learn more, I hope you do the same.