16 ms·

There is a lot of misinformation about COVID-19 lung disease. This article's title is alarming, but most of its content is mainstream. Lung protective ventilat

There is a lot of misinformation about COVID-19 lung disease. This article's title is alarming, but most of its content is mainstream. Lung protective ventilation - the standard approach for ARDS (which COVID-19 seems to cause) - avoids high pressure and high volume ventilation. Broadly, I would suggest that interested people read Corey Hardin's response to the cacophony of voices saying that COVID-19 respiratory failure is not ARDS: https://mailchi.mp/e10a89ac5988/tz4idnzryr-4388986?e=96507de8e5 https://mailchi.mp/e10a89ac5988/tz4idnzryr-4388986?e=96507de...

ramraj07 7y ago
This article says though that in New York 80% of people put on a ventilator die; is that fact refuted by anyone? For a machine that's in short supply and quite invasive, a 20% survival probability seems extremely low.
- carbocation 7y ago
  Yes, this seems to be an extremely morbid disease. The current protocols became widely agreed upon after clinical trials showed that this approach to mechanical ventilation reduced mortality. It is in physicians' nature to speculate about new approaches to care for sick patients. But it's important (for MDs) to put that speculation into the proper context and understand equipoise.
  - ramraj07 7y ago
    Okay first of all thank you for that resource. I read through it (not all the references yet but that's next). Clearly written by experts, but something I'll still fully disagree. The mailing list analysis seems far more concerned with trying to determine if this is "ARDS as we define it" or not. It touches on way too many angles and tries to address many random hypothesis (the hemoglobin one is so outrageous to even bother addressing!), That I'm afraid they're losing focus on the fundamental question - should patients with covid-19 be ventilated the moment their pO2 drops below 90? The author has not convinced me (an amateur) that they should be. They don't address the first primary hypothesis properly, which is that perhaps the pCO2 is actually in acceptable ranges in covid patients for some reason. Clearly the mortality for ventilated patients is higher for covid cases than other sources of past, so it's very intriguing they mix and match findings from 2016 with what we observe in covid. This is not to question the authority of the authors, clearly they are experts, but personal experience from working with experts in academia is that they can also be very wrong because they're lost in the details, which is my worry here. We should hope to strive and be great scientists though, so if a doctor or a scientist asks _why_ we should consider that the ARdS is slightly different in covid, they are owed some explanation and some data. Which we should explore together. In the meanwhile though, unless my further reading is going to change my mind, my current working hypothesis is going to be that the ARDS or whatever in covid patients is fundamentally slightly different in some way that means patients should be put on ventilators much later than conventional wisdom would suggest.
    - carbocation 7y ago
      What is the relevance of the pCO2? What is the counterfactual that you or others are proposing? One could use that counterfactual to set up a clinical trial.
- Zigurd 7y ago
  That could be the effect of conserving ventilators for the most seriously ill, in a C19 hotspot. That is, selection bias caused by a tight supply of ventilators.
  - bpodgursky 7y ago
    That could be the case in Italy, but New York has not run out of ventilators, and I have not seen any reports of pre-emptive rationing.
    - lbeltrame 7y ago
      ICUs are still under pressure in Italy, but not at the levels of a couple of weeks ago.
  - djsumdog 7y ago
    Except that there don't appear to be shortages yet. It appears that doctors who need them are able to get access for patients, but they're still seeing these mortality rates https://covid19.healthdata.org/united-states-of-america/new-york https://covid19.healthdata.org/united-states-of-america/new-...
- pbhjpbhj 7y ago
  The figure for the England that I've seen is 50% (vs 20% death rate for viral pneumonia in 2017-2019, see [0]). I think that's for intubated ventilation as opposed to "just" non-invasive ventilation like BiPAP (which IIRC is contra-indicated; maybe because it impairs expectoration???). But as others have said, if you only use the ventilator for the very sickest people, then the more pressed you are the fewer survivors you'll get because people who have a chance without it will be kept off the ventilator if at all possible. My very limited understanding is that ventilation has major issues around bacterial infection. [0] https://www.icnarc.org/Our-Audit/Audits/Cmp/Reports https://www.icnarc.org/Our-Audit/Audits/Cmp/Reports other sources I've seen recently: [1] https://emcrit.org/ibcc/support/ https://emcrit.org/ibcc/support/ [2] https://icmanaesthesiacovid-19.org/covid-19-airway-management-principles https://icmanaesthesiacovid-19.org/covid-19-airway-managemen... (good detail on managing risk to staff, and on tracheal intubation)
  - DanBC 7y ago
    In England we have the ICNARC (Intensive Care National Audit & Research Centre) reports. https://www.icnarc.org/ https://www.icnarc.org/ The report and data can be found here: https://www.icnarc.org/Our-Audit/Audits/Cmp/Reports https://www.icnarc.org/Our-Audit/Audits/Cmp/Reports It's a short report but it's crammed full of information. Critical care unit outcome Patients receiving advanced respiratory support* (N=1053) (first and second columns) Patients receiving only basic respiratory support* (N=444) (third and forth columns) Outcome at end of critical care, n (%) Alive 355 (33.7) 358 (80.6) Dead 698 (66.3) 86 (19.4) The ICNARC report is important because it gives us clear information about people who die. It's not just those who are severely ill or those who are very old. Most people who die needed no help with day to day living. There are lots of deaths in the 50 to 80 age range. Comorbidities can be things which are well controlled and otherwise relatively minor.
  - HeadsUpHigh 7y ago
    >But as others have said, if you only use the ventilator for the very sickest people, then the more pressed you are the fewer survivors you'll get because people who have a chance without it will be kept off the ventilator if at all possible. My very limited understanding is that ventilation has major issues around bacterial infection. This is why everybody is locking down so you don't have to make a choice between those that will benefit the most from ventilation and those that have little hope left. For most socialized healthcare systems once a resource is in sort supply guidelines for selecting those that will benefit the most are established. So at the end of the day the 80 y.o won't receive the ventilator but the 50 y.o. will( at least that's how it works here).
- dchichkov 7y ago
  Should they be trying experimental antiviral or immune system therapies instead of ventilators? At the very least these therapies are not as invasive (or expensive).
  - jpxw 7y ago
    Like what?
    - dchichkov 7y ago
      It is not like there is a lack of options. But it is all experimental. Here is a recent review on the therapeutic options from Nature - https://www.researchgate.net/publication/339161688_Therapeutic_options_for_the_2019_novel_coronavirus_2019-nCoV https://www.researchgate.net/publication/339161688_Therapeut... Or maybe looking at the therapy in countries that show low death rates? Could it be that some countries got lucky with the choice of therapy? For example, Russia seem to show surprisingly low death rate so far - 1 per million, as per today's Worldmeter data. As per Reuters/30 Jan, their health ministry recommended "ribavirin, lopinavir/ritonavir and interferon beta-1b".
      - viraptor 7y ago
        > Russia seem to show surprisingly low death rate so far - 1 per million Officially low rate. There could be low rates, just like there are no gays in Chechnya, or actually low. But it would be very surprising if any recommendation from January wasn't verified by now in other countries and used worldwide if it's successful.
        dchichkov 7y ago
        Well, how about this, in New York on Apr 14, rate is 552/M. In California it is 19/M. This is 30x factor. Maybe people just do different things in different places. And this results in different numbers. It might be worth to examine what people are doing in different places.
  - 7y ago
- j45 7y ago
  News articles written by corporate or citizen journalists are not always authorities on interpretation. There is a Facebook group with 10 or 20,000 doctors exchanging real-time information. One topic coming up is ventilators may be provided too late.
- snapetom 7y ago
  They've reported this two times in Seattle briefings. I believe the first number reported was 75% die. I can't remember the lastest number. It was lower, but still very high. So, IMO, Seattle's number is within the ballpark of NYC's
- redis_mlc 7y ago
  Yes, you've stated the most important statistic. US doctors are using ventialtors because that's how they've always done it. But China found out months ago they're not working. The general recommendation now is to use a cannula until you faint, since almost nobody survives the ventilator after a week - it's like major surgery.
  - dkarras 7y ago
    That statistic alone does not mean much. You need the death rates of people that "needed" a ventilator but didn't get one. Maybe 90%-100% of them die?
podgaj 7y ago
What about decreasing pulmonary vasodilation? Wouldn't pulmonary hypertension be beneficial here? Is this a role zinc might play? If there is a zinc deficiency would this not lead to vasodialtion and the dilution of the pneumocytes? https://www.frontiersin.org/articles/10.3389/fphys.2018.00641/full https://www.frontiersin.org/articles/10.3389/fphys.2018.0064... Further evidence for abnormal iron handling was demonstrated by Decker et al. (2011) who showed that zinc protoporphyrin (Zn-pp) levels are high in patients with PAH (mainly iPAH) indicating deficient iron incorporation to form heme suggestive of iron deficiency; levels were closely related to clinical severity (Decker et al., 2011). Zinc competes with iron for binding sites, therefore when iron levels are diminished zinc replaces iron at these sites. PAH patients also had a high red cell distribution width (RDW), again corresponding to markers of clinical severity, such as higher pulmonary arterial pressures and lower 6MWT. Most recently, using proteome analysis in the plasma of patients with PAH, Rhodes et al. (2017) were able to identify a combination of nine circulating proteins associated with a high risk of mortality, two of which, plasminogen and erythropoietin, are associated with abnormal iron metabolism (Rhodes et al., 2017).
- podgaj 7y ago
  Why am I being down voted for a question? Sorry I am old and new to Hacker News but I have a Phd. Am I doing something wrong?
  - nitrogen 7y ago
    Welcome to HN! I'm not an expert on the subject, nor am I anybody important here, but give it time. Sometimes downvotes are accidental, sometimes it takes a while for a refutation to make it clear what was wrong, sometimes you just never find out. Best to just take it in stride as something random until more information is available.
    - podgaj 7y ago
      Thanks!
deleted 7y ago
[deleted]
rurban 7y ago
This is a better explanation, but got censored by Medium. Joining Facebook in its propaganda efforts. http://web.archive.org/web/20200405061401/https://medium.com/@agaiziunas/covid-19-had-us-all-fooled-but-now-we-might-have-finally-found-its-secret-91182386efcb http://web.archive.org/web/20200405061401/https://medium.com...
- carbocation 7y ago
  This is the sort of stuff ("There is no ‘pneumonia’ nor ARDS.") that Corey Hardin is refuting. Like, literally some of these hypotheses (e.g., that SARS-COV-2 disrupts heme binding - as if that could cause a decreased P:F ratio!) are specifically refuted. Good on Medium for refusing to host that.

ramraj07 7y ago

This article says though that in New York 80% of people put on a ventilator die; is that fact refuted by anyone? For a machine that's in short supply and quite invasive, a 20% survival probability seems extremely low.

carbocation 7y ago
Yes, this seems to be an extremely morbid disease. The current protocols became widely agreed upon after clinical trials showed that this approach to mechanical ventilation reduced mortality. It is in physicians' nature to speculate about new approaches to care for sick patients. But it's important (for MDs) to put that speculation into the proper context and understand equipoise.
- ramraj07 7y ago
  Okay first of all thank you for that resource. I read through it (not all the references yet but that's next). Clearly written by experts, but something I'll still fully disagree. The mailing list analysis seems far more concerned with trying to determine if this is "ARDS as we define it" or not. It touches on way too many angles and tries to address many random hypothesis (the hemoglobin one is so outrageous to even bother addressing!), That I'm afraid they're losing focus on the fundamental question - should patients with covid-19 be ventilated the moment their pO2 drops below 90? The author has not convinced me (an amateur) that they should be. They don't address the first primary hypothesis properly, which is that perhaps the pCO2 is actually in acceptable ranges in covid patients for some reason. Clearly the mortality for ventilated patients is higher for covid cases than other sources of past, so it's very intriguing they mix and match findings from 2016 with what we observe in covid. This is not to question the authority of the authors, clearly they are experts, but personal experience from working with experts in academia is that they can also be very wrong because they're lost in the details, which is my worry here. We should hope to strive and be great scientists though, so if a doctor or a scientist asks _why_ we should consider that the ARdS is slightly different in covid, they are owed some explanation and some data. Which we should explore together. In the meanwhile though, unless my further reading is going to change my mind, my current working hypothesis is going to be that the ARDS or whatever in covid patients is fundamentally slightly different in some way that means patients should be put on ventilators much later than conventional wisdom would suggest.
  - carbocation 7y ago
    What is the relevance of the pCO2? What is the counterfactual that you or others are proposing? One could use that counterfactual to set up a clinical trial.
Zigurd 7y ago
That could be the effect of conserving ventilators for the most seriously ill, in a C19 hotspot. That is, selection bias caused by a tight supply of ventilators.
- bpodgursky 7y ago
  That could be the case in Italy, but New York has not run out of ventilators, and I have not seen any reports of pre-emptive rationing.
  - lbeltrame 7y ago
    ICUs are still under pressure in Italy, but not at the levels of a couple of weeks ago.
- djsumdog 7y ago
  Except that there don't appear to be shortages yet. It appears that doctors who need them are able to get access for patients, but they're still seeing these mortality rates https://covid19.healthdata.org/united-states-of-america/new-york https://covid19.healthdata.org/united-states-of-america/new-...
pbhjpbhj 7y ago
The figure for the England that I've seen is 50% (vs 20% death rate for viral pneumonia in 2017-2019, see [0]). I think that's for intubated ventilation as opposed to "just" non-invasive ventilation like BiPAP (which IIRC is contra-indicated; maybe because it impairs expectoration???). But as others have said, if you only use the ventilator for the very sickest people, then the more pressed you are the fewer survivors you'll get because people who have a chance without it will be kept off the ventilator if at all possible. My very limited understanding is that ventilation has major issues around bacterial infection. [0] https://www.icnarc.org/Our-Audit/Audits/Cmp/Reports https://www.icnarc.org/Our-Audit/Audits/Cmp/Reports other sources I've seen recently: [1] https://emcrit.org/ibcc/support/ https://emcrit.org/ibcc/support/ [2] https://icmanaesthesiacovid-19.org/covid-19-airway-management-principles https://icmanaesthesiacovid-19.org/covid-19-airway-managemen... (good detail on managing risk to staff, and on tracheal intubation)
- DanBC 7y ago
  In England we have the ICNARC (Intensive Care National Audit & Research Centre) reports. https://www.icnarc.org/ https://www.icnarc.org/ The report and data can be found here: https://www.icnarc.org/Our-Audit/Audits/Cmp/Reports https://www.icnarc.org/Our-Audit/Audits/Cmp/Reports It's a short report but it's crammed full of information. Critical care unit outcome Patients receiving advanced respiratory support* (N=1053) (first and second columns) Patients receiving only basic respiratory support* (N=444) (third and forth columns) Outcome at end of critical care, n (%) Alive 355 (33.7) 358 (80.6) Dead 698 (66.3) 86 (19.4) The ICNARC report is important because it gives us clear information about people who die. It's not just those who are severely ill or those who are very old. Most people who die needed no help with day to day living. There are lots of deaths in the 50 to 80 age range. Comorbidities can be things which are well controlled and otherwise relatively minor.
- HeadsUpHigh 7y ago
  >But as others have said, if you only use the ventilator for the very sickest people, then the more pressed you are the fewer survivors you'll get because people who have a chance without it will be kept off the ventilator if at all possible. My very limited understanding is that ventilation has major issues around bacterial infection. This is why everybody is locking down so you don't have to make a choice between those that will benefit the most from ventilation and those that have little hope left. For most socialized healthcare systems once a resource is in sort supply guidelines for selecting those that will benefit the most are established. So at the end of the day the 80 y.o won't receive the ventilator but the 50 y.o. will( at least that's how it works here).
dchichkov 7y ago
Should they be trying experimental antiviral or immune system therapies instead of ventilators? At the very least these therapies are not as invasive (or expensive).
- jpxw 7y ago
  Like what?
  - dchichkov 7y ago
    It is not like there is a lack of options. But it is all experimental. Here is a recent review on the therapeutic options from Nature - https://www.researchgate.net/publication/339161688_Therapeutic_options_for_the_2019_novel_coronavirus_2019-nCoV https://www.researchgate.net/publication/339161688_Therapeut... Or maybe looking at the therapy in countries that show low death rates? Could it be that some countries got lucky with the choice of therapy? For example, Russia seem to show surprisingly low death rate so far - 1 per million, as per today's Worldmeter data. As per Reuters/30 Jan, their health ministry recommended "ribavirin, lopinavir/ritonavir and interferon beta-1b".
    - viraptor 7y ago
      > Russia seem to show surprisingly low death rate so far - 1 per million Officially low rate. There could be low rates, just like there are no gays in Chechnya, or actually low. But it would be very surprising if any recommendation from January wasn't verified by now in other countries and used worldwide if it's successful.
      - dchichkov 7y ago
        Well, how about this, in New York on Apr 14, rate is 552/M. In California it is 19/M. This is 30x factor. Maybe people just do different things in different places. And this results in different numbers. It might be worth to examine what people are doing in different places.
- 7y ago
j45 7y ago
News articles written by corporate or citizen journalists are not always authorities on interpretation. There is a Facebook group with 10 or 20,000 doctors exchanging real-time information. One topic coming up is ventilators may be provided too late.
snapetom 7y ago
They've reported this two times in Seattle briefings. I believe the first number reported was 75% die. I can't remember the lastest number. It was lower, but still very high. So, IMO, Seattle's number is within the ballpark of NYC's
redis_mlc 7y ago
Yes, you've stated the most important statistic. US doctors are using ventialtors because that's how they've always done it. But China found out months ago they're not working. The general recommendation now is to use a cannula until you faint, since almost nobody survives the ventilator after a week - it's like major surgery.
- dkarras 7y ago
  That statistic alone does not mean much. You need the death rates of people that "needed" a ventilator but didn't get one. Maybe 90%-100% of them die?

podgaj 7y ago

What about decreasing pulmonary vasodilation? Wouldn't pulmonary hypertension be beneficial here? Is this a role zinc might play? If there is a zinc deficiency would this not lead to vasodialtion and the dilution of the pneumocytes? https://www.frontiersin.org/articles/10.3389/fphys.2018.00641/full https://www.frontiersin.org/articles/10.3389/fphys.2018.0064... Further evidence for abnormal iron handling was demonstrated by Decker et al. (2011) who showed that zinc protoporphyrin (Zn-pp) levels are high in patients with PAH (mainly iPAH) indicating deficient iron incorporation to form heme suggestive of iron deficiency; levels were closely related to clinical severity (Decker et al., 2011). Zinc competes with iron for binding sites, therefore when iron levels are diminished zinc replaces iron at these sites. PAH patients also had a high red cell distribution width (RDW), again corresponding to markers of clinical severity, such as higher pulmonary arterial pressures and lower 6MWT. Most recently, using proteome analysis in the plasma of patients with PAH, Rhodes et al. (2017) were able to identify a combination of nine circulating proteins associated with a high risk of mortality, two of which, plasminogen and erythropoietin, are associated with abnormal iron metabolism (Rhodes et al., 2017).

podgaj 7y ago
Why am I being down voted for a question? Sorry I am old and new to Hacker News but I have a Phd. Am I doing something wrong?
- nitrogen 7y ago
  Welcome to HN! I'm not an expert on the subject, nor am I anybody important here, but give it time. Sometimes downvotes are accidental, sometimes it takes a while for a refutation to make it clear what was wrong, sometimes you just never find out. Best to just take it in stride as something random until more information is available.
  - podgaj 7y ago
    Thanks!

deleted 7y ago

[deleted]

rurban 7y ago

This is a better explanation, but got censored by Medium. Joining Facebook in its propaganda efforts. http://web.archive.org/web/20200405061401/https://medium.com/@agaiziunas/covid-19-had-us-all-fooled-but-now-we-might-have-finally-found-its-secret-91182386efcb http://web.archive.org/web/20200405061401/https://medium.com...

carbocation 7y ago
This is the sort of stuff ("There is no ‘pneumonia’ nor ARDS.") that Corey Hardin is refuting. Like, literally some of these hypotheses (e.g., that SARS-COV-2 disrupts heme binding - as if that could cause a decreased P:F ratio!) are specifically refuted. Good on Medium for refusing to host that.