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UChicago doctors see ‘remarkable’ success using ventilator alternatives
- bobowzki 7y agoI'm an intensivist based in Sweden. From my perspective there is absolutely nothing new in this article. We have been using HFC for years if not decades.
- wl 7y agoAs I understand it, what's new is that it's being used under these circumstances. The ARDS algorithm would have these patients be intubated. Instead, they're putting these patients on HFC and letting them get hypoxic, reasoning that the mixture of damage caused by the infection and the vent is what's fatal. Edit: Also, people have been avoiding HFC for COVID-19 because of aerosolization risks.
- hprotagonist 7y agothis is my understanding as well. when i was an EMT if someone had O2 sats in the 50s and was conscious i would’ve told you that the pulse ox was broken. And it it wasn’t broken, i’d be yelling for a paramedic to tube my patient asap.
- klmadfejno 7y agoMy non-medical understanding is that the long term damage threat of the disease is primarily due to to organs dealing with low oxygen for long periods of time. Would you say it's fair to say that an approach which saved more lives by not addressing would probably leave a greater proportion with organ damage?
- hprotagonist 7y agohonest answer? we have absolutely no idea, and whether or not we like it (mostly we don't like it), we're in the process of finding out.
- ceejayoz 7y agoNot for COVID-19, presumably.
- joshgel 7y agoOur* guidance has been HFNC only in negative pressure rooms because of the aersolization risk. We've converted a huge number of beds to negative pressure in order to maximize use of HFNC. Anecdotally, I feel like it works, but would be great to see a trial. *major nyc health system
- amluto 7y agoIs management of an HFNC patient simple enough that it could be done outside a hospital? I’m imagining a converted stadium or similar area in which patients use HFNC and everyone who isn’t a patient puts on serious PPE before entering and takes it off only when they’re quite far away.
- ceejayoz 7y agoOr staff it with recovered healthcare workers.
- eternalny1 7y ago'No evidence' that recovering from Covid-19 gives people immunity, WHO says https://www.france24.com/en/20200425-no-evidence-that-recovering-from-covid-19-gives-people-immunity-who-says https://www.france24.com/en/20200425-no-evidence-that-recove...
- roywiggins 7y agoThere's no evidence, but should we expect evidence? Has anyone looked? The Bayesian prior that they should have some level of immunity is pretty high, seems to me. Exactly how long and how strong such immunity is a good question, but it would be really unlikely if there was no immunity.
- ceejayoz 7y agoThere was no evidence of human-to-human transmission early on, too. “No evidence” is not “evidence against immunity”. It means we don’t know yet.
- theobeers 7y agoOne of the most active figures in this debate has been a New York doctor named Cameron Kyle-Sidell. He frequently posts interesting sources on Twitter: https://twitter.com/cameronks https://twitter.com/cameronks
- not_a_moth 7y agoYes, rather absurdly, I learned about him like a month ago on ZeroHedge when they started following him; he was brushed off for weeks, his message being, "Look at patient behavior, this is not actually ARDS, our ventilator strategy is probably wrong." Crazy to think that so many doctors around the world, experts, and policy makers didn't really question the fundamental nature of the disease, and perhaps telling that it took an ER doctor in NYC posting on youtube for a month to bring it proper attention.
- nerdponx 7y agoWhat I don't understand about this is - didn't China figure this all out already?
- pests 7y agoI distinctly remember months ago of a Chinese doctor in China claiming this same thing. I thought it was a bit far fetched at the time but I'm getting incredible deja vu with this new release.
- jplayer01 7y agoIt's not just the Chinese. Doctors have been concerned about the abnormally high death rate for ventilators for months too. I've been seeing comments to the effect of looking for alternatives to ventilators because there were indications that did more harm than good. I guess not every hospital had this idea, but I know the sentiment was around for a while.
- jonkho 7y agoAlso, how does this affect the actual death rate numbers in NYC if unnecessary deaths caused by outcomes of ventilator use are factored into the picture? Could change the picture quite drastically.
- DanielBMarkham 7y agoOne of the most interesting parts of this press release, following it on other boards, is the immediate "We already do that. Nothing new here." That kind of reply would immediately lead me to think it was just a useless release, but then I see people posting comments along the lines of "No, we don't do that. In fact, we have a policy against doing that because of the danger of aerosolization" For my hacker/systems wonks, this a great example of group learning happening world wide. I imagine there are many ICUs that do this, and many that forbid it. In such an environment, releases like this aren't submarines or spam; they're recurring prompts to administrators elsewhere that they might be missing something important. I hate to sound cold, but damn this is an interesting example of how organizations learn. One commenter asked "I wonder how many of those hospitals who forbid intubation are doing it to patients with good insurance" For the record, as far as I know this is a horrible thing to suggest. But the overall point, that large organizations have incentives that are many times removed from the actual work being done, is a good one. This kind of conversation facilitation across borders is what the internet was supposed to be doing. I think this is the first time I've seen it working the way we had hoped. What's especially interesting to me is that many of the signals we look for in social forums, like "this is just a spam press release", "nothing new to see", or "there's some ulterior motivation here" voting up or down, etc., are actually counter-indicators and inhibitors of overall progress.
- joshgel 7y agoEven better would be randomized experimental data that this was better than an alternative... 'It works' can mean lots of different things...
- DanielBMarkham 7y agoIt's an excellent point. Learning is not the same as science, and we need randomized trials to actually be sure of anything. Unfortunately, in the middle of a pandemic, that's not going to happen with enough speed to prevent a lot of people dying. The perfect can be the enemy of the good enough. We don't have to guess or learn about the mass of an electron; that's been well-established through great lab work. But not all decisions are like that. Many times the hardest decisions are those you make with incomplete and contradictory information ... and not making a decision is, in effect, making a decision. This is one of the things that's so interesting here. If it were simple yes/no, what's science and what's speculation, there wouldn't be much interesting learning or decision-making happening.
- 40four 7y agoSounds like a promising strategy to manage patients, assuming the hospital has the necessary negative pressure rooms, etc. Especially since ventilators don’t even seem to be very effective. We’ve been seeing stories last few days that the large majority (88%) of folks put on ventilators in NYC, end up dying.
- joshgel 7y agoThat 88% number is pretty misleading. They only looked at: (number of patients who died) / (number of patients who died + number of patients discharged alive). And didn't consider the other patients on ventilators who are still alive, but still in the hospital (many likely no longer on ventilators). Don't get me wrong, the fatality rate for intubated patients is going to be high. but probably more like 40-60%.
- maxerickson 7y agoBe careful with that number. It's 88% of the cases that had resolved after ~4.5-5 days, which was only 25% of the cases included in the study. If there is some bias in the study population, the overall rate can change quite a lot (for example, a possibility is that the weakest patients succumb in that period, with stronger patients coming off the ventilators after a longer period...).
- W_G_T 7y agoThey converted the entire MICU (24 beds) to negative pressure rooms.
- firasd 7y agoRelated: "The respiratory distress appears to include an important vascular insult that potentially mandates a different treatment approach than customarily applied for ARDS." https://twitter.com/jama_current/status/1253722428053823492 https://twitter.com/jama_current/status/1253722428053823492
- IlyaMoroshkin 7y agoWith treatment so simple, we have effectively removed the healthcare system as a bottleneck on the rest of society. I think we can safely reopen fully now and treat any serious cases using our existing healthcare systems in combination with this kind of new knowledge. The longer we 'suppress the curve', when we are already far below hospital system capacity, the more economic and social damage we cause unnecessarily.
- sp332 7y agoStronger pandemic response yields better economic recovery. http://news.mit.edu/2020/pandemic-health-response-economic-recovery-0401 http://news.mit.edu/2020/pandemic-health-response-economic-r...
- dr_dshiv 7y agoAge difference in workforce from 1918 flu
- mrfusion 7y agoNot sure why you’re being downvoted. Here’s an article that puts sources and numbers on your thought: https://thehill.com/opinion/healthcare/494034-the-data-are-in-stop-the-panic-and-end-the-total-isolation https://thehill.com/opinion/healthcare/494034-the-data-are-i... I’d be curious to hear counterpoints. I could be wrong. It does anyone think this will go away with a long enough lockdown? Or is there any solution other than herd immunity?
- anon1385 7y agoThe most important counterpoint is that the Stanford study cited there is really bad: https://statmodeling.stat.columbia.edu/2020/04/19/fatal-flaws-in-stanford-study-of-coronavirus-prevalence/ https://statmodeling.stat.columbia.edu/2020/04/19/fatal-flaw... The more recent numbers from New York put the IFR at 0.5 to 1%, which matches what most organisations (WHO, governments etc) have been assuming for a couple of months now. Also the actual death count from NY makes the Stanford numbers pretty much impossible (0.2% of people in NYC have already died).
- mrfusion 7y agoI heard on Reddit that Medicare pays 3x more for intubation. Can anyone find a source?
- deleted 7y ago[deleted]
- ceejayoz 7y agoIt’s a far more complicated procedure, of course it pays more. A five year old can install a nasal cannula.
- 1996 7y agoand it could be done at home, using an O2 cannister, that should be cheap even for those paying out of pocket without medical insurance. no wonder why the medical establishment would be opposed to a simple work around that would remove the need for hospitalization or ICU
- ceejayoz 7y agoThese patients still need the care and monitoring you'd get in an ICU, and there's zero indication the "medical establishment" is opposed to it - high-flow oxygen is used regularly in hospitals in a variety of scenarios.
- 1996 7y agodefine care and monitoring. - care, like taking the drugs they have been prescribed and regularly take at home? Any family member can do that. - monitoring that the saturation does not fall too low... so that patients can be intubated with a 90% risk of death? I'd rather opt out of that one. To be clear, I'm talking about de-medicalizing covid: no ICU, no hospital. Just O2 nasal canula at home. It seems unimaginable, but a large number of in the world deal with no hospital healthcare.
- caymanjim 7y agoHospitals are losing money on covid patients, and the more treatment they require (ICU, ventilator, medication), the more the hospital is losing. They do get paid about three times more for an intubated patient, but they lose more money too. Hospitals make their profit off voluntary procedures like shoulder and knee surgeries and the constant flow of voluntary tests and procedures ("I just want to get this checked out"). They lose a lot of money when people spend three weeks in the ICU. This is especially true when a huge percentage of the patients are Medicare or completely uninsured. Privately insured patients with good policies are better, but they still aren't getting rich off those people. I have no sympathy for the hospital systems or the entire medical industry that has created a massive bureaucracy full of perverse incentives, exploitation, overbilling, and accounting games, but in this particular situation, even with the massive federal handouts, they're not making bank.
- DenisM 7y agoSo about CPAP / BiPAP? If all one needs it to push air down the lungs a CPAP can produce a lot of pressure. Anyone knows enough about it?
- caymanjim 7y agoThe main problem with CPAP in a clinical setting is that it's not sealed and filtered like a proper ventilator, so it aerosolizes and disperses virus at high pressure. It's the same concern that they mention in this article about dispersal and the need for negative pressure rooms and more PPE. It's being used on some patients who aren't bad enough to require intubation.
- piannucci 7y agoFirst-- and I'm sure you weren't suggesting this, but I feel I need to mention-- it's extremely dangerous to pressurize a person's lungs above the surrounding environment[1]. Not to mention that pressurizing the inside of the throat could pressurize the middle ear and blow out your eardrums. Second, I'm not a physician, I'm a physicist. What follows is for curiosity's sake. I suspect that the goal is to maximally enrich the patient's airstream in oxygen, whenever it is that they happen to breathe in. In a patient with fluid-filled alveoli, the surface area available for diffusion of oxygen into the bloodstream is greatly diminished. Additionally, the distance that oxygen needs to diffuse before it reaches hemoglobin is increased: rather than just the lining of alveoli and capillaries, it has to first dissolve into the fluid gunk filling the space, then diffuse through the fluid, then pass through the lining of the alveolus and capillary. To top it off, water doesn't have great solubility for oxygen, and atmospheric air is mostly nitrogen anyways. Each of these passive transport phenomena occurs at a rate that depends on the gradient (roughly...) of available O2. This concentration is greatest in the air, and lowest in the bloodstream adjacent to the alveoli, where hemoglobin binds up oxygen. One way to increase the rate of dissolution and diffusion is to increase the concentration gradient. That means enriching the airstream in O2. [1] https://en.wikipedia.org/wiki/Barotrauma#Pulmonary_barotrauma https://en.wikipedia.org/wiki/Barotrauma#Pulmonary_barotraum...
- agumonkey 7y agoHa yes, the good old Louis Pouzin runcom #frenchtech
- ineedasername 7y agoI wonder how they decide which patients would get the cannula instead of a ventilator? Otherwise, intubation w/ a ventilator generally requires some form of sedation-- I wonder if that sedation has an impact on the body's ability to fight back.
- wl 7y agoFrom what I've read here and elsewhere, they're putting everyone they would normally put on a vent on high flow. They only move to the vent when not doing so in the near term would likely result in death. That means, among other things, that they tolerate lower SpO2 levels than they would otherwise.
- Izkata 7y agoBy seeing what type of damage is being done to the lungs through CT scan or X-Ray, according to this article on a similar topic from two weeks ago: https://www.webmd.com/lung/news/20200407/doctors-puzzle-over-covid19-lung-problems https://www.webmd.com/lung/news/20200407/doctors-puzzle-over... More and more it's starting to look to me like we have two different novel viruses going around.
- ineedasername 7y agoTwo viruses may be possible, but other diseases certainly can have similar ranges of problems: The Flu might case different type of lung problems-- pneumonia, bronchitis, exacerbate asthma. Or it might hit your stomach, or result in ear infections by allowing other opportunistic infections to fester, or seizures. It may cause pericarditis or other heart problems, or strokes. So it is not unreasonable to assume that Covid-19 might cause the same symptoms through 2 different mechanisms.
- loeg 7y agoThe article mentions 40% O2 sat to 80 or 90%; aren't the latter still really low? I'm certainly no doctor, but wikipedia[1] claims "Prolonged hypoxia induces neuronal cell death via apoptosis, resulting in a hypoxic brain injury" and suggests that 80-85% is considered severe and 86-90% moderate. Granted, both are a hell of a lot better than 40%! It adds, "Mild and moderate cerebral hypoxia generally has no impact beyond the episode of hypoxia; on the other hand, the outcome of severe cerebral hypoxia will depend on the success of damage control, amount of brain tissue deprived of oxygen, and the speed with which oxygen was restored." So I guess my questions are: * How does this stack up against an intubated ventilator, assuming one is available? * My understanding is the patients needing respiratory support are often on ventilation for 1-2 weeks; how much damage would one expect from having severe hypoxia for that duration? [1]: https://en.wikipedia.org/wiki/Cerebral_hypoxia https://en.wikipedia.org/wiki/Cerebral_hypoxia
- tomohawk 7y agoBeing on a ventilator is traumatic. So much so that they generally put you under. Can you imagine waking up with a tube through your mouth and down your throat forcing you to breathe? It happens and people panic and have to be restrained. People get PTSD. https://www.hopkinsmedicine.org/news/media/releases/ptsd_common_in_icu_survivors https://www.hopkinsmedicine.org/news/media/releases/ptsd_com... If you can get the O2 up to a livable level without a ventilator so that the patient is supported enough to get well, that that is a good outcome.
- Izkata 7y ago> The article mentions 40% O2 sat to 80 or 90%; aren't the latter still really low? I'm certainly no doctor, but wikipedia[1] claims "Prolonged hypoxia induces neuronal cell death via apoptosis, resulting in a hypoxic brain injury" and suggests that 80-85% is considered severe and 86-90% moderate. Yeah, unfortunately I can't find it now, but I remember reading a "what the fuck is going on, these patients should be dead!" statement from a doctor a week or two ago about exactly that.
- grizzles 7y agoSound a lot like the devices people criticized Tesla for delivering.
- redis_mlc 7y agoYes, it turns out the Tesla devices were actually more practical than first thought. The caveats are: 1) Would US hospitals accept or recommend them? 2) If US hospitals accepted them, was there an acceptable solution to the aerosolization problem? Wuhan hospitals were segregated into corona and non-corona locations, so aerosolization wasn't a problem for other patients, but I don't know if US hospital systems got that organized. I highly recommend reading the Wuhan accounts and papers. They really moved fast on improving their response, which the US totally ignored. Only now, Apr. 26, are we catching up to what they found in Jan./Feb. I doubt if it affected the body count much, but time was wasted. Instead HN wasted months on endless navel-gazing and "IFR vs. CFR" chatter. Really a new low for HN.
- reticular 7y agoI don't doubt that this works well but there is a good reason that other hospitals are not using this approach. As the article mentions: "This approach is not without risk, however. HFNCs blow air out, and convert the COVID-19 virus into a fine spray in the air. To protect themselves from the virus, staff must have proper personal protective equipment (PPE), negative pressure patient rooms, and anterooms, which are rooms in front of the patient rooms where staff can change in and out of their safety gear to avoid contaminating others." "UChicago Medicine’s Emergency Department recently doubled its number of anterooms, thereby doubling its capacity to give ?high-flow nasal cannula to patients. The main hospital also added negative pressure rooms on two floors, making it safer and easier to take care of COVID-19 patients." Not all hospitals have the ability to double the number of negative pressure rooms or even provide needed PPE to all caregivers. A ventilator on the other hand allows for a HEPA filter in-line that prevents the spread of the disease within the hospital.
- forgetcolor 7y agoI wonder how this technique differs from CPAP. CPAP doesn't use pure O2, but perhaps the pressures can be similar?