12 ms·

I appreciate the effort, but it looks like we aren't going to need nearly as many ventilators as expected because COVID lung problems are different than other l

I appreciate the effort, but it looks like we aren't going to need nearly as many ventilators as expected because COVID lung problems are different than other lung conditions and seem not to respond well to invasive ventilation. https://www.youtube.com/watch?v=Elgct0nOcKY https://www.youtube.com/watch?v=Elgct0nOcKY https://www.reuters.com/article/us-health-coronavirus-ventilators-specia/special-report-as-virus-advances-doctors-rethink-rush-to-ventilate-idUSKCN2251PE https://www.reuters.com/article/us-health-coronavirus-ventil... https://www.cnn.com/2020/04/22/health/coronavirus-ventilator-patients-die/index.html https://www.cnn.com/2020/04/22/health/coronavirus-ventilator... The video in particular is telling, highlighting the difficulty in getting a hospital to change what is considered the standard procedure in the face of new conditions (told by a frontline doc). We are going to be up to our eyeballs in excess ventilators. Maybe they'll be handy for the next pandemeic ...

vlovich123 6y ago
I think this refrain is a bit over-simplified. TLDR it's a complex evolving situation, lots of uncertainty, insufficient specialists to handle the new influx, & no protocols around effective treatment leaving all doctors to do their best in the face of lots of unknowns. Do we have sufficient ventilators for everyone who would need it? Probably. Are there not enough in practice? Yes. Why? We don't know how to differentiate between who needs it and who doesn't effectively. So people are getting put on them excessively to try to save the ones for whom it would help and we have no way currently to distinguish those people better. Should we fill this knowledge gap? Absolutely. I'm sure doctors & researchers are scrambling to do that. https://time.com/5820556/ventilators-covid-19/ https://time.com/5820556/ventilators-covid-19/ > But Dr. David Hill, a pulmonary and critical care physician who treats COVID-19 patients in Waterbury, Conn. and serves as a volunteer medical spokesperson for the American Lung Association, says arguments against COVID-19 ventilation have been over-simplified. It may be less that ventilators aren’t the proper treatment for coronavirus, and more that they’re not a panacea for a pandemic that has pushed the health care system to its breaking point, Hill argues. > “You have really sick people, [while] the people who have the best training are in short supply and ventilator management is not simple,” Hill says. If a dedicated lung specialist were available for each patient, he believes, outcomes would probably be better. They could make the subtle adjustments required for effective long-term ventilation, or try less-invasive options and only move to intubation when absolutely necessary. But with many hospitals nearly at capacity, last resorts can become first resorts. > Few doctors are saying COVID-19 patients should never be ventilated, but there is a growing subset that thinks it’s happening too quickly. <snip> > Dr. Ken Lyn-Kew, a pulmonologist at National Jewish Health in Colorado, agrees that there are some differences between classic ARDS and COVID-19, but he emphasizes that there’s a lot of variation among COVID-19 patients he’s treated. He says most still meet the criteria for an ARDS diagnosis. In his view, coronavirus patients likely have ARDS plus other issues, but they still have ARDS. With so much unknown, and with treatment protocols being updated on the fly, he thinks it’s too soon for doctors to go off-book and avoid conventional protocols like mechanical ventilation. > “The world is not a dichotomous, black-and-white place, but a lot of people are having trouble with that,” Lyn-Kew says. “We might be able to do better, but in the absence of data on the way to do that, we need to follow our societal guidelines and 25 years of research.”
newacct583 6y ago
That's a somewhat cynical take, and I don't think any public policymakers would agree with your framing. What you're saying amounts to "We don't need more ventilators because all those people are probably going to die anyway and it won't save many lives." A better reason is because we beat the outbreak. A few areas like Milan/Madrid/Brussels went past their health care capacity and could have used more hardware. But they're all past peak now, and everywhere else (almost -- there are a few worrisome spots in the US still growing, and the developing world is still a big question mark due to lack of testing) managed to reach peak without hitting their limit. That's good news. We won. It's certainly not a problem that some of the efforts turned out not to be needed. It's like a war effort: everyone had a part to play, we needed to be conservative with our risk analysis and try different things.
- nichohel 6y ago
  I said nothing even approximately like "all those people are probably going to die anyway" and that is not, in fact, what I think! It is offensive that you would make up something like that and claim that is what I said. What a growing number of doctors are saying is that ventilators often turn out to do more harm than good in treating COVID, ventilators have been used too soon and too often in treating COVID, and ventilators have probably resulted in excess deaths over alternative treatments.
  - newacct583 6y ago
    I apologize if I offended you. That certainly seemed like what you were saying. The take is not new, and has been circulating among the "open up" community for a while. As far as whether ventilators have "probably resulted in excess deaths"... that's just not justified by any science yet. We don't know. There's some suspicion in that direction, based mostly on New York ICU fatality rates (which are quite high despite otherwise good numbers through the rest of the process). But there's equally good evidence from e.g. Milan, which experienced very high death rates due presumptively to lack of treatment hardware.
- jplayer01 6y ago
  You've completely misunderstood his argument. It's widely accepted and known that fatality rates once you're put on a ventilator (due to Coronavirus) is ridiculously high compared to when you're put on a ventilator for other illnesses (something like 80% vs 20%). It suggests that ventilators might not be the right solution to what's happening to these people. So some doctors have been questioning the wisdom of continuing to use ventilators, and some doctors have been looking to alternative solutions that might have more success and better outcomes. One idea that was floated was CPAP (though I don't know what happened to that). Nobody here is saying "ah, ventilators aren't working, fuck it, let everybody die". That's offensive to everybody here and a bad faith argument that isn't constructive in any way.
deelowe 6y ago
I think the issue is coming up with a new protocol. Right now, it's not clear what should be don in lieu of ventilators. There are trials going on to see if oxygen alone has better results. I recommend the r/covid19 subreddit and medcram youtube channel for this sort of thing, by the way. They seem to be doing a good job of staying on top of new developments with proper references.
rkangel 6y ago
That is not the UK experience. In the UK, ramping of manufacturing of existing ventilators has been more successful than expected, and social distancing has kept the demand on the NHS to a manageable level. Together that has meant that we haven't needed emergency designs. Whether that is true in other countries is a different matter.
- arcticfox 6y ago
  I'm not sure about developing countries, but I think by this point developed countries are probably on the right track to not need emergency-design ventilators. That said, I hope the most promising of these designs get carried through to 'production-ready', in case we get hit with something even worse than COVID in the future, which is easy to imagine. Basically the US govt attempt detailed in this story, but with a sucessful conclusion instead of a failure. https://www.nytimes.com/2020/03/29/business/coronavirus-us-ventilator-shortage.html https://www.nytimes.com/2020/03/29/business/coronavirus-us-v...
deleted 6y ago
[deleted]
carbocation 6y ago
The report that you cite of 25% mortality for COVID patients on a ventilator is in line with COVID causing ARDS. There is currently no reason to believe that it causes some fundamentally different process from other ARDS-inducing diseases. Our experience at MGH also puts severe COVID lung disease squarely into the ARDS category, and it responds to standard ARDS ventilation protocols[1]. Our mortality to date is shy of 20%. Data over anecdote. 1 = https://www.atsjournals.org/doi/abs/10.1164/rccm.202004-1163LE https://www.atsjournals.org/doi/abs/10.1164/rccm.202004-1163...
- elliekelly 6y ago
  > Our mortality to date is shy of 20%. Is that across all Covid patients? Or ventilated Covid patients?
  - carbocation 6y ago
    Ventilated. I should clarify since my positioning of the citation may have been a bit weird - the data is in the linked paper.
- nichohel 6y ago
  Thanks for the link. In the paper I see no direct comparison between COVID response to ventilation vs ARDS response to ventilation, but I think I understand that you say the responses are similar, based on your experience. Am I getting that right? Also, of course, there is nothing in the paper comparing COVID invasive ventilation outcomes with, for example, oxygen and positioning treatment outcomes. So, interesting, but I don't think this qualifies as "data over anecdote". I take it you are a pulmonary or ER doctor. If so, can you comment on the widely circulated claim that high death rates on ventilators in NYC are likely in part attributable to very aggressive ventilation and/or reduced attention to ventilation settings due to extreme fear of exposure to the virus (tubes leading from patients to other rooms and the like)?
  - carbocation 6y ago
    Because of the high volume of patients, those of us with more critical care experience were redeployed to newly created MICUs, but I am not a pulmonologist (details in profile). The high death rates in NYC that were published were attributable to a statistical error (failing to use adequate censoring of people still on ventilators). Note that the article has been updated with correctly censored numbers (hence 25%): https://jamanetwork.com/journals/jama/fullarticle/2765184 https://jamanetwork.com/journals/jama/fullarticle/2765184 Finally, we only intubate patients after maneuvers like awake proning fail, so it’s not something that is comparable.
dehrmann 6y ago
It was also pretty clear when people were pushing hard for ventilator production that they were a month too late once you consider even aggressive design, supply chains, lead time, etc. I doubt there will really be a surplus because a lot of these are under-tested and hastily assembled. We've been a month+ behind on a lot of the response. Now's not the time to talk about ventilators, it's the time to start working out logistics of vaccine production and distribution.

vlovich123 6y ago

I think this refrain is a bit over-simplified. TLDR it's a complex evolving situation, lots of uncertainty, insufficient specialists to handle the new influx, & no protocols around effective treatment leaving all doctors to do their best in the face of lots of unknowns. Do we have sufficient ventilators for everyone who would need it? Probably. Are there not enough in practice? Yes. Why? We don't know how to differentiate between who needs it and who doesn't effectively. So people are getting put on them excessively to try to save the ones for whom it would help and we have no way currently to distinguish those people better. Should we fill this knowledge gap? Absolutely. I'm sure doctors & researchers are scrambling to do that. https://time.com/5820556/ventilators-covid-19/ https://time.com/5820556/ventilators-covid-19/ > But Dr. David Hill, a pulmonary and critical care physician who treats COVID-19 patients in Waterbury, Conn. and serves as a volunteer medical spokesperson for the American Lung Association, says arguments against COVID-19 ventilation have been over-simplified. It may be less that ventilators aren’t the proper treatment for coronavirus, and more that they’re not a panacea for a pandemic that has pushed the health care system to its breaking point, Hill argues. > “You have really sick people, [while] the people who have the best training are in short supply and ventilator management is not simple,” Hill says. If a dedicated lung specialist were available for each patient, he believes, outcomes would probably be better. They could make the subtle adjustments required for effective long-term ventilation, or try less-invasive options and only move to intubation when absolutely necessary. But with many hospitals nearly at capacity, last resorts can become first resorts. > Few doctors are saying COVID-19 patients should never be ventilated, but there is a growing subset that thinks it’s happening too quickly. <snip> > Dr. Ken Lyn-Kew, a pulmonologist at National Jewish Health in Colorado, agrees that there are some differences between classic ARDS and COVID-19, but he emphasizes that there’s a lot of variation among COVID-19 patients he’s treated. He says most still meet the criteria for an ARDS diagnosis. In his view, coronavirus patients likely have ARDS plus other issues, but they still have ARDS. With so much unknown, and with treatment protocols being updated on the fly, he thinks it’s too soon for doctors to go off-book and avoid conventional protocols like mechanical ventilation. > “The world is not a dichotomous, black-and-white place, but a lot of people are having trouble with that,” Lyn-Kew says. “We might be able to do better, but in the absence of data on the way to do that, we need to follow our societal guidelines and 25 years of research.”

newacct583 6y ago

That's a somewhat cynical take, and I don't think any public policymakers would agree with your framing. What you're saying amounts to "We don't need more ventilators because all those people are probably going to die anyway and it won't save many lives." A better reason is because we beat the outbreak. A few areas like Milan/Madrid/Brussels went past their health care capacity and could have used more hardware. But they're all past peak now, and everywhere else (almost -- there are a few worrisome spots in the US still growing, and the developing world is still a big question mark due to lack of testing) managed to reach peak without hitting their limit. That's good news. We won. It's certainly not a problem that some of the efforts turned out not to be needed. It's like a war effort: everyone had a part to play, we needed to be conservative with our risk analysis and try different things.

nichohel 6y ago
I said nothing even approximately like "all those people are probably going to die anyway" and that is not, in fact, what I think! It is offensive that you would make up something like that and claim that is what I said. What a growing number of doctors are saying is that ventilators often turn out to do more harm than good in treating COVID, ventilators have been used too soon and too often in treating COVID, and ventilators have probably resulted in excess deaths over alternative treatments.
- newacct583 6y ago
  I apologize if I offended you. That certainly seemed like what you were saying. The take is not new, and has been circulating among the "open up" community for a while. As far as whether ventilators have "probably resulted in excess deaths"... that's just not justified by any science yet. We don't know. There's some suspicion in that direction, based mostly on New York ICU fatality rates (which are quite high despite otherwise good numbers through the rest of the process). But there's equally good evidence from e.g. Milan, which experienced very high death rates due presumptively to lack of treatment hardware.
jplayer01 6y ago
You've completely misunderstood his argument. It's widely accepted and known that fatality rates once you're put on a ventilator (due to Coronavirus) is ridiculously high compared to when you're put on a ventilator for other illnesses (something like 80% vs 20%). It suggests that ventilators might not be the right solution to what's happening to these people. So some doctors have been questioning the wisdom of continuing to use ventilators, and some doctors have been looking to alternative solutions that might have more success and better outcomes. One idea that was floated was CPAP (though I don't know what happened to that). Nobody here is saying "ah, ventilators aren't working, fuck it, let everybody die". That's offensive to everybody here and a bad faith argument that isn't constructive in any way.

deelowe 6y ago

I think the issue is coming up with a new protocol. Right now, it's not clear what should be don in lieu of ventilators. There are trials going on to see if oxygen alone has better results. I recommend the r/covid19 subreddit and medcram youtube channel for this sort of thing, by the way. They seem to be doing a good job of staying on top of new developments with proper references.

rkangel 6y ago

That is not the UK experience. In the UK, ramping of manufacturing of existing ventilators has been more successful than expected, and social distancing has kept the demand on the NHS to a manageable level. Together that has meant that we haven't needed emergency designs. Whether that is true in other countries is a different matter.

arcticfox 6y ago
I'm not sure about developing countries, but I think by this point developed countries are probably on the right track to not need emergency-design ventilators. That said, I hope the most promising of these designs get carried through to 'production-ready', in case we get hit with something even worse than COVID in the future, which is easy to imagine. Basically the US govt attempt detailed in this story, but with a sucessful conclusion instead of a failure. https://www.nytimes.com/2020/03/29/business/coronavirus-us-ventilator-shortage.html https://www.nytimes.com/2020/03/29/business/coronavirus-us-v...

deleted 6y ago

[deleted]

carbocation 6y ago

The report that you cite of 25% mortality for COVID patients on a ventilator is in line with COVID causing ARDS. There is currently no reason to believe that it causes some fundamentally different process from other ARDS-inducing diseases. Our experience at MGH also puts severe COVID lung disease squarely into the ARDS category, and it responds to standard ARDS ventilation protocols[1]. Our mortality to date is shy of 20%. Data over anecdote. 1 = https://www.atsjournals.org/doi/abs/10.1164/rccm.202004-1163LE https://www.atsjournals.org/doi/abs/10.1164/rccm.202004-1163...

elliekelly 6y ago
> Our mortality to date is shy of 20%. Is that across all Covid patients? Or ventilated Covid patients?
- carbocation 6y ago
  Ventilated. I should clarify since my positioning of the citation may have been a bit weird - the data is in the linked paper.
nichohel 6y ago
Thanks for the link. In the paper I see no direct comparison between COVID response to ventilation vs ARDS response to ventilation, but I think I understand that you say the responses are similar, based on your experience. Am I getting that right? Also, of course, there is nothing in the paper comparing COVID invasive ventilation outcomes with, for example, oxygen and positioning treatment outcomes. So, interesting, but I don't think this qualifies as "data over anecdote". I take it you are a pulmonary or ER doctor. If so, can you comment on the widely circulated claim that high death rates on ventilators in NYC are likely in part attributable to very aggressive ventilation and/or reduced attention to ventilation settings due to extreme fear of exposure to the virus (tubes leading from patients to other rooms and the like)?
- carbocation 6y ago
  Because of the high volume of patients, those of us with more critical care experience were redeployed to newly created MICUs, but I am not a pulmonologist (details in profile). The high death rates in NYC that were published were attributable to a statistical error (failing to use adequate censoring of people still on ventilators). Note that the article has been updated with correctly censored numbers (hence 25%): https://jamanetwork.com/journals/jama/fullarticle/2765184 https://jamanetwork.com/journals/jama/fullarticle/2765184 Finally, we only intubate patients after maneuvers like awake proning fail, so it’s not something that is comparable.

dehrmann 6y ago

It was also pretty clear when people were pushing hard for ventilator production that they were a month too late once you consider even aggressive design, supply chains, lead time, etc. I doubt there will really be a surplus because a lot of these are under-tested and hastily assembled. We've been a month+ behind on a lot of the response. Now's not the time to talk about ventilators, it's the time to start working out logistics of vaccine production and distribution.