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Is our treatment approach to covid19 dangerously wrong?
Leading ICU doctors in covid19 hotpots (China, Italy, New York) are raising serious alarm bells.
Aggressive ventilation may be needlessly killing thousands of people.
A thread with expert citations/data.
1/13
Leading ICU doctors in covid19 hotpots (China, Italy, New York) are raising serious alarm bells.
Aggressive ventilation may be needlessly killing thousands of people.
A thread with expert citations/data.
1/13
This thread will discuss two conditions.
High Altitude Pulmonary Edema (HAPE), known as altitude sickness. Lung CT scans look like type L.
Acute Respiratory Distress Syndrome (ARDS) would be like severe pneumonia. Lung CT scans look like type H.
This is important.
2/13
High Altitude Pulmonary Edema (HAPE), known as altitude sickness. Lung CT scans look like type L.
Acute Respiratory Distress Syndrome (ARDS) would be like severe pneumonia. Lung CT scans look like type H.
This is important.
2/13
At the present time, treatment protocols for covid19 treat it as ARDS.
But there's a problem.
Patients presenting with covid19 do not present with type H lungs (ARDS).
They present with type L lungs, and their symptoms more closely resemble HAPE
https://twitter.com/srrezaie/status/1245389444049485832
3/13
But there's a problem.
Patients presenting with covid19 do not present with type H lungs (ARDS).
They present with type L lungs, and their symptoms more closely resemble HAPE
https://twitter.com/srrezaie/status/1245389444049485832
3/13
Why does this matter?
Because treatment protocols for ARDS are completely different to HAPE.
But it gets worse than just misdiagnosis.
Applying ARDS treatment to Type L lungs means increasingly aggressive ventilation, which is killing people.
4/13 https://twitter.com/MRamzyDO/status/1246793802255347713
Because treatment protocols for ARDS are completely different to HAPE.
But it gets worse than just misdiagnosis.
Applying ARDS treatment to Type L lungs means increasingly aggressive ventilation, which is killing people.
4/13 https://twitter.com/MRamzyDO/status/1246793802255347713
ARDS ventilator protocols force air into the lungs at ever increasing pressure to try to maintain oxygen levels.
But pressure isn't the issue in someone presenting with HAPE symptoms.
That high pressure is just ripping lungs to shreds.
5/13 https://twitter.com/cameronks/status/1245311511649816576
But pressure isn't the issue in someone presenting with HAPE symptoms.
That high pressure is just ripping lungs to shreds.
5/13 https://twitter.com/cameronks/status/1245311511649816576
The statistics speak for themselves.
In the UK so far, 67% of covid19 patients who move onto ventilators die.
This compares to 35% of ventilated patients with regular ARDS.
Why are so many covid19 patients dying on ventilators compared to 'normal' ARDS patients?
6/13
In the UK so far, 67% of covid19 patients who move onto ventilators die.
This compares to 35% of ventilated patients with regular ARDS.
Why are so many covid19 patients dying on ventilators compared to 'normal' ARDS patients?
6/13
The answer is that covid19 is not ARDS, lungs are initially in good shape despite low oxygen levels.
Treating it as ARDS is actually causing ARDS due to damage from aggressive ventilation.
This heartfelt plea from an NYC ICU doctor is a must watch
7/13
Treating it as ARDS is actually causing ARDS due to damage from aggressive ventilation.
This heartfelt plea from an NYC ICU doctor is a must watch
7/13
That covid19 should not be treated as ARDS has been highlighted in research published 2 days ago by leading Italian expert on mechanical ventilation, Dr Luciano Gattinoni.
He urges a change in treatment protocols. But for now those protocols remain
8/13 https://twitter.com/gattinon/status/1246448312686911489
He urges a change in treatment protocols. But for now those protocols remain
8/13 https://twitter.com/gattinon/status/1246448312686911489
The implications of this are terrifying.
We don't need thousands of extra ventilators. And those we are using need treatment protocols radically changed.
It's possible that we need to start treating covid19 as we would HAPE, with hyperbaric oxygen chambers or ECMO.
9/13
We don't need thousands of extra ventilators. And those we are using need treatment protocols radically changed.
It's possible that we need to start treating covid19 as we would HAPE, with hyperbaric oxygen chambers or ECMO.
9/13
The problem is that we've spent months preparing for a disease that resembles ARDS, and covid19 is not ARDS.
The Nightingale hospitals, the ventilators, the treatment protocols - they could needless kill thousands of people.
So what to do now?
10/13 https://twitter.com/DavidZodda/status/1245811805198442497
The Nightingale hospitals, the ventilators, the treatment protocols - they could needless kill thousands of people.
So what to do now?
10/13 https://twitter.com/DavidZodda/status/1245811805198442497
The NHS has barely any hyperbaric oxygen chambers or ECMO machines. Fewer than 30.
We are not equipped to deal with covid19 at all.
But we can change the way we use ventilators to minimise the damage caused - more oxygen, less pressure.
11/13 https://www.aaem.org/resources/publications/podcasts/critical-care-in-emergency-medicine/episode-19
We are not equipped to deal with covid19 at all.
But we can change the way we use ventilators to minimise the damage caused - more oxygen, less pressure.
11/13 https://www.aaem.org/resources/publications/podcasts/critical-care-in-emergency-medicine/episode-19
And we can immediately start trials of drugs used to treat HAPE:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7096066/
Combining this with different ventilation protocols could save thousands of lives.
12/13
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7096066/
Combining this with different ventilation protocols could save thousands of lives.
12/13
And what can we do personally?
Medical professionals - lobby for change
Patients/families of patients - refuse ventilation unless absolutely necessary, such as blood oxygen levels below 70%
Being put on a ventilator with current protocols is as good as a death sentence.
END
Medical professionals - lobby for change
Patients/families of patients - refuse ventilation unless absolutely necessary, such as blood oxygen levels below 70%
Being put on a ventilator with current protocols is as good as a death sentence.
END
Update: increasing number of reports of patients WALKING IN with ~50% blood oxgyen, put on HFNC, and recovering after 2-3 days.
To put in context - someone presenting with under 85% blood oxygen for ARDS would normally be put on a ventilator immediately. Protocols must change.
To put in context - someone presenting with under 85% blood oxygen for ARDS would normally be put on a ventilator immediately. Protocols must change.
Covid19 patients need HFNC not ventilators.
The 'second stage' of the disease seems to be caused by damage to lungs from ventilator protocols. Not natural disease progression.
Cannot under-state how catastrophic this is, we may be killing thousands of people with ARDS protocols
The 'second stage' of the disease seems to be caused by damage to lungs from ventilator protocols. Not natural disease progression.
Cannot under-state how catastrophic this is, we may be killing thousands of people with ARDS protocols
