Much of the concern about treating COVID-19 patients has focused on ventilators—specifically, whether hospitals will have enough ventilators to treat everyone who needs them. But, with a high death rate among patients on ventilators and some unexpected differences between COVID-19 patients and patients with other sources of respiratory distress, some doctors are starting to reevaluate, saying “What we thought we knew, we don’t know” and “It’s hard to switch tracks when the train is going a million miles an hour,” but “This may be an entirely new disease.”
Patients look different than the usual expectation for people with such low oxygen levels, doctors say. “Never in my life have I had to ask a patient to get off the telephone because it was time to put in a breathing tube,” one told The New York Times. “[C]linically they look a lot more like high-altitude sickness than they do pneumonia,” another told Medscape.
“Intubated patients with Covid lung disease are doing very poorly, and while this may be the disease and not the mechanical ventilation, most of us believe that intubation is to be avoided until unequivocally required,” Dr. Reuben Strayer, an emergency medicine physician in a Brooklyn hospital, told The New York Times. Some doctors, instead, are moving to a much, much lower-tech solution in some cases: telling patients to lie on their stomachs.
What isn’t known yet is how the results for the technique called “proning,” or having patients lie on their stomachs or sides while taking oxygen in less-invasive ways, will play out over the long term and with sustained scientific research. But in the short term, doctors say the results are promising. “At Lincoln Hospital in the Bronx, Dr. Nicholas Caputo followed 50 patients who arrived with low oxygen levels between 69 and 85 percent (95 is normal),” The Times reports. “After five minutes of proning, they had improved to a mean of 94 percent. Over the next 24 hours, nearly three-quarters were able to avoid intubation; 13 needed ventilators.”
Some doctors say that in addition to reevaluating whether to use ventilators, they need to reassess how to do so. Some COVID-19 patients’ “lungs are relatively elastic (‘compliant), a sign of health ‘in sharp contrast to expectations for severe ARDS,’” Stat reported on a letter from German and Italian researchers. “Their low blood oxygen might result from things that ventilators don’t fix. Such patients need ‘the lowest possible [air pressure] and gentle ventilation,’ they said, arguing against increasing the pressure even if blood oxygen levels remain low. ‘We need to be patient.’”
Anecdotally, “we’ve had a number of people who improved and got off CPAP or high flow [nasal cannulas] who would have been tubed 100 out of 100 times in the past,” Dr. Scott Weingart, a New York City doctor and podcaster, told Stat. One problem, though, is that some ways of giving patients more oxygen without putting them on ventilators, like continuous positive airway pressure (CPAP) devices, can aerosolize the virus and risk spreading it.
The big and overarching problem, though, is that the need for effective treatments is way ahead of the ability to do actual research about the best treatments. Everything is happening on the fly as exhausted, overworked doctors fight for the lives of their patients. If the science can catch up with the need, though, the picture might start looking a little brighter.