MESSAGE
| DATE | 2020-07-02 |
| FROM | Ruben Safir
|
| SUBJECT | Subject: [Hangout - NYLXS] ICU treatment for COVID-19 is still under debate
|
sj.com
Months Into Coronavirus Pandemic, ICU Doctors Are Split on Best
Treatment
Sarah Toy and Mark Maremont
9-11 minutes
Several months into the coronavirus pandemic, hospital physicians are
split on whether long-established treatment protocols for patients in
respiratory distress are helping or harming patients with Covid-19.
In the intensive-care unit, doctors are trying to balance their own
knowledge and past experiences treating respiratory illness with their
current experiences treating the novel coronavirus and newly emerging
data on Covid-19 therapies.
The result is there is little consensus among physicians about
treatment, even as cases and hospitalizations surge in parts of the U.S.
It also means the particular treatment a patient gets can vary widely
from hospital to hospital, and even from doctor to doctor.
A ventilator at Greenwich Hospital in Greenwich, Conn. Doctors disagree
on the best way to use ventilators to help Covid-19 patients.
Photo: Tyler Sizemore/Hearst Connecticut Media/Associated Press
To begin with, physicians dont agree on the type of lung injury the
novel coronavirus causes. One camp says it leads to classic acute
respiratory distress syndrome (ARDS), caused by widespread inflammation
in the lungs where the tiny air sacs, the alveoli, thicken, fill with
fluid and stiffen. The other camp says many Covid-19 patients are
showing up with a different form of injury, marked by lungs that are
stretchy and more elastic, not stiffsomething not typically seen in
classic ARDSthough their blood-oxygen levels are still low.
Although young patients make up more of the recent surge in cases at
many hospitals, doctors say they dont see age as a factor in the type of
lung injury a patient might have.
In April, researchers published an article in the Journal of the
American Medical Association suggesting many Covid-19 patients with
respiratory distress might require a different treatment approach than
typically used for ARDS.
The disagreement has roiled the critical-care community, with those in
favor of nontypical protocols accusing the other camp of being
inflexible and tied to tradition at the expense of patient care during a
pandemic. Those who favor sticking to longstanding approaches say the
other side is playing fast and loose with treatment guidelines that have
been proven to work.
The debate has crystallized around the best way to use ventilators to
help Covid-19 patients breathe when they cant on their own. Normally,
for a patient with ARDS who required mechanical ventilation, the
ventilator would be set to apply positive pressurecalled positive
end-expiratory pressure, or PEEPto prevent the air sacs from collapsing
at the end of each breath. The ventilator would also apply a low volume
of air per breath, or tidal volume, to help minimize ventilator-induced
lung injury.
But some doctors say these traditional settings are too extreme for
Covid-19 patients who have good lung elasticity. The traditional PEEP
settings could damage the lung and redirect blood flow away from parts
of the lung that need it most, leading to poor patient outcomes, these
doctors say. Instead, these patients should be placed on lower levels of
PEEP and higher tidal volumes, they say.
Doctors have differing opinions on the use of ventilators. A GE
Carescape R860 ventilator.
Photo: daniel acker/Reuters
Maurizio Cereda, an anesthesiologist and head of the surgical ICU at the
Hospital of the University of Pennsylvania, said doctors normally use
standardized tables to match the level of oxygen in the blood with the
amount of PEEP needed. Penn tends to use a table with lower PEEP values,
he said, but even those lower levels seem to damage the lungs of some of
his Covid-19 patients. As a result, he disregards the table entirely at
times, he said, even though some in his institution disagree with his
approach.
You cant wait for somebody to make a giant study, Dr. Cereda said. You
are alone with your clinical observation. A lot of people dont feel
comfortable with that because they want to have big guidelines. People
seem to be afraid theyre going to do something wrong.
John Marini, a professor of medicine at the University of Minnesota and
one of the authors of the JAMA article, said patients with normal lung
elasticity tend to present at the hospital earlier in their disease
course. Some doctors have nicknamed them happy hypoxemics. Because their
lungs arent as stiff, they breathe relatively normally when they show up
at the hospital, despite having low blood-oxygen levels. They require
different treatment than patients with classic ARDS, Dr. Marini said.
Long Road Ahead for Covid-19 Patient Back Home From ICU
0:00 / 2:32
Long Road Ahead for Covid-19 Patient Back Home From ICU
Long Road Ahead for Covid-19 Patient Back Home From ICU
Maury Hanks was in intensive care and on a ventilator. He survived, but
like many Covid-19 patients returning from the ICU, he could face
cognitive, emotional and physical challenges. Photo: Gabe Johnson/The
Wall Street Journal (Originally published April 7, 2020)
Robert Dickson, an assistant professor in the division of pulmonary and
critical-care medicine at the University of Michigan, disagreed. He said
most patients who come in dont have good lung elasticity, and the PEEP
levels recommended by Dr. Marini and others are too low. Allowing higher
tidal volumes can be dangerous as that can overstretch the lungs, he
added.
By saying that this is not ARDS or some kind of atypical ARDS, were
abandoning evidence-based practices and swapping them out for intuition,
which has not served us well in the past, Dr. Dickson said.
At Maimonides Medical Center in Brooklyn, critical-care and
emergency-medicine doctor Cameron Kyle-Sidell said he was initially
seeing much higher mortality rates from Covid19 patients on ventilators
than he would have expected from classic ARDS, possibly because
physicians were sticking to PEEP levels used to treat traditional ARDS.
There are people who are treating this the way they would have treated
any other ARDS, he said. Then therere people on the flip sideand I am on
that flip sidethat think you should treat it as a different disease than
we treated in the past.
Some clinicians say the split could be due in part to how ARDS is
defined. Past studies that formed the basis of how doctors treat ARDS
today looked at patients who met a broad set of clinical criteria, but
what was going on underneath varied widely, they note.
Dr. Marini, the co-author of the JAMA article, said patients presenting
at the hospital at different stages of Covid-19 could also account in
part for the differing views. Some hospitals might see more patients in
the earlier stages of the disease; others might get patients further
along, whose lungs more closely resemble whats seen in classic ARDS. How
a patients lungs look could also depend on the individuals inflammatory
response to the virus, he added.
SHARE YOUR THOUGHTS
Should doctors take a more patient-specific approach when treating
people with Covid-19? Join the conversation below.
Some in the critical-care community think there will be less divergence
in opinion as time passes. Some doctors tend to lean on evidence from
the population level, while others tend to treat patients on a more
individual basis, said Marc Moss, head of the division of pulmonary
sciences and critical-care medicine at the University of Colorado School
of Medicine. Most use a mix, but some may be leaning more heavily on
what they see at the bedside for their Covid-19 patients, as
population-level evidence is still emerging, he said.
As we learn more and as more evidence comes out, some of the variability
that were seeing thats based on peoples individual perceptions will
probably go away, Dr. Moss said.
Write to Sarah Toy at sarah.toy-at-wsj.com and Mark Maremont at
mark.maremont-at-wsj.com
Copyright 2020 Dow Jones & Company, Inc. All Rights Reserved.
--
So many immigrant groups have swept through our town
that Brooklyn, like Atlantis, reaches mythological
proportions in the mind of the world - RI Safir 1998
http://www.mrbrklyn.com
DRM is THEFT - We are the STAKEHOLDERS - RI Safir 2002
http://www.nylxs.com - Leadership Development in Free Software
http://www2.mrbrklyn.com/resources - Unpublished Archive
http://www.coinhangout.com - coins!
http://www.brooklyn-living.com
Being so tracked is for FARM ANIMALS and extermination camps,
but incompatible with living as a free human being. -RI Safir 2013
_______________________________________________
Hangout mailing list
Hangout-at-nylxs.com
http://lists.mrbrklyn.com/mailman/listinfo/hangout
|
|
