While governors, mayors and hospital officials conduct much-publicized life-and-death struggles to acquire ventilators, for most COVID-19 patients the oxygen-providing apparatus will merely serve as a bridge from life to death.
New York Gov. Andrew Cuomo recently estimated that only 20% of coronavirus patients placed on ventilators “will ever come off.” Dennis Carroll, who led the U.S. Agency for International Development’s infectious disease unit for more than a decade, told USA TODAY perhaps one-third of COVID-19 patients on ventilators survive.
But for many, ventilators represent their last chance.
“If you were one of the one-third, I suspect you’d be very appreciative that that capability was available,” Carroll said.
Ventilators won’t fix the ailments that put patients on them, but they can provide support until other treatments work or the patient’s body overcomes the disease. And physicians are determined to use the tool in the last-ditch effort to keep patients alive.
At Lenox Hill Hospital on Manhattan’s Upper East Side, “hope huddles” allow emergency room staffers to take a moment amid the suffering to discuss small victories – such as successful “extubations” when patients are weaned from the machines.
“Our goal is to save the most number of lives possible, while also being realistic when evaluating a person’s chances of survival,” said Robert Glatter, an emergency physician at Lenox Hill.
‘Buying time’ for coronavirus patients
A ventilator uses “positive pressure” to blow air into the lungs through a tube inserted in the patient’s nose or mouth and moved down into the airway. Longer-term ventilation can involve the tube being introduced through the windpipe. Patients generally exhale on their own, but sometimes the ventilator helps with that as well.
“Ventilators aren’t really making any therapeutic contributions,” said Ogbonnaya Omenka, an assistant professor and public health specialist at Butler University’s College of Pharmacy and Health Sciences. “What they do in essence, is provide life support – and buy time for the patient.”
Some patients may be on a ventilator for only a few hours or days, but experts say COVID-19 patients often remain on the ventilators for 10 days or more.
Longer duration of intubation is often related to worsening acute respiratory distress syndrome, ARDS. And patients who have issues with kidneys or other organs in addition to lungs stay intubated for longer periods of time.
Melissa Nolan, an infectious disease expert and professor at the University of South Carolina, said people on ventilators tend to be the most critically ill patients and often are receiving renal or cardiovascular mechanical support that can further complicate their chance of recovery.
There are risks associated with ventilators. The artificial breathing tube sometimes can allow germs to enter the lungs, causing infection. But for these patients there are no alternatives.
“Ventilation and intubation are currently our best tools for treating the pulmonary manifestations of COVID-19 – and often clinicians’ only choice” given the lack of effective drug therapies, Nolan said.
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Glatter said it’s impossible to accurately predict how many days each person who is intubated will require use of the ventilator. It ultimately depends on a patient’s degree of lung involvement, he said.
“The reality is that the longer a person remains intubated, the chance for survival decreases,” Glatter said. “Simply put, they are unable to be weaned off the ventilator.”
Early COVID-19 symptoms can include fever, a dry cough and shortness of breath. Most patients essentially heal themselves in a couple weeks. For some, however, the challenge to the lungs becomes critical.
Dr. Marjorie Jenkins, dean of the University of South Carolina School of Medicine, said that without ventilators, COVID-19 induced ARDS is “uniformly fatal.”
“Doctors are on the front lines to save lives, not to allow patients to suffer a horrible death,” she said. “A death that comes via slow painful suffocation for minutes, hours, perhaps days.”
Physicians lack the “granular details” of the disease’s presentation, course and outcomes, Jenkins said. But how a patient deals with the virus appears to be a function of their immune system response, genetics and environmental and lifestyle factors such as smoking, along with other conditions, she said.
Patients with underlying ailments – such as hypertension, diabetes, obesity, chronic lung disease asthma, sleep apnea and cardiovascular disease – are at higher risk for “adverse outcomes” and thus more likely to require mechanical ventilation as their disease progresses, Glatter said.
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The outcome for these patients is based on how they respond to specific treatments and measures, not just the ventilator itself, Glatter said. The ventilator, he said, is just one aspect of the overall resuscitation of the patient.
“Ventilators are saving lives all over world during this global pandemic,” Jenkins said. “Medical personnel are trained to do everything possible to save a life. This is no different.”
The effort to secure more ventilators
Some hospitals are desperate for more ventilators. The University of Mississippi Medical Center is building its own, using garden hoses, lamp timers and other gadgets found at local hardware stores. Physicians at New York’s Mount Sinai Health System have repurposed machines used to treat sleep apnea.
General Motors this week announced a $500 million deal to make 30,000 ventilators for the national stockpile, and Ford has pledged to make 50,000 ventilators in 100 days. California was among states providing ventilators to the national stockpile, sending 500 – on the condition that they will get them back if needed later.
Jenkins also works for Prisma Health, a not-for-profit health organization in South Carolina that partnered with others to develop a device that allows a ventilator to be split between two patients. The device was approved by the FDA in just two weeks. The goal: double ventilatory capacity “to prevent our front line personnel from having to make the call of who lives or dies.”
Most ventilator patients are monitored in an ICU, hooked up to monitors that measure vital signs including blood pressure, heart rate, respiratory rate, oxygen saturation as well as tracking and measuring the effects of the ventilator itself on the person’s heart and lungs. Ventilators, especially for cases of COVID-19, involve highly trained intensive care professionals – anesthesiologists, nurses and respiratory therapists.
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Providing sufficient staff is becoming a problem as COVID-19 patients overwhelm hospitals, Omenka said. And more of those health care professionals, dealing with the highly contagious disease every day, are becoming patients.
“The health care system is getting increasingly burdened,” Omenka said. “With the exponential rise in cases and depletion of front-line health care workers, the level of care for intensive care may become compromised.”
Shortages in ICU beds for ventilator patients is also a problem but not an insurmountable one, Glatter said. Demand for ventilators, ICU nurses and doctors to care for these critically ill patients is more pressing, he said.
“We can be creative, create space for makeshift ICUs to help accommodate ventilated patients,” Glatter said.
Makeshift ICU beds, homemade ventilators – all are part of the unrelenting battle between the world of medicine and a pandemic that has brought the world to its knees.
“Health professionals and hospitals are doing their very best to save lives during this pandemic,” Jenkins said. “Every opportunity to leverage our resources is being explored and engaged.”