The Covid-19 pandemic has shined a spotlight on how unprepared most states were for a crisis of its magnitude. Most directly, the world collectively faces a critical shortage of essential equipment for fighting this pandemic including face masks and life-saving ventilation machines.
Although ventilators have commonly been the last resort option for critical cases, some doctors are now questioning whether they do more harm than good, according to a report from the Associated Press.
Covid-19 is Not Well Understood and Doctors are Still Figuring out the Right Tools to Fight it
As the COVID-19 disease is incredibly new, the scientific and medical fields do not have a firm grasp on how to treat it. Researchers cannot simply refer back to decades of case studies to determine what works best; there is no textbook except for the one which is being written at this moment through bitter experience on the ground. While ventilator machines seemed like a logical option — as they are traditionally used to fight severe respiratory illnesses — data gleaned from the coronavirus battle has revealed this pandemic may be different than previous viral outbreaks.
Typically, 40% to 50% of patients who are placed on ventilators die while on the machines. With Covid-19, that figure is as 80% and possibly higher, according to New York City officials. Statistics from China and the UK also tell a story of an unusually high fatality rate while on ventilation.
Why Are Ventilation Machines Dangerous?
“We know that mechanical ventilation is not benign,” explained Dr. Eddy Fan, respiratory treatment export at Toronto General Hospital. “One of the most important findings in the last few decades is that medical ventilation can worsen lung injury — so we have to be careful how we use it.”
During ventilation, a patient is sedated while a tube is inserted in their throat, a procedure known as intubation. Oxygen is then pumped into their lungs via this tube at a rhythm set on the machine. For other illnesses such as bacterial pneumonia, a short period of ventilation allows a patient to recover, but Covid-19 patients have spent as many as 15 days on the machine — an oddly high number.
Some evidence suggests that the high pressure at which ventilators force oxygen into lungs may be part of the problem. In fact, delivering oxygen to the lungs may not be the problem at all, suggested Dr. Martin Gillick of Harvard Medical School. Instead, the bottleneck may be at the exchange point where oxygen leaves the lungs and enters the bloodstream. In this case, ventilators may only exacerbate the situation by putting unneeded pressure on the lungs.
The virus itself may also be different than other types of common respiratory illnesses. Instead of making the lungs stiffer, it appears to attack the air sacs within the lungs, as Quartz reported. This “makes them extremely inflamed and very susceptible to pressure-induced injury,” saiid Dr. Govind Rajan, director of clinical services in the anesthesiology department at the University of California, Irvine, Medical Center.
Why Do Many Hospitals Prefer to Use Ventilators?
Hospitals favor ventilation over alternatives because once a patient is on the machine, their breathing becomes a closed system. “The moment the tube goes in, the system becomes closed, the spread of the virus becomes zero,” Rajan said.
Some medical facilities have established separate rooms specifically for the procedure of intubation, which does have risks of virus transmission in the beginning. Medical personnel must protect themselves when inserting the tube, a task that is more difficult with the current shortage of protective equipment.
Still, a patient with acute respiratory distress (ARDS) is less at risk of spreading the virus when on a ventilator than other forms of breathing devices such as nasal tubes and face masks. As a result, politicians and doctors are pleading for ventilators even though they carry a high mortality rate.
Doctors are Trying Alternatives to Ventilators
As more evidence against ventilation comes out in the fight against Covid-19, doctors are experimenting with possible alternatives. These techniques could be as simple as having the patient lay in a different position, such as on their stomach, to using nitric oxide to assist the flow of blood and oxygen.
“If we’re able to make them better without intubating them, they are more likely to have a better outcome — we think,” said Dr. Joseph Habboushe, an emergency medicine doctor in New York City.
Another alternative is a noninvasive BiPap — bilevel positive airway pressure device. The machines deliver air through a face mask. Unlike ventilation, a BiPap machine does not require sedation, meaning a patient could adjust the mask and accidentally let the virus spread.
Helmet ventilation is another option that is safer than BiPaps. Essentially a patient wears a pressurised fish bowl that is clamped to their body. Patients do not require sedation on it either. However, the procedure is not common in America and only one US company makes the machines, although it is ramping up production.
Ventilators Can Have Long-Term Damaging Consequences — Even for Those Who Survive
All evidence on Covid-19 suggests that patients who undergo ventilation are likely not to recover. Even intubated patients who recover from Covid-19 are likely to have permanent lung damage and breathing complications.
Ventilation “required to help patients survive can damage the delicate tissues of the lung that are involved in oxygen transfer, which may affect the function of the lungs even after recovery from acute Covid-19 disease,” said Julie Fischer, associate research professor of microbiology and immunology at Georgetown University.
Doctors and researchers are still learning from Covid-19 and it may very well take the life-cycle of the virus to determine the best practices for treating severe cases. In the meantime, there is a continued push to produce more ventilators while doctors also try alternative forms of treatment that may prove effective and less damaging for the long-term health of patients.