'What we thought we knew, we don't know,' doctors say of COVID-19

[babylonsister]

https://www.dailykos.com/stories/2020/4/19/1937848/--What-we-thought-we-knew-we-don-t-know-doctors-say-of-COVID-19#read-more

'What we thought we knew, we don't know,' doctors say of COVID-19
Laura Clawson for Daily Kos
Daily Kos Staff
Sunday April 19, 2020 · 11:40 AM EDT


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.

[Hortensis]

1. "This may be an entirely new disease."

It's amazing this far in how few questions have solid answers. And when answers are identified by professionals, contradictions are identified by others.

[mucifer]

2. Rush University Hospital in Chicago is doing a study on having people proning to avoid intubation.

I hope it works

[Igel]

3. Recommendations as early as late January called for specific type of ventilator use.

Low tidal volume with half the cycle length.

Don't displace much volume with each mechanical pulse, but pulse at twice the rate. To avoid damaging lungs that lacked flexibility.

[Bernardo de La Paz]

4. Days ago read similar report "like high-altitude sickness", using low pressure non-vent techniques.n

[McCamy Taylor]

5. Good article about why prone lungs work better

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173887/

Basically there is 1) more lung dorsally than ventrally (meaning more lung in the back than the front) and which ever lung is in the down position gets more pressure, more swelling, more fluid and works less well while the up lung works better

and

2) Prone the abdominal contents no longer press against the lungs as much as they do when the patient is supine.

Still think they ought to try hypertonic saline nebulizer treatments which can draw fluid out of the lungs and into the bronchioles. This is the only treatment proven to help pediatric bronchiolitis and adult COVID seems to resemble this disorder.

Oh, look. The prone position has been found to help ventilated kids with bronchiolitis too.

https://pubmed.ncbi.nlm.nih.gov/30448014/

[BigmanPigman]

6. Good info.

It makes sense too, especially the part regarding the the supine position.

[yellowdogintexas]

7. cyatic fibrosis patients benefit from proning and gentle pounding on the back

my friend used to put her son head down on the stairs and pound his back with cupped hands. Not hard, but enough to break up the god awful mucus they get.

So proning in this case makes perfect sense.

[Hermit-The-Prog]

8. Lie on your stomach, then hike your ass in the air -- shoulders low, hips high.

Gravity works when the cilia in your airways are not doing so well.

[EndlessWire]

9. LOL!

I'm sorry, but that's funny! I can think of a few people I'd like to see practice that!

[EndlessWire]

10. We can do that right now.

We can all sleep on our sides even if we don't feel sick.

Another treatment I haven't seen discussed is hyperbaric chambers. You could rotate patients in and out, with plenty of disinfection in between patients, and using UV light. Then you could treat patients 24/7 with just one chamber. If it worked.

Let's see him try to hijack that.