COVID19 - Are Ventilators Doing More Harm Than Good?

If you cast your mind back (what seems like seven years) just a few weeks to just prior to the announcement that the new novel coronavirus, COVID19 was a pandemic you will remember that most discussions were about ventilators. Do we have enough? Can we manufacture enough in time? Who should get priority over usage of a ventilator?.... and so on.

We had articles like this one from The New York Times[1] which opened the article with:

The coronavirus pandemic could soon force American physicians to face a tragic challenge — rationing medical care as the number of ill patients overwhelms the supplies, space and staff available in hospitals.

Today, the United States has fewer than 800,000 hospital beds, about 68,000 adult intensive care unit beds of any kind, and, even with the strategic reserve, fewer than 100,000 ventilators. As the coronavirus spreads, this will not be enough.[1]

and this one from ABC News[2]:

It could become our biggest coronavirus challenge yet.

An infectious disease specialist is sounding the alarm about a potential shortage of ventilators, should more people get sick.

This fear of lack of ventilators was the dominant conversation throughout much of the World. But with the UK and the US specifically, ventilator shortage has not been a problem. In fact, the UK's contract with Dyson to produce 10,000 ventilators has now been cancelled[3]

But aside from the understandable yet misplaced fear over the lack of ventilators, it seems that ventilators may be doing more harm than good.

In a letter to the editor published in the American Journal of Respiratory and Critical Care Medicine on March 30, Luciano Gattinoni, MD, of the Medical University of Göttingen in Germany, and his colleagues raise their concerns over the protocol-driven ventilator use for patients with COVID-19, they make the case that it could be doing more harm than good.

Medscape[4] reported:

Dr. Gattinoni noted that COVID-19 patients in intensive care units in northern Italy had an atypical ARDS presentation with severe hypoxemia and well-preserved lung gas volume. He and his colleagues suggested that instead of high positive end-expiratory pressure (PEEP), physicians should consider the lowest possible PEEP and gentle ventilation-practicing patience to "buy time with minimum additional damage."

Similar observations were made by Cameron Kyle-Sidell, MD, a critical care physician working in New York City.[4]

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Dr. Gattinoni said that one center in Europe has had a 0% mortality rate among COVID-19 patients in the intensive care unit when using his suggested alternative approach, compared with a 60% mortality rate at a nearby hospital using a protocol-driven approach.

To summarize what Dr. Gattinoni is saying, basically one protocol does not suit all patients. The existing comorbidities of the patient and the severity of the virus will decide the protocol that should be taken. But he also states protocols evolve as the state of the patient evolves.

"This is a kind of disease in which you don't have to follow the protocol – you have to follow the physiology," he said. "Unfortunately, many, many doctors around the world cannot think outside the protocol."[4]

So Has the Protocol Changed?

These concern's over the usage of ventilators has been going on for several weeks now, with more and more doctors and scientists coming to the same conclusion however it is still unclear whether this knowledge has been passed on and whether any changes to protocol have been made.

With unusually high mortality rates in some regions compared to others, information on how each region is treating patients would help us understand better exactly what's causing this large variance across the World in mortality rates.

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