I’ve been working towards emergency drugs for 30 years. In 1994 I invented an imaging system for educating intubation, the process of inserting respiration tubes. This led me to carry out analysis into this process, and subsequently educate airway process programs to physicians worldwide for the final 20 years.
So on the finish of March, as a crush of Covid-19 sufferers started overwhelming hospitals in New York City, I volunteered to spend 10 days at Bellevue, serving to on the hospital the place I educated. Over these days, I spotted that we aren’t detecting the lethal pneumonia the virus causes early sufficient and that we could possibly be doing extra to maintain sufferers off ventilators — and alive.
On the lengthy drive to New York from my dwelling in New Hampshire, I referred to as my buddy Nick Caputo, an emergency doctor within the Bronx, who was already within the thick of it. I needed to know what I used to be dealing with, find out how to keep secure and about his insights into airway administration with this illness. “Rich,” he stated, “it’s like nothing I’ve ever seen before.”
He was proper. Pneumonia brought on by the coronavirus has had a shocking influence on town’s hospital system. Normally an E.R. has a mixture of sufferers with situations starting from the intense, akin to coronary heart assaults, strokes and traumatic accidents, to the nonlife-threatening, akin to minor lacerations, intoxication, orthopedic accidents and migraine complications.
During my latest time at Bellevue, although, nearly all of the E.R. sufferers had Covid pneumonia. Within the primary hour of my first shift I inserted respiration tubes into two sufferers.
Even sufferers with out respiratory complaints had Covid pneumonia. The affected person stabbed within the shoulder, whom we X-rayed as a result of we apprehensive he had a collapsed lung, really had Covid pneumonia. In sufferers on whom we did CT scans as a result of they have been injured in falls, we coincidentally discovered Covid pneumonia. Elderly sufferers who had handed out for unknown causes and quite a lot of diabetic sufferers have been discovered to have it.
And here’s what actually shocked us: These sufferers didn’t report any sensation of respiration issues, though their chest X-rays confirmed diffuse pneumonia and their oxygen was under regular. How might this be?
We are simply starting to acknowledge that Covid pneumonia initially causes a type of oxygen deprivation we name “silent hypoxia” — “silent” due to its insidious, hard-to-detect nature.
Pneumonia is an an infection of the lungs by which the air sacs fill with fluid or pus. Normally, sufferers develop chest discomfort, ache with respiration and different respiration issues. But when Covid pneumonia first strikes, sufferers don’t really feel in need of breath, whilst their oxygen ranges fall. And by the point they do, they’ve alarmingly low oxygen ranges and moderate-to-severe pneumonia (as seen on chest X-rays). Normal oxygen saturation for many individuals at sea degree is 94 % to 100 %; Covid pneumonia sufferers I noticed had oxygen saturations as little as 50 %.
To my amazement, most sufferers I noticed stated that they had been sick for per week or so with fever, cough, upset abdomen and fatigue, however they solely grew to become in need of breath the day they got here to the hospital. Their pneumonia had clearly been occurring for days, however by the point they felt they needed to go to the hospital, they have been typically already in essential situation.
In emergency departments we insert respiration tubes in critically unwell sufferers for a wide range of causes. In my 30 years of observe, nonetheless, most sufferers requiring emergency intubation are in shock, have altered psychological standing or are grunting to breathe. Patients requiring intubation due to acute hypoxia are sometimes unconscious or utilizing each muscle they will to take a breath. They are in excessive duress. Covid pneumonia circumstances are very totally different.
A overwhelming majority of Covid pneumonia sufferers I met had remarkably low oxygen saturations at triage — seemingly incompatible with life — however they have been utilizing their cellphones as we put them on screens. Although respiration quick, that they had comparatively minimal obvious misery, regardless of dangerously low oxygen ranges and horrible pneumonia on chest X-rays.
We are solely simply starting to know why that is so. The coronavirus assaults lung cells that make surfactant. This substance helps the air sacs within the lungs keep open between breaths and is essential to regular lung operate. As the irritation from Covid pneumonia begins, it causes the air sacs to break down, and oxygen ranges fall. Yet the lungs initially stay “compliant,” not but stiff or heavy with fluid. This means sufferers can nonetheless expel carbon dioxide — and with out a buildup of carbon dioxide, sufferers don’t really feel in need of breath.
Patients compensate for the low oxygen of their blood by respiration quicker and deeper — and this occurs with out their realizing it. This silent hypoxia, and the affected person’s physiological response to it, causes much more irritation and extra air sacs to break down, and the pneumonia worsens till oxygen ranges plummet. In impact, sufferers are injuring their very own lungs by respiration more durable and more durable. Twenty percent of Covid pneumonia patients then go on to a second and deadlier phase of lung injury. Fluid builds up and the lungs become stiff, carbon dioxide rises, and patients develop acute respiratory failure.
By the time patients have noticeable trouble breathing and present to the hospital with dangerously low oxygen levels, many will ultimately require a ventilator.
Silent hypoxia progressing rapidly to respiratory failure explains cases of Covid-19 patients dying suddenly after not feeling short of breath. (It appears that most Covid-19 patients experience relatively mild symptoms and get over the illness in a week or two without treatment.)
A major reason this pandemic is straining our health system is the alarming severity of lung injury patients have when they arrive in emergency rooms. Covid-19 overwhelmingly kills through the lungs. And because so many patients are not going to the hospital until their pneumonia is already well advanced, many wind up on ventilators, causing shortages of the machines. And once on ventilators, many die.
Avoiding the use of a ventilator is a huge win for both patient and the health care system. The resources needed for patients on ventilators are staggering. Vented patients require multiple sedatives so that they don’t buck the vent or accidentally remove their breathing tubes; they need intravenous and arterial lines, IV medicines and IV pumps. In addition to a tube in the trachea, they have tubes in their stomach and bladder. Teams of people are required to move each patient, turning them on their stomach and then their back, twice a day to improve lung function.
There is a way we could identify more patients who have Covid pneumonia sooner and treat them more effectively — and it would not require waiting for a coronavirus test at a hospital or doctor’s office. It requires detecting silent hypoxia early through a common medical device that can be purchased without a prescription at most pharmacies: a pulse oximeter.
Pulse oximetry is no more complicated than using a thermometer. These small devices turn on with one button and are placed on a fingertip. In a few seconds, two numbers are displayed: oxygen saturation and pulse rate. Pulse oximeters are extremely reliable in detecting oxygenation problems and elevated heart rates.
Pulse oximeters helped save the lives of two emergency physicians I know, alerting them early on to the need for treatment. When they noticed their oxygen levels declining, both went to the hospital and recovered (though one waited longer and required more treatment). Detection of hypoxia, early treatment and close monitoring apparently also worked for Boris Johnson, the British prime minister.
Widespread pulse oximetry screening for Covid pneumonia — whether people check themselves on home devices or go to clinics or doctors’ offices — could provide an early warning system for the kinds of breathing problems associated with Covid pneumonia.
People using the devices at home would want to consult with their doctors to reduce the number of people who come to the E.R. unnecessarily because they misinterpret their device. There also may be some patients who have unrecognized chronic lung problems and have borderline or slightly low oxygen saturations unrelated to Covid-19.
All patients who have tested positive for the coronavirus should have pulse oximetry monitoring for two weeks, the period during which Covid pneumonia typically develops. All persons with cough, fatigue and fevers should also have pulse oximeter monitoring even if they have not had virus testing, or even if their swab test was negative, because those tests are only about 70 percent accurate. A vast majority of Americans who have been exposed to the virus don’t know it.
There are other things we can do as well to avoid immediately resorting to intubation and a ventilator. Patient positioning maneuvers (having patients lie on their stomach and sides) open up the lower and posterior lungs most affected in Covid pneumonia. Oxygenation and positioning helped patients breathe easier and seemed to prevent progression of the disease in many cases. In a preliminary study by Dr. Caputo, this strategy helped keep three out of four patients with advanced Covid pneumonia from needing a ventilator in the first 24 hours.
To date, Covid-19 has killed more than 40,600 people nationwide — more than 10,000 in New York State alone. Oximeters are not 100 percent accurate, and they are not a panacea. There will be deaths and bad outcomes that are not preventable. We don’t fully understand why certain patients get so sick, or why some go on to develop multi-organ failure. Many elderly people, already weak with chronic illness, and those with underlying lung disease do very poorly with Covid pneumonia, despite aggressive treatment.
But we can do better. Right now, many emergency rooms are either being crushed by this one disease or waiting for it to hit. We must direct resources to identifying and treating the initial phase of Covid pneumonia earlier by screening for silent hypoxia.
It’s time to get ahead of this virus instead of chasing it.
Richard Levitan, an emergency physician in Littleton, N.H., is president of Airway Cam Technologies, a company that teaches courses in intubation and airway management.
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