Doctors intubate patients to reduce Covid-19 mortality

In recent weeks, from Italy to the United States, a debate has risen among the doctors treating Covid-19 patients: when should they be placed on an artificial respirator? This is one of the biggest questions today, as well as those on the real effectiveness of hydroxychloroquine, says an American doctor to AFP.

The lifts are patchy and studies are still lacking in the middle of the pandemic, without much hindsight. It is impossible to know if the people who died on respirators would have survived otherwise.

But many doctors have found that the condition of patients with Covid-19 seems to deteriorate quickly after intubation, which has led for several weeks several American hospitals to a delicate exercise to delay the use of respirators - including the US government ordered more than 130,000 after fear of shortage.

The first alerts came from Italy, where a large majority of patients placed in intensive care and on artificial respirators died. The statistics are just as fierce in the UK and New York, where 80% of intubated patients have died, according to the state governor, often after one or two weeks in intensive care, long durations that weaken the body, because almost all patients are placed in an artificial coma and lose muscle.

At the start of the epidemic, patients who were out of breath were treated according to a well-established and established protocol for what is known as acute respiratory distress syndrome (ARDS). This syndrome, which causes the lungs to no longer take in enough oxygen to properly supply the organs, can be caused by an infection (pneumonia) or an accident. The practice for these patients in respiratory distress is to intubate relatively early.

This is how seriously ill people with the new coronavirus were treated. Until doctors realized that Covid-19 syndrome was not entirely identical to "usual" respiratory distress, at least for some of them. The lungs are not damaged in the same way (they would be less "rigid").

Doctor Luciano Gattinoni and colleagues from Milan described in late March how they had adjusted their procedures.

"All we can do to intubate these patients is to save time by doing as little damage as possible," they wrote to the journal of the American Thoracic Society. "We have to be patient."

"We learn on the job"

"Most doctors are concerned about these bad stories of people deteriorating on ventilators, and many have started to delay intubation," said Kevin Wilson, professor of medicine at Boston University, to AFP. and responsible for developing guidelines for the American Thoracic Society. "But never to the point of waiting for it to become an emergency," he said.

Doctors realized that in reality, patients with low blood oxygen levels, who would normally initiate intubation, were not that bad.

Instead of intubating quickly, doctors use lower levels of oxygen support: nasal cannulas (small tubes in the nostrils), conventional or more sophisticated masks, high flow oxygenation, or even place the patient on the stomach. , which helps the lungs.

"We learn on the job," adds Kevin Wilson.

This is what is happening in New York, where more than 10,000 people have died from the virus.

"We try to wait a little longer, if possible, before intubating them," said AFP Daniel Griffin, chief of infectious diseases at ProHealth Care, a network of 1,000 doctors who work in around 20 hospitals. from New York.

"If it feels like they are holding on, they are allowed to tolerate low oxygen saturation levels," said the doctor. Some recover without going further.

And if patients end up needing a respirator, Daniel Griffin says that respirators are set differently to deliver air with less pressure.

Medical societies, including international experts from the Surviving Sepsis Campaign, are in the process of writing good practice guidelines. None have yet a definitive answer.