Yes, people going on ventilators are in an extreme condition, but the success rate is very low for COVID-19. The standard of care appears to be based on experience with pneumonia from other kinds of diseases such as flu. COVID-19 appears to have an autoimmune component not found in flu other diseases, and the risk is that the ventilator will further irritate sensitive lung tissue and increase the risk of a damaging immune response.

The implicit assumption is that 100% of the people placed on ventilators would have died without them, and therefore any recoveries are net benefit. In reality some fraction may recover with or without a ventilator.

Here is an alternative treatment that does not use a ventilator that may have some promise:
https://www.msn.com/en-us/health/medical/new-study-tests-alternative-to-ventilators-for-covid-19-patients/ar-BB12sfi4

Here is another alternative:

In this scenario we are skipping a couple of steps. Normally when we deal with patients with otherwise healthy lungs and having oxygenation problems we can use a few devices to deliver oxygen in different ways. We normally dont just put them on the vent. But this virus progresses so rapidly we are going from a low flow oxygen device right to ventilation.
I do believe there are some patients that we could stick on those oxygen devices and they would be ok. But CDC has come out with the recommendation not to because they feel it will aerosolize the virus. My feelings is we already have the patients in a negative pressure rooms why not try. If it saves patients from being on the ventilator and possibly shortens their recovery, the benefits outweigh the risk.

Honestly I have not seen any different outcomes with turning the patients face down. In the health field we call that proning and this is something that will circle around every few years like a fad. There are facilities saying it has proven helpful, the one I work at not so much.
But non invasive ventilation is certainly key to this. The cdc came out with requirements on what not to use. Non invasive is one of them because they feel it will aerosolize the virus. I have been hearing those regulations are loosening some. Let’s hope so.

If I’m not mistaken the experimental arm also receives the standard of care so as to have only one variable in the experiment (or as close to one as you can ever get).

Depends on the study. If you’re looking to see if the experimental intervention/drug is non-inferior to (or better than) the standard of care, it is given in place of the standard of care. This is almost always done when there is some strong evidence (animal studies, use in other situations) that the experimental intervention is not obviously inferior to the standard of care and there is marginal risk to the patient not receiving the standard of care. The more life-saving that standard of care (intubation when needed), the more difficult it is to conduct this type of randomized control trial.

You could also do a study that looks if an experimental intervention leads to a better outcome when used in tandem with the standard of care. This seems to be the type of study you’re referring to. There would be fewer issues in this type of study, but you would not be able to compare no treatment vs treatment as both are getting some treatment.

Well, since your point is that since there is no proven treatment for COVID-19, then no off label treatments should be done, you can log this as a victory.

In your equation, there is no evidence that the ventilators saved any lives.

Helmets or face masks should prevent aerosols.

The reported success rate for ventilators has been very poor. Surely there are better ways to treat patient if the intent is to prevent aerosols from spreading infection.

Gosh … maybe they should try an antiviral drug like Hydroxychloroquine or Chloroquine before they get that sick so that perhaps they never reach that state. :thinking:

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Nope that wasn’t the point at all but thanks for playing.

We typically humidify the air going into a mask. But yeah if we can get the CDC to loosen up and stop the hysteria to actually find out if in fact we can prevent intubation and improve outcome, I would love to try.

The CDC has no guidelines for mechanical intubation. Their COVID-19 interim guidance paper specifically defers to the WHO and Surviving Sepsis Campaign for those matters, although neither are binding. Guidelines for intubation have largely been determined by the various medical societies and hospital systems. You’re free to delay or not intubate whoever you’d wish. The first complication or death deemed secondary to delay or failure to treat could be unpleasant.

https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-faq.html

" Which procedures are considered aerosol generating procedures in healthcare settings?

Some procedures performed on patients are more likely to generate higher concentrations of infectious respiratory aerosols than coughing, sneezing, talking, or breathing. These aerosol generating procedures (AGPs) potentially put healthcare personnel and others at an increased risk for pathogen exposure and infection.

Development of a comprehensive list of AGPs for healthcare settings has not been possible, due to limitations in available data on which procedures may generate potentially infectious aerosols and the challenges in determining if reported transmissions during AGPs are due to aerosols or other exposures.

There is neither expert consensus, nor sufficient supporting data, to create a definitive and comprehensive list of AGPs for healthcare settings.

Commonly performed medical procedures that are often considered AGPs, or that create uncontrolled respiratory secretions, include:

  • open suctioning of airways
  • sputum induction
  • cardiopulmonary resuscitation
  • endotracheal intubation and extubation
  • non-invasive ventilation (e.g., BiPAP, CPAP)
  • bronchoscopy
  • manual ventilation

Based on limited available data, it is uncertain whether aerosols generated from some procedures may be infectious, such as:

  • nebulizer administration*
  • high flow O2 delivery

*Aerosols generated by nebulizers are derived from medication in the nebulizer. It is uncertain whether potential associations between performing this common procedure and increased risk of infection might be due to aerosols generated by the procedure or due to increased contact between those administering the nebulized medication and infected patients.

References related to aerosol generating procedures:

Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J (2012) Aerosol Generating Procedures and Risk of Transmission of Acute Respiratory Infections to Healthcare Workers: A Systematic Review. PLoS ONE 7(4); https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3338532/#!po=72.2222external icon)."

This type of information is what is being given to hospitals. Whether that is recited by the cdc from some other organization. We are placed in a rather small box to operate.
Absolutely, I agree with you should the patient present with respiratory failure then intubation is the only option. But if we are seeing patients who present with low oxygenation, then non invasive and high flow oxygen could likely mean a better outcome. We wont know unless we try.

Ah, the “thanks for playing” card. How original. :smile:

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What you have quoted are recommendations for disease spread secondary to aerosol generating procedures. They are to assist in making sure adequate and appropriate PPE is used. They are not saying when or when not to intubate a patient.

Patients are placed on escalating supplemental oxygen until they meet intubation criteria as described by medical societies, institutions, and ultimately the one performing the intubation. If you personally decide to delay or even not intubate a patient for whatever reason, then you as the one performing the procedure have the ability to do so. That won’t excuse you legally or professionally for any bad outcomes deemed secondary to that decision. Just hope it goes well.