Time to Reconsider Ventilator Settings in COVID-19 Patients?
With some ophthalmologists being pressed into service treating COVID-19 patients (the AAO has a bulletin for its members on the proper ventilator settings if they need to operate one), there’s some new thinking emerging from Europe that says doctors may be going about mechanical ventilation incorrectly.
In a letter to the editor (in press) to the American Journal of Respiratory and Critical Care, Luciano Gattitoni, MD, of the Anesthesiology and Intensive Care service at the Medical University of Gottingen, along with co-workers from Italy, argues that COVID-19’s effects on the lungs appear to be more like high-altitude pulmonary edema than acute respiratory distress.1Around the same time as Dr. Gattinoni was developing these ideas, in the United States Cameron Kyle-Sidell, MD, a New York physician, started to come to similar conclusions, which he discussed in several tweets and online videos. He stepped back from his intensive care unit at his institution, Maimonides Medical Center, because he didn’t believe the current ventilator approach was correct. He now sees patients in the ER.
If Dr. Gattitoni’s observations about the disease are correct, some physicians argue, then ventilators shouldn’t be set for high positive end-expiratory pressure. Instead, the priority should be as low PEEP as possible-gentle ventilation-to allow the patient to get as much oxygen as possible.
In a video interview on the subject with Medscape’s John Whyte, MD, Dr. Kyle-Sidell says that, for patients he sees in his ER, “We’re taking an approach that’s different from than the typical ARDSNet protocol, in that we’re going to do an oxygen-first strategy: We’re going to leave the oxygen levels as high as possible, and use the lowest pressures possible to try to keep the oxygen levels high. That’s the approach we’re going to continue to do as long as the patients continue to display the physiology of a low-elastance/high-compliance disease.” Dr. Kyle-Sidell says he’s not trying to get everyone to switch to this way of treating severe cases of the disease, but instead he hopes the experts in the field of pulmonology can get together and possibly come up with some “fresh recommendations” for treating COVID-19.
In Dr. Gattinoni’s paper, the researchers sum up their proposed approach: “…all we can do ventilating these patients is “buying time” with minimum additional damage: The lowest possible PEEP and gentle ventilation. We need to be patient.”
1. Gattitoni L, Coppola S, Massimo C, et al. Covid-19 does not lead to a “typical” acute respiratory distress syndrome. Am J Respir Crit Care 2020 (in press). https://www.atsjournals.org/doi/pdf/10.1164/rccm.202003-0817LE. Accessed 6 April 2020.
AAO and Fellow Physicians’ Societies Stand Up for Physicians’ Rights
The American Academy of Ophthalmology joined 44 other specialty groups to urge health-care institutions and governmental agencies to take physicians’ safety more seriously during the pandemic.
The statement was issued by the Council of Medical Specialty Societies in response to incidences of health-care providers being reprimanded or fired for criticizing their working conditions. At base, it states that adequate personal protective equipment should be a fundamental expectation for health-care professionals working on the front line of the pandemic. The statement’s more specific points:
• CMSS and its member societies urge federal, state and local authorities to ensure an adequate supply and distribution of PPE for every frontline health-care professional in the United States. Physicians and other health-care professionals can and should expect their institutions to provide appropriate means to limit occupational exposure.
• Physicians and other health-care professionals should be allowed to bring their own PPE to protect themselves, colleagues and patients when these items are in short supply at their institutions. CMSS supports the Joint Commission statement allowing the use of private PPE, but this option does not obviate an institution’s responsibility to provide adequate PPE to all health-care personnel.
• The United States needs a simple, uniform mechanism for all health-care facilities to report their PPE needs and other medical supply needs to help guide optimal distribution of supplies across the country.
• Physicians and other healthcare professionals should not be at risk of having their employment terminated, or be otherwise disciplined, for speaking out, within their health-care systems or publicly, on conditions and practices related to care of COVID-19 patients (including lack of PPE) that the physician and other health-care professional has direct knowledge of and deems to be in conflict with the health and safety of patients, themselves, and others involved in providing care to patients.
• CMSS supports the American Medical Association statement that “no employer should restrict physicians’ freedom to advocate for the best interest of their patients.” Physicians and other health-care professionals may appropriately decide that going public (including to the news media and on social media) with their concerns is necessary to achieve needed change for the health and safety of patients and clinicians, both within the health-care facility and more broadly.
The statement comes on the heels of a Facebook post by a Bellingham, Washington, ER physician, Ming Lin, MD, in which he says he was terminated by his employer. Dr. Lin had been critical of the COVID-19 infection safety measures, or lack thereof, employed by his hospital.