Months Into Coronavirus Pandemic, ICU Doctors Are Split on Best Treatment
Several months into the coronavirus pandemic, hospital physicians are split on whether long-established treatment protocols for patients in respiratory distress are helping or harming patients with Covid-19. In the intensive-care unit, doctors are trying to balance their own knowledge and past experiences treating respiratory illness with their current experiences treating the novel coronavirus and newly emerging data on Covid-19 therapies. The result is there is little consensus among physicians about treatment, even as cases and hospitalizations surge in parts of the U.S. It also means the particular treatment a patient gets can vary widely from hospital to hospital, and even from doctor to doctor.
To begin with, physicians don’t agree on the type of lung injury the novel coronavirus causes. One camp says it leads to classic acute respiratory distress syndrome (ARDS), caused by widespread inflammation in the lungs where the tiny air sacs, the alveoli, thicken, fill with fluid and stiffen. The other camp says many Covid-19 patients are showing up with a different form of injury, marked by lungs that are stretchy and more elastic, not stiff—something not typically seen in classic ARDS—though their blood-oxygen levels are still low. Although young patients make up more of the recent surge in cases at many hospitals, doctors say they don’t see age as a factor in the type of lung injury a patient might have.
In April, researchers published an article in the Journal of the American Medical Association suggesting many Covid-19 patients with respiratory distress might require a different treatment approach than typically used for ARDS. The disagreement has roiled the critical-care community, with those in favor of nontypical protocols accusing the other camp of being inflexible and tied to tradition at the expense of patient care during a pandemic. Those who favor sticking to longstanding approaches say the other side is playing fast and loose with treatment guidelines that have been proven to work.
The debate has crystallized around the best way to use ventilators to help Covid-19 patients breathe when they can’t on their own. Normally, for a patient with ARDS who required mechanical ventilation, the ventilator would be set to apply positive pressure—called positive end-expiratory pressure, or PEEP—to prevent the air sacs from collapsing at the end of each breath. The ventilator would also apply a low volume of air per breath, or tidal volume, to help minimize ventilator-induced lung injury.
But some doctors say these traditional settings are too extreme for Covid-19 patients who have good lung elasticity. The traditional PEEP settings could damage the lung and redirect blood flow away from parts of the lung that need it most, leading to poor patient outcomes, these doctors say. Instead, these patients should be placed on lower levels of PEEP and higher tidal volumes, they say.
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Some in the critical-care community think there will be less divergence in opinion as time passes. Some doctors tend to lean on evidence from the population level, while others tend to treat patients on a more individual basis, said Marc Moss, head of the division of pulmonary sciences and critical-care medicine at the University of Colorado School of Medicine. Most use a mix, but some may be leaning more heavily on what they see at the bedside for their Covid-19 patients, as population-level evidence is still emerging, he said. “As we learn more and as more evidence comes out, some of the variability that we’re seeing that’s based on people’s individual perceptions will probably go away,” Dr. Moss said.
https://www.wsj.com/articles/months-into-coronavirus-pandemic-icu-doctors-are-split-on-best-treatment-11593602756 (subscription)
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The JAMA article:
Management of COVID-19 Respiratory Distress
https://jamanetwork.com/journals/jama/fullarticle/2765302
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