Doctors rethinking coronavirus: Are we using ventilators the wrong way?

Across the country, hospital administrators, doctors and public officials are pleading for ventilators, as the spread of coronavirus is making growing numbers of patients dependent on the machines that pump oxygen into their lungs to keep them alive. The subject comes up at almost every White House briefing on coronavirus, and the administration has even proposed an emergency effort to retool automobile factories to make more of the devices.

In New York, the epicenter of the coronavirus outbreak in the U.S., Gov. Andrew Cuomo has largely focused his energy on efforts to bolster the state's dwindling stockpile of ventilators, while officials in a number of other states have begun developing or updating guidelines for how to ration ventilators in the event of a shortage.

But while hospitals and health care workers grapple with the grim reality that they may soon be forced to deny potentially life-saving treatments to certain patients due to a lack of supplies, some doctors are raising questions about how ventilators are currently being used on coronavirus patients - and whether they may actually be doing more harm than good. Early reporting on coronavirus deaths from China, Italy and the U.S. show that more than half - and as many as two-thirds - of COVID-19 patients who are placed on ventilators don't survive.

"What we're doing now is not working, and I think making the same mistake over and over is a sign of stupidity," Dr. Paul Marik told Yahoo News. "If it's not working, we've got to look for something else."

Marik is promoting a treatment of his own devising, a combination of corticosteroids and high-dose ascorbic acid, or vitamin C, as a first-line therapy for patients hospitalized with COVID-19. Marik is a respected clinician, chief of Pulmonary and Critical Care Medicine at Eastern Virginia Medical School. The protocol is controversial and untested, but the theory behind it illuminates a growing shift in thinking about the disease that may have important implications for how it is treated.

Marik's theory is based on an idea that is becoming widespread among researchers: that the cause of death for a significant number of COVID-19 patients, especially younger ones, is severe inflammation of the lungs resulting from an overly vigorous immune-system response. By administering anti-inflammatory drugs early and regularly after a patient is admitted to the emergency room, Marik believes he can prevent this complication, known as a "cytokine storm."

In those cases, "it's not the virus that's killing the host, it's the host's response to the virus," said Marik. Coronavirus is highly contagious and can cause fatal disease in some patients, but immune reactions to the infection varies dramatically from person to person.

"People who are doing fine don't need steroids, it's the people who get sick from the storm," Marik said. "Corticosteroids are really effective in downregulating that storm."

Marik has been touting the anti-inflammatory properties of vitamin C and steroids since 2017, when he first released the results of a somewhat controversial study claiming that intravenous vitamin C, hydrocortisone and thiamine are an effective treatment for sepsis. The treatment failed in a larger study whose results were published in January, but he believes it may still hold promise for COVID-19.

Marik's protocol is untested, and his advocacy of vitamin C is very much a minority view. It is absolutely not something people can or should try for themselves; the corticosteroids are administered intravenously. One doctor who has been treating COVID-19 patients at a New York-area hospital says there's no reason to believe it would work. Marik acknowledged that the World Health Organization has advised against the use of corticosteroids to treat viral pneumonia in patients with COVID-19 (except in clinical trials) citing previous studies on other viral diseases like SARS and MERS, which found insufficient evidence that the drugs were effective.

But Marik's view encapsulates a growing suspicion among doctors treating COVID-19 that the disease has some novel features that may require a unique approach.

In addition to early anti-inflammatory treatment, the protocol followed by Marik and his colleagues includes alternatives to using a ventilator, a machine that delivers oxygen under pressure directly into the trachea by means of a tube inserted through the mouth. This requires deep sedation and prevents the patient from talking. He favors a technique called high-flow nasal cannula therapy, which delivers humidified and heated oxygen through nostril tubes, a less invasive procedure than intubation, and suggests positioning the patient on the stomach to improve oxygenation.

The goal is to delay, or avoid entirely, the need for the patient to go on a ventilator.

"Plenty of patients will need to go on a ventilator, you can't help it, but you want to do whatever you can to prevent [that]," said Marik, adding that "fewer patients that go on ventilators, frees up [more] for those who really need them."

For those who need to be intubated, however, Marik and his colleagues are also recommending a different, gentler approach than the high-pressure ventilator settings typically used for patients with acute respiratory distress syndrome (ARDS), which Marik and others believe may actually be causing damage to the lungs of patients with COVID-19.

"It's becoming a vicious cycle," said Marik. "The ventilator is causing lung injury, which causes them to stay on the ventilator longer, and basically is depleting the supply of ventilators for people who need them."

Marik and his colleagues are not the only ones who believe a new approach may be needed to treat this new disease.

While health care providers in the U.S. have been able to glean some insights about the coronavirus from the earlier experiences of doctors in China and Italy, there is much about this completely new disease that remains unknown. As a result, doctors have been forced to treat patients for an illness they don't fully understand, relying on conventional wisdom in scenarios that have proven thoroughly unconventional.

One example of this, some doctors argue, is the use of ventilators for coronavirus patients.

In a video posted to YouTube on March 31, which has been widely circulated and discussed among doctors on the front lines of fighting COVID-19, Cameron Kyle-Sidell, an emergency medicine doctor at Maimonides Medical Center in Brooklyn, explains how, like most health care workers around the U.S., when he first started providing critical care for coronavirus patients in March, he was under the impression that he would be treating patients with a "viral pneumonia infection that would progress into acute respiratory distress syndrome." It's based on this understanding, he explained, that doctors in New York and elsewhere have been using ventilators to treat coronavirus patients who suddenly become unable to breath on their own, in the same way that they would treat respiratory failure in people with ARDS.

However, over the course of nine days, Kyle-Sidell says he concluded that the lung disease developing in patients with COVID-19 was nothing like the typical presentation of ARDS.

"COVID-19 lung disease, as far as I can see, is not a pneumonia and should not be treated as one," said Kyle-Sidell. "Rather, it appears as if some kind of viral-induced disease most resembling high altitude sickness. It is as if tens of thousands of my fellow New Yorkers are on a plane at 30,000 feet and the cabin pressure is slowly being let out. These patients are slowly being starved of oxygen."

He now believes the treatment method being widely adopted for those suffering from coronavirus-induced lung disease is based on "a false paradigm."

"I fear," he said, that using ventilators "to increase pressure on the lungs in order to open them up, is actually doing more harm than good, and that the pressure we are providing to lungs, we may be providing to lungs that cannot take it, and that the ARDS that we are seeing may be nothing more than lung injury caused by the ventilator."

"COVID-positive patients need oxygen, they do not need pressure," he argued. "They will need ventilators, but they must be programmed differently." Kyle-Sidell could not be reached by Yahoo News, but he reiterated his observations and concerns in an interview with John Whyte, the chief medical officer at WebMD, published on the medical news site MedScape on Monday.

Other doctors in the U.S. and Italy have made similar observations about the difference between typical ARDS and loss of oxygen that appears to develop rapidly in COVID-19 patients.

On March 30, the American Thoracic Society published a report titled "Covid-19 Does Not Lead to a 'Typical' Acute Respiratory Distress Syndrome," based on the findings of three physicians treating patients with COVID-19 pneumonia and acute respiratory failure at an intensive care unit in northern Italy. The authors note that "while the clinical approach to these patients is the one typically applied to severe ARDS, namely high Positive End Expiratory Pressure (PEEP) and prone positioning," patients with COVID-19 pneumonia present an atypical form of ARDS. Specifically, they observed a wide disparity between these patients' "relatively well preserved lung mechanics and the severity of hypoxemia" or low levels of oxygen.

The authors of the report concluded that "all we can do ventilating these patients is 'buying time' with minimum additional damage: the lowest possible PEEP [a measure of air pressure within the lungs] and gentle ventilation. We need to be patient."

"It's a basic concept of medicine: You treat patients based on the disease they have, not for disease you think they have or the disease you want them to have," said Marik, expressing frustration that top health officials in the U.S. have not responded to his own calls to consider a different approach to treating patients with COVID-19.

"It pains me to see all of these patients dying and I know they don't have to die," he said.

While doctors like Marik and Kyle-Sidell are pushing to change the way ventilators are used to treat coronavirus, others are drawing attention to the possible long-term physical and neurological damage caused by the current method of treatment.

In a New York Times op-ed over the weekend, Dr. Kathryn Dreger, a clinical assistant professor of medicine at Georgetown University, urged coronavirus patients and their loved ones to consider the brutal and lasting toll ventilators can cause before they become "sick enough to need them."

For many COVID-19 patients who, she explains, must be "put into a medically induced coma before being placed on a ventilator," the treatment itself can cause significant damage to the heart, kidneys or brain that may be permanent, or even fatal.

"Even among the Covid-19 patients who are ventilated and then discharged from the intensive care unit, some have died within days from heart damage," wrote Dreger. For those who survive, "the amount of sedation needed for Covid-19 patients can cause profound complications, damaging muscles and nerves, making it hard for those who survive to walk, move or even think as well as they did before they became ill. Many spend most of their recovery time in a rehabilitation center, and older patients often never go home. They live out their days bed bound, at higher risk of recurrent infections, bed sores and trips back to the hospital."

Dreger clarified that she is not suggesting "we shouldn't use ventilators to try to save people," but rather that Americans should consider these facts and figure out out what they would want for themselves and their loved ones now, before it's too late.

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