It started in New York City, in the trenches in the battle against COVID-19. Stressed doctors began worrying that the breathing tubes and pressures being used to open up the tiny air sacs in the lungs of the critically sick could be causing worse harm.

Some are now asking, can we stave off ventilating some patients, and increase the chances of people being discharged from hospital alive?

“In many ways, it’s different than anything we have seen before,” Dr. James Downar, a specialist in critical care and palliative care said Thursday from inside an ICU at The Ottawa Hospital dedicated to critically ill COVID-19 patients. On Thursday, the unit was full.

The pandemic virus seems not only to affect the lungs, making them stiff and inflamed, but other parts of the body as well, including the heart. It’s not clear if it’s a direct effect of the virus on the heart that’s causing heart failure in some cases, or if it’s because the virus is playing with the body’s coagulation system, increasing the risk of blood clots.

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It’s different in another way, too: In a phenomenon reported in the U.S., as well as Italy, and, now, Canada, some patients with severe COVID-19 are arriving in hospital with such low blood oxygen levels they should be gasping for breath, unable to speak in full sentences, disoriented and barely conscious.

Except they’re not in any sort of distress, or very little distress, compared to the burden of illness. They’re talking. They’re lucid. It’s not the classic acute respiratory distress syndrome doctors are used to seeing, and that most guidelines recommend doctors treat as such. One Brooklyn critical care doctor has likened it to high altitude sickness and is urging his colleagues to be cautious about who is being ventilated, and how. The concern is that the pressure may be harming lungs, and that some patients could be more safely treated with less invasive means such as high-flow nasal oxygen.

“To think that we understand this infection, I think is very naive,” Dr. Ashika Jain, an associate professor in trauma critical care and emergency ultrasound at New York University/Bellevue Hospital Center said on a recent  REBEL Cast podcast. “There are so many different theories about how this is behaving. There’s no one cohesive picture. We don’t really understand how to really treat this, because it’s a four-month old virus that we just don’t understand how it’s already running when it didn’t really learn how to walk yet.”

With some Ottawa patients, “we’re giving them all the oxygen we can give them without putting them on a breathing machine, and they’re wide awake and talking,” Downar said. In some situations, people are being flipped onto their stomachs, into the prone position, to improve gas exchanges.

High-flow nasal oxygen, where little plastic tubes are placed in the nostrils, can deliver up to six times the amount of oxygen. “And those high flows actually generate a little bit of positive pressure within the patient’s upper airway, which helps keep the lungs open and improve the oxygen levels in the blood,” said Dr. Claudio Martin, a critical care physician and medical director of critical care at London Health Sciences Centre and Western University.

“The problem with that is, when you’re giving oxygen with such high flows, there is a high possibility the viral particles in the airways are being aerosolized, so you can increase the possibility of spread of the virus in the environment,” Martin said. “Which is why if we do use that it has to be in a negative pressure environment, so that you contain the air in the room. You basically try to contain any virus particles that are aerosolized.” It also means any staff  looking after the patient need to be wearing N95 masks.

It’s not the classic acute respiratory distress syndrome doctors are used to seeing

While the vast majority, some 80 per cent of infections, are mild, the COVID-19 virus can cause pneumonia, which interferes with the ability of oxygen to get in through the lungs, and into the bloodstream. Currently, about six per cent of confirmed cases in Canada have required admission to an ICU.

A ventilator does two things: it provides oxygen as well as pressure to open up the alveoli, the little lung units, to allow the lungs to get oxygen in, and carbon dioxide out. While potentially life saving, it can worsen lung injury.

The strategy, for now, is not to rush to intubate, said Downar, who led the drafting of an Ontario “triage protocol” if hospitals are forced to ration ICU beds and ventilators. “Unless somebody seems to be failing, or their oxygen level is truly at this critical life-changing level, we can maybe hesitate,” Downar said. Even when the decision is made to ventilate, in some cases, “you almost end up having to talk them into it, which is a very unusual situation.”

“But let me be explicitly clear here: These are still the exceptions. The majority are failing … They need to have a tube put down (their throats) and put on a breathing machine to help them breathe.”

It’s not clear what proportion will be discharged alive.

A study published this week in the Journal of the American Medical Association involved 1,591 people infected with the pandemic virus admitted to ICUs in the Lombardy region of Italy between Feb. 20 and March 18. A high proportion — 88 per cent — required mechanical ventilation. As of March 25, 26 per cent of the ICU patients had died, 16 per cent had been discharged, and 58 per cent were still in the ICU. The median age was 62; 82 per cent were men.

British Prime Minister Boris Johnson remained in an ICU Thursday, where his condition reportedly continues to improve. The 55-year-old is not on a ventilator; according to a spokesman, he’s receiving standard oxygen therapy.

People who have been ventilated have described the experience as awful beyond belief.

The person is sedated, so that they’re calm. “Sometimes you have to relax the breathing muscles so they’re able to open their mouth and accept the tube being inserted,” said Dr. John Granton, head of the division of respirology at Toronto’s University Health Network- Sinai Health System. “If they’re incredibly sick we need to take over their breathing completely, and so we fully sedate them,” meaning a medically induced coma.

“We don’t allow them to wake up from that anaesthetic until their lungs have healed. And then once they’ve healed, or if they’re not that sick, we can allow them to be reasonably aware,” Granton said.

If this ever happened to me, this is what I would not want to look like at the end

With a tube down their throat, however, they can’t speak. They have to communicate by using a board, or moving their lips. “We’ve become expert lip readers in the intensive care unit,” Granton said.

From the experience with H1N1 and SARS, it can sometimes take several weeks, or a month or more for people to recover to the point they can be “liberated” from the machines. For some with a significant underlying condition, like chronic obstructive pulmonary disease, there’s a risk they may never come off.

If nothing else, the pandemic should be encouraging discussions about what people value in life, Granton said, including conversations such as, “If this ever happened to me, this is what I would not want to look like at the end.”

With hospitals in COVID-19 lockdown, families aren’t allowed inside the ICU. Normally, they’re at the bedside. “We’re trying to update them by phone, we’re trying to do Facetime,” Downar said. “To have to see a critically ill family member through a video call and have your questions answered by somebody wearing a face mask … it’s not the way we like to do things. But it’s better than nothing.”

“We’re tired, but this is our job,” Downar said. “People are sending us food. People are honking their horns and putting up signs … It’s really touching.

“We’re going to do our best, and we’re pretty damn good. This is a really strong team. I wouldn’t want to be anywhere else while this is going on than where I am right now.”

(This story has been updated with comments from Dr. Claudio Martin of Western University.)

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