Some are now asking, can we stave off ventilating some patients, and increase the chances of people being discharged from hospital alive?
Health
'Different than anything we've seen': ICU doctors question use of ventilators on some COVID-19 patients – Timmins Press
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.
Related
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.)
• Email: skirkey@postmedia.com | Twitter: sharon_kirkey
Health
Women in states with bans are getting abortions at similar rates as under Roe, report says
Women living in states with abortion bans obtained the procedure in the second half of 2023 at about the same rate as before the U.S. Supreme Court overturned Roe v. Wade, according to a report released Tuesday.
Women did so by traveling out of state or by having prescription abortion pills mailed to them, according to the #WeCount report from the Society of Family Planning, which advocates for abortion access. They increasingly used telehealth, the report found, as medical providers in states with laws intended to protection them from prosecution in other states used online appointments to prescribe abortion pills.
“The abortion bans are not eliminating the need for abortion,” said Ushma Upadhyay, a University of California, San Francisco public health social scientist and a co-chair of the #WeCount survey. “People are jumping over these hurdles because they have to.”
Abortion patterns have shifted
The #WeCount report began surveying abortion providers across the country monthly just before Roe was overturned, creating a snapshot of abortion trends. In some states, a portion of the data is estimated. The effort makes data public with less than a six-month lag, giving a picture of trends far faster than the U.S. Centers for Disease Control and Prevention, whose most recent annual report covers abortion in 2021.
The report has chronicled quick shifts since the Supreme Court’s Dobbs v. Jackson Women’s Health Organization ruling that ended the national right to abortion and opened the door to enforcement of state bans.
The number of abortions in states with bans at all stages of pregnancy fell to near zero. It also plummeted in states where bans kick in around six weeks of pregnancy, which is before many women know they’re pregnant.
But the nationwide total has been about the same or above the level from before the ruling. The study estimates 99,000 abortions occurred each month in the first half of 2024, up from the 81,000 monthly from April through December 2022 and 88,000 in 2023.
One reason is telehealth, which got a boost when some Democratic-controlled states last year began implementing laws to protect prescribers. In April 2022, about 1 in 25 abortions were from pills prescribed via telehealth, the report found. In June 2024, it was 1 in 5.
The newest report is the first time #WeCount has broken down state-by-state numbers for abortion pill prescriptions. About half the telehealth abortion pill prescriptions now go to patients in states with abortion bans or restrictions on telehealth abortion prescriptions.
In the second half of last year, the pills were sent to about 2,800 women each month in Texas, more than 1,500 in Mississippi and nearly 800 in Missouri, for instance.
Travel is still the main means of access for women in states with bans
Data from another group, the Guttmacher Institute, shows that women in states with bans still rely mostly on travel to get abortions.
By combining results of the two surveys and comparing them with Guttmacher’s counts of in-person abortions from 2020, #WeCount found women in states with bans throughout pregnancy were getting abortions in similar numbers as they were in 2020. The numbers do not account for pills obtained from outside the medical system in the earlier period, when those prescriptions most often came from abroad. They also do not tally people who received pills but did not use them.
West Virginia women, for example, obtained nearly 220 abortions monthly in the second half of 2023, mostly by traveling — more than in 2020, when they received about 140 a month. For Louisiana residents, the monthly abortion numbers were about the same, with just under 700 from July through December 2023, mostly through shield laws, and 635 in 2020. However, Oklahoma residents obtained fewer abortions in 2023, with the monthly number falling to under 470 from about 690 in 2020.
Telehealth providers emerged quickly
One of the major providers of the telehealth pills is the Massachusetts Abortion Access Project. Cofounder Angel Foster said the group prescribed to about 500 patients a month, mostly in states with bans, from its September 2023 launch through last month.
The group charged $250 per person while allowing people to pay less if they couldn’t afford that. Starting this month, with the help of grant funding that pays operating costs, it’s trying a different approach: Setting the price at $5 but letting patients know they’d appreciate more for those who can pay it. Foster said the group is on track to provide 1,500 to 2,000 abortions monthly with the new model.
Foster called the Supreme Court’s 2020 decision “a human rights and social justice catastrophe” while also saying that “there’s an irony in what’s happened in the post-Dobbs landscape.”
“In some places abortion care is more accessible and affordable than it was,” she said.
There have no major legal challenges of shield laws so far, but abortion opponents have tried to get one of the main pills removed from the market. Earlier this year, the U.S. Supreme Court unanimously preserved access to the drug, mifepristone, while finding that a group of anti-abortion doctors and organizations did not have the legal right to challenge the 2000 federal approval of the drug.
This month, three states asked a judge for permission to file a lawsuit aimed at rolling back federal decisions that allowed easier access to the pill — including through telehealth.
Health
How many smoke-related deaths from wildfires are linked to climate change every year?
Climate change may be contributing to thousands more wildfire smoke-related deaths every year than in previous decades, a new study suggests — results a Canadian co-author says underline the urgency of reducing planet-warming emissions.
The international study published Monday is one of the most rigorous yet in determining just how much climate change can be linked to wildfire smoke deaths around the world, said Sian Kou-Giesbrecht, an assistant professor at Dalhousie University.
“What stands out to me is that this proportion is increasing just so much. I think that it really kind of attests to just how much we need to take targeted action to reducing greenhouse-gas emissions,” she said in an interview.
The study estimates, using mathematical modeling, that about 12,566 annual wildfire smoke-related deaths in the 2010s were linked to climate change, up from about 669 in the 1960s, when far less carbon dioxide was concentrated in the atmosphere.
Translated to a proportion of wildfire smoke mortality overall, the study estimates about 13 per cent of estimated excessdeaths in the 2010s were linked to climate change, compared to about 1.2 per cent in the 1960s.
“Adapting to the critical health impacts of fires is required,” read the study, published in the peer-reviewed journal Nature Climate Change.
While wildfires are a natural part of the boreal forest ecosystem, a growing number of studies have documented how climate change, driven by the burning of fossil fuels, is making them larger and more intense — and contributing more to air pollution.
The same research group is behind another study published in the same journal Monday that suggests climate change increased the global area burned by wildfire by about 16 per cent from 2003 to 2019.
Those climate-fuelled fires then churn out more fine particle pollution, known as PM2.5, that’s tiny enough to get deep into the lungs — and in the long run can have serious health effects.
The study that estimated the scale of those effects is based on modeling, not historical data about reported deaths from air pollution.
Researchers used established public-health metrics for when pollution is thought to contribute to mortality, then figured out the extent to which wildfire smoke may have played a role in that overall exposure to arrive at the estimates.
Meanwhile, Health Canada estimates that between 2013 and 2018, up to 240 Canadians died every year due to short-term exposure to wildfire air pollution.
Kou-Giesbrecht said Monday’s study did not find that climate change had a major influence on the number of smoke-related deaths from Canada’s boreal wildfires.
She suggested that’s likely due to the country’s relatively small population size, and how tricky it is to model forest fires in the region, given its unique mix of shrubs and peat.
But she also noted that a stretch of devastating Canadian wildfire seasons over the past several years was not captured in the study, and she expects future research could find a bigger increase in deaths and public-health problems linked to climate change.
The most affected regions in the study were South America, Australia and Europe.
Kou-Giesbrecht said the more studies that uncover the link between climate change and disasters as “tangible” as wildfires, the more the case for “drastic climate action” will be bolstered.
“I think that the more and more evidence that we have to support the role of climate change in shaping the past 100 years, and knowing that it will continue to shape the next 100 years, is really important,” she said.
“And I find that personally interesting, albeit scary.”
The study used three highly complex models to estimate the relationship between climate change, land use and fire.
The models, which each contain thousands upon thousands of equations, compare what wildfires look like in the current climate to what they may have looked like in pre-industrial times, before humans started to burn vast amounts of fossil fuels.
The researchers used the models to calculate gas and aerosol emissions from wildfires between 1960 and 2019, and then make estimates about annual smoke-related deaths.
The type of methodology used by Monday’s studies, known as attribution science, is considered one of the fastest-growing fields of climate science. It is bolstered in part by major strides in computing power.
This report by The Canadian Press was first published Oct. 21, 2024.
Health
Some Ontario docs now offering RSV shot to infants with Quebec rollout set for Nov.
Some Ontario doctors have started offering a free shot that can protect babies from respiratory syncytial virus while Quebec will begin its immunization program next month.
The new shot called Nirsevimab gives babies antibodies that provide passive immunity to RSV, a major cause of serious lower respiratory tract infections for infants and seniors, which can cause bronchiolitis or pneumonia.
Ontario’s ministry of health says the shot is already available at some doctor’s offices in Ontario with the province’s remaining supply set to arrive by the end of the month.
Quebec will begin administering the shots on Nov. 4 to babies born in hospitals and delivery centers.
Parents in Quebec with babies under six months or those who are older but more vulnerable to infection can also book immunization appointments online.
The injection will be available in Nunavut and Yukon this fall and winter, though administration start dates have not yet been announced.
This report by The Canadian Press was first published Oct. 21, 2024.
-With files from Nicole Ireland
Canadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content.
The Canadian Press. All rights reserved.
-
News21 hours ago
Sentencing hearing continues for University of Waterloo gender studies class stabber
-
News14 hours ago
Toronto FC captain Jonathan Osorio making a difference off the pitch as well as on it
-
News20 hours ago
Inequality has broad impacts on the health of Montreal children, report finds
-
News21 hours ago
Liberal majority victory shifts political landscape in New Brunswick
-
Business21 hours ago
Thomson Reuters acquires AI accounting assistant developer Materia
-
News15 hours ago
Legault ‘shocked’ by Montreal teacher scandal, pledges to toughen secularism measures
-
News21 hours ago
Ontario aiming to become energy superpower, Energy Minister Stephen Lecce says
-
News14 hours ago
Sonia Furstenau staying on as B.C. Greens leader in wake of indecisive election