A nurse recently comforted a woman suffering from Covid-19 who was struggling with anxiety because of her noninvasive ventilator at a hospital in Chicago.
Photo: Ashlee Rezin Garcia/Associated PressIt is another medical mystery of the coronavirus pandemic: Large numbers of Covid-19 patients arrive at hospitals with blood-oxygen levels so low they should be unconscious or on the verge of organ failure. Instead they are awake, talking—not struggling to breathe.
Although nobody is quite sure what about the coronavirus causes these patients to react this way, they are rapidly changing how many doctors are treating the disease. Instead of rushing to put such patients on mechanical ventilators for fear of them suddenly getting worse and dying, some doctors are now holding off on the invasive treatment, believing that many of these patients will do just fine without them.
Pre-Covid, doctors looking to boost a patient’s blood-oxygen levels would often turn first to less invasive methods of support such as CPAP or BiPAP machines that push air into a patient’s airway through a face mask, or high-flow nasal cannulas—prongs that blow heated, humidified oxygen into a patient’s nostrils. If that didn’t work, physicians would use mechanical ventilators.
But people with Covid-19 began showing up at the hospital with rarely seen, ultra-low blood-oxygen levels. Even for those who weren’t struggling to breathe, doctors were concerned that patients’ conditions could suddenly worsen, which with Covid-19 could swiftly turn deadly. So they often intubated sooner.
“In the past, you’d see these kinds of oxygen levels, and your brain would intuit all these other things,” said Scott Weingart, chief of emergency critical care in the department of emergency medicine at Stony Brook Hospital in Stony Brook, N.Y. “For instance, you’d assume the patient’s lungs must be so bad that if we don’t intubate now, they might crap out.”
Doctors have dubbed these patients “happy hypoxemics,” a reference to the paradox of abnormally low levels of oxygen found in their blood combined with an ability to breathe relatively easily. In recent weeks, doctors at Stony Brook Hospital have used ventilators less on these patients, turning instead to the CPAP or BiPAP machines or high-flow nasal cannulas.
Dr. Weingart remembers one of his first such patients in March—a 42-year-old man with blood-oxygen levels so low he should have been unconscious. Instead, he was sitting up, smiling and talking. He was breathing quickly, but seemed fine otherwise. Dr. Weingart and his team used a high-flow nasal cannula to boost the patient’s oxygen levels. They also turned him on his front, a method known as “prone positioning” that doctors have found can also help boost oxygen levels partly by reducing the pressure of the heart and diaphragm on the lungs. The patient was never put on a ventilator and was discharged in a week, Dr. Weingart said.
Several other doctors said they are having success with such simpler approaches. That, in turn, is reducing demand for ventilators—a critical concern early in the crisis—and easing strain on hospital staff, they say.
Mechanical ventilators, such as this one at a hospital in Yonkers, N.Y., help people breathe when they can’t on their own.
Photo: John Minchillo/Associated PressAbdul Khan, medical director for Ochsner Medical Center’s West Bank intensive care unit in Gretna, La., has also encountered these so-called “happy hypoxemic” Covid-19 patients.
“We’ve learned that they are able to tolerate these lower levels of oxygen for a significant period of time,” he said. Dr. Khan and his colleagues now use ventilators as a last resort for such patients.
Mechanical ventilators help people breathe when they can’t on their own. A tube is inserted through the nose or mouth into their trachea. The tube is connected to the ventilator, which pushes a mix of air and oxygen into patients’ lungs. The ventilator can also apply a constant amount of low pressure that helps keep air sacs in the lung from collapsing.
Ventilators play an important part in care, but there are serious risks to being on one for too long. Patients can get secondary infections like bacterial pneumonia. They can get urinary tract infections from being bed-bound and are at higher risk of kidney failure and getting blood clots. If the ventilator isn’t set properly, patients can sustain lung injury.
Recently published data also suggest ventilators may not be as effective at keeping seriously ill Covid-19 patients alive as they are with other patients with severe respiratory problems.
In the U.K., 58.8% of Covid patients on invasive breathing support had died as of May 7, according to data from the country’s National Health Service. That compares with a 34.5% death rate among patients with other types of viral pneumonia who receive invasive breathing support, according to historic data. Of the Covid patients placed on basic breathing support, 17.8% died.
In New York, 88% of 320 Covid patients placed on mechanical ventilation in the state’s Northwell Health System died, according to a study in the Journal of the American Medical Association. Of the 2,314 who didn’t receive mechanical ventilation, 11.7% died.
Experts note that the studies may at least partly reflect that Covid patients who start ventilation tend to be the sickest, and therefore the least likely to survive.
At University College Hospital, a large teaching hospital in central London, doctors are placing patients on less-invasive breathing support, and only progressing them to ventilators if they are still struggling. Under that system, around half of patients are managing with simpler breathing support.
“It’s worked out well for us,” said Mervyn Singer, an intensive care consultant who said UCH adopted this approach on the advice of doctors in China and Italy. “We’ve been able to retain our capacity to ventilate because we haven’t immediately put lots of people on ventilators.”
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At the outset of the pandemic, doctors rushed to put Covid-19 patients on ventilators in part due to concerns that less invasive methods—where the air patients breathe in and out isn’t contained in tubes—posed a greater infection risk to health-care workers.
Benjamin Medoff, chief of the division of pulmonary and critical care medicine at Massachusetts General Hospital in Boston, said his hospital continues to recommend against the routine use of these less invasive methods because the devices can potentially push virus particles into the air and CPAP and BiPAP masks can leak. (Dr. Khan of Ochsner West Bank and Dr. Weingart of Stony Brook said their hospitals place filters on these masks, and use specially ventilated rooms to keep their staff safe.)
In a study recently published in the American Journal of Respiratory and Critical Care Medicine, Dr. Medoff and other researchers at MGH and Beth Israel Deaconess Medical Center said 50 of the 66 patients on mechanical ventilators between March 11 and March 30 at those hospitals were discharged from the ICU, while 11 of the patients died.
“We don’t have to think too much outside of the box here,” Dr. Medoff said.
—Mark Maremont contributed to this article.
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Write to Sarah Toy at sarah.toy@wsj.com and Denise Roland at Denise.Roland@wsj.com
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