As our nation searches for ways to augment the ventilator supply — with Medtronic rushing to release ventilator design specs and anyone with a 3-D printer or some extra wood wondering if they could help with the problem — there’s another path available. The number of ventilators could be increased, and the shortage of sedatives, respiratory therapists and nurses lessened, by getting people off ventilators faster and making those same machines available for the next patients sooner. That would improve the heartbreaking crisis of depersonalization and isolation felt by covid-19 patients and their families. A protocol already developed over the past 20 years and tested in thousands of patients in critical care successfully shortens time on mechanical ventilation, reduces coma and delirium, accelerates getting out of bed even if in isolation and increases survival.
At the bedside of a covid-19 patient, it’s easy to let fear take over — to feel as though nothing in our training has prepared us for this. Perhaps as a result, critical care doctors like us find themselves deviating from our proven techniques. We are regularly placing coronavirus patients on ventilators earlier than we would were it not for their diagnosis, out of fear that they might decompensate rapidly. We are starting neuromuscular blockade (paralysis) in 40 percent of patients, half of whom would generally not be considered sick enough to require it considering standard approaches to other viral illnesses like severe influenza, which also means these people are sedated very heavily into a coma — begetting another shortage, this one in sedative medications. Doctors typically use the precarious practice of paralysis less than 10 percent of the time, usually only in severely stiff lungs to prevent damaging them further by a ventilator. Now, reports from the field show, it’s being used to treat lungs that are not very stiff at all. Rather than turn to the protocols we know, critical care doctors are flying by the seat of our pants.
That all started because an incredibly talented Italian physician, Luciano Gattinoni — as famous globally as National Institute of Allergies and Infectious Diseases director Anthony S. Fauci is — submitted a paper on 16 patients with covid-19 that was published just three days later. Everyone in the critical care community listened. With just four words in his journal article, “intubation should be prioritized,” tidal shifts in thinking occurred (likely much larger than Gattinoni ever intended), and the usual operating procedures shifted. A ventilator shortage accelerated, which sent policy planners scrambling for solutions.
Covid-19 is “the story of dissemination of anecdotal medicine in a disease you don’t know, and the walk away from evidence-based medicine,” Christopher Thomas, a critical care physician at Louisiana State University Health Sciences Center in Baton Rouge, told us. “And it’s driven by fear and anxiety.”
Critical care itself is just 150 years old. During the Crimean War, Florence Nightingale requested to place the most seriously ill patients closer to the nurses’ station so they could be monitored more carefully. Specialized shock units were used in World War II to provide efficient resuscitation for the large numbers of severely injured soldiers. In 1952, in Copenhagen, the polio epidemic ballooned to 900 patients locally, which forced a medical response that thrust the discipline forward. Some providential and seemingly random connections between folks who met on a transatlantic ship journey led to the development and use of rudimentary ventilators, but there weren’t enough. Through the night and day, hundreds of nurses joined with approximately 1,500 medical and dental students to bag ventilate the tracheostomized polio patients manually. Thus, critical care was born — under conditions that seem eerily reminiscent of the stories we’ve been hearing from Bergamo and New York.
Images of modern critical care from the 1990s show rows of patients, sedated into the Stone Age, unmoving, tethered to ventilators, families nowhere in sight. This was not an accident. Until about 20 years ago, patients were heavily sedated throughout their critical care stay with the dual goals of pain control and amnesia. Clinicians hoped to spare patients the discomfort and memory of the breathing tube and other procedures and — mistakenly — believed that if the patients appeared to be asleep, they would not remember anything of what went on.
But when patients are sedated, they aren’t asleep. For many covid-19 patients, the nightmares of ICU delirium — caused by suspected brain invasion of the coronavirus, immense inflammation throughout the body, toxic effects of over-sedation and new lows of social isolation — are now setting in as a harbinger of ensuing acquired dementia, plus depression and post-traumatic stress disorder.
We already know this isn’t the best practice. In 1996 and 2000, the New England Journal of Medicine published data showing that interrupting sedation and the breathing machine nearly every day in intubated patients shortened the amount of time they spent on ventilators and got patients out of the ICU faster. As a result, daily breaks in sedation and the ventilator, known as “spontaneous awakening and breathing trials” (SATs and SBTs), became standard practice globally. We also learned that delirium itself, a waxing and waning in consciousness that is being seen so commonly in covid-19 patients, is the most robust driver of acquired dementia after the ICU — and that we must select and minimize our sedative meds with this in mind.
That groundbreaking research led to the creation of what’s known as the “A2F safety bundle,” which reminds us how best to care for critically ill patients. The basic tenets are to make sure that our patients have the chance to wake up from sedation each day, unless that proves dangerous. We must assess and manage pain and monitor our patients for delirium daily, in addition to making sure our choice of sedation is the right one, usually avoiding drugs like benzodiazepines, to minimize long-term side effects. The safety bundle emphasizes the importance of early mobility (getting patients up and walking or using in-bed exercises even when they are still on the vent) and engaging families — both of which are challenges in covid-19 patients, since the virus demands that we isolate them. Unfortunately, this guide can’t be completely followed in all covid-19 patients every day. But we must try.
David Janz, director of medical critical care at the University Medical Center in New Orleans, says that these steps were often being lost there early on. “At the beginning of this, we did things that weren’t evidence-based,” he told us. “They were probably not good practices. We would deeply sedate patients who were remarkably hypoxemic [meaning their blood had very low levels of oxygen]. They’d be on deep sedation for days. When we’d extubate them, if and when we’d extubate them, they’d be laying in bed with little to no attention about mobilizing them.” Covid-19 has made doctors much more likely to leave patients on sedation too long to avoid the hypothetical risk that patients might pull out their breathing tubes and the shortages of personal protective equipment that would be required to intubate them again. In truth, this risk is grossly exceeded by the true danger of subjecting people to ongoing sedation and even one extra day on a ventilator. Without spontaneous awakenings and adherence to the A2F bundle, we have repeatedly shown that patients stay an average of two to four extra days immobilized on life support — and die more often. ICU teams have reams of data from famous ICU physicians like JP Kress at the University of Chicago and Dale Needham at Johns Hopkins showing that prolonged immobilization is extremely dangerous for the human body. But, Janz says, “everyone was very scared, and now we are getting back to our basics.”
In a pandemic, everything seems uncertain. There is still so much that we do not know about the coronavirus. But we do know that from years of rigorous research in tens of thousands of patients that the more we comply with our A2Fs, the better our patients do. Our guidelines are perhaps at their most essential in times like these — when we are in the midst of a crisis. No doubt there are heroes with scrubs on in many major cities of the world right now, doing the best they can. But let us not forget the key components of care that we know. They could save us ventilators, sedation — and lives.