The coronavirus dilemma: Are we using ventilators too much?

Although potentially lifesaving, ventilators have their own inherent risks.

April 21, 2020, 10:18 AM

As hospitals seek innovative solutions to treat the surge of COVID-19 patients with resources running thin, expanding ventilator supply has been central to the conversation.

Research has shown that only a third of patients placed on a ventilator survive the experience. Now, some experts are wondering if ventilators could be contributing to the poor survival rate and whether ventilators are being overused.

Patients with COVID-19 struggle to get sufficient levels of oxygen due to the severe lung damage caused by the virus, according to Dr. Scott Kopec, a pulmonology/critical care physician and former director of the pulmonary and critical care fellowship program at the University of Massachusetts. Kopec explained that lungs can be so severely compromised by COVID-19 that sometimes even a ventilator is not enough help.

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Although potentially lifesaving, ventilators come with their own set of inherent risks, including causing additional damage to the lungs. That poses a challenge to physicians.

To compensate for the severe lung damage in COVID-19, patients sometimes require high levels of oxygen and large amounts of air pressure to be supplied by the ventilator, Kopec said. But these extremely high levels of oxygen can do harm.

"If you force too much pressure in, you can cause damage to the lungs," he said.

COVID-19 patients also typically remain on ventilators for a relatively long time, an average of 10 days, according to a study from University of Washington. Prolonged periods of time on ventilators also introduce the risk of contracting lung infections.

The ventilator's tube carrying air and extra oxygen to the lung can be an entry pathway for germs, which increases the risk of secondary lung infection, according to Jay Bhatt, DO, internal medicine physician and former chief medical officer of the American Hospital Association.

PHOTO: Nurses receive training on using ventilators recently provided by the World Health Organization at the intensive care ward of a hospital allocated for coronavirus patients.
Nurses receive training on using ventilators recently provided by the World Health Organization at the intensive care ward of a hospital allocated for coronavirus patients in preparation for any possible spread of the coronavirus disease (COVID-19), in Sanaa, Yemen April 8, 2020.
Khaled Abdullah/Reuters

Although ventilators pose challenges, physicians find themselves balancing the benefits with the risks so they can help critically ill patients who are no longer able to breathe safely on their own.

"It's a careful balance of maintaining a minimum level of oxygenation with the possible side effects," said Dr. Katherine Fischkoff, surgeon and critical care physician at Columbia University.

These challenges have prompted some physicians and medical groups to publicly question the value of using ventilators early and often among patients with COVID-19.

So are we using ventilators too much? Right now, the answer is complicated.

Some have argued that less invasive ways of supporting breathing may be just as good, and avoid the undesirable complications that come with using a ventilator.

A study of critically ill patients with COVID-19 in Wuhan, China, found that for those in severe respiratory failure, use of a non-invasive method of ventilation, called "high flow nasal cannula," was effective in preventing doctors from needing to use a ventilator on a majority of these patients. High flow nasal cannula is a method of oxygen delivery where a small plastic prong is fitted into each nostril and blows in oxygen at a high flow rate.

Another method, called "helmet non-invasive ventilation," also seems to help avoid the need for a ventilator. Use of this method was seen during the Italian epidemic, but it is not widely used in the United States.

PHOTO: Marcelo Larrosa demonstrates the use of a ventilator powered by a motor modeled after a windshield wiper motor, in Montevideo, Uruguay April 9, 2020.
Marcelo Larrosa demonstrates the use of a ventilator powered by a motor modeled after a windshield wiper motor, in Montevideo, Uruguay April 9, 2020.
Mariana Greif/Reuters

Despite the alternative ways to give a patient extra oxygen, experts agreed that when a patient's lungs start failing and oxygen gets critically low, ventilators are usually the best option available -- sometimes because they are the only option left.

"Believe me, we don't want to use them, but I don't think that there are other good enough options at this time. We're using them as judiciously as we can," said Kopec.

He explained that some non-invasive options run a much higher risk of spreading the virus through tiny droplets in the air, particularly one called "bilevel positive airway pressure" or "BiPAP," which delivers oxygen through a face mask. Because of the increased risk it poses to health care workers, its use is minimized.

Doctors can also help patients by just changing the position of their bodies. One strategy is called "prone positioning," which refers to lying a patient on their stomach to improve their breathing.

"We are managing patients as best as possible with [non-invasive ventilation] ... we are also using prone positioning when feasible," said Dr. Subhash Krishnamoorthy, critical care physician at Columbia University. Ventilators are being used only "when all other available techniques have failed," Krishnamoorthy said.

While a ventilator is often the best or only option left when a patient's oxygen gets critically low, there has been shifting consensus about the right time to put a patient on a ventilator. Early on, multiple studies and guidelines lauded early transition to a ventilator as a "best practice" for COVID-19. However, that opinion has been shifting as physicians learn more about the virus and how it affects the lungs.

Now, some believe that delaying ventilator use may actually be preferred, particularly given the inherent risks that come with ventilator use, such as lung damage and infections. A recently published article in the American Journal of Respiratory and Critical Care Medicine detailed how some patients with COVID-19 don't seem to benefit from a ventilator, even when their blood oxygen levels are low.

Another recent article published in the Journal of the American Medical Association showed similar findings among patients with COVID-19 in Italy.

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Ultimately, using ventilators to help COVID-19 patients whose lungs fail boils down to two important things: using them thoughtfully, and using them correctly.

"The critical care community tries to be really thoughtful about all the lessons that we've learned and how to reduce injury," said Dr. Anthony Massaro, pulmonology/critical care physician and director of the medical intensive care unit at Brigham and Women's Hospital in Boston. "And all of that knowledge and expertise is put into considerations of the right way to use the ventilator."

Nancy A. Anoruo, MD MPH, is an internal medicine resident physician at the University of Massachusetts Medical School, and a contributor to the ABC News Medical Unit. ABC News' Dr. Jay Bhatt contributed to this article.

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