COVID-19 and Ireland – Part 33
~Part 1~
In his inflammatory paper on the covid-19 pandemic, All-Cause Mortality during COVID-19: No Plague and a Likely Signature of Mass Homicide by Government Response, the independent Canadian researcher Denis Rancourt claimed that many of the deaths attributed to SARS-CoV-2 during the pandemic were actually the direct result of government measures taken to curtail the spread of a supposedly deadly virus. In the last article in this series we saw how some jurisdictions tried to free up hospital beds by transferring elderly patients to nursing homes, where many of them subsequently died. But this is not the only policy implicated in Rancourt’s paper. Of the two scientific papers he cites in support of his thesis the second presents statistical proof that mechanical ventilators killed critical COVID-19 patients:
Of the 5700 patients in this study more than one fifth received mechanical ventilation―including 320 who required invasive mechanical ventilation. The outcomes of those who received ventilation were in stark contrast with the outcomes of those who did not:
As of April 4, 2020, for patients requiring mechanical ventilation (n = 1151, 20.2%), 38 (3.3%) were discharged alive, 282 (24.5%) died, and 831 (72.2%) remained in hospital. Mortality rates for those who received mechanical ventilation in the 18-to-65 and older-than-65 age groups were 76.4% and 97.2%, respectively. Mortality rates for those in the 18-to-65 and older-than-65 age groups who did not receive mechanical ventilation were 1.98% and 26.6%, respectively. There were no deaths in the younger-than-18 age group. ―Richardson et al 2056
In the over-65s it seems that being put on a ventilator was almost tantamount to a death sentence: more than 97 out of every 100 died. Note, though, that certain comorbidities were taken into account when deciding whether to ventilate:
Of the patients who died, those with diabetes were more likely to have received invasive mechanical ventilation or care in the ICU compared with those who did not have diabetes ... Of the patients who died, those with hypertension were less likely to have received invasive mechanical ventilation or care in the ICU compared with those without hypertension. ―Richardson et al 2057
The authors also caution against reading too much into the mortality rate of 97.2% among the over-65s who were ventilated:
This study has several limitations. First, the study population only included patients within the New York metropolitan area ... Third, the median postdischarge follow-up time was relatively brief at 4.4 days ... Fifth, clinical outcome data were available for only 46.2% of admitted patients. The absence of data on patients who remained hospitalized at the final study date may have biased the findings, including the high mortality rate of patients who received mechanical ventilation older than age 65 years. ―Richardson et al 2058
In other words, of the 5700 patients in the study the authors only knew how 2634 ultimately fared. 320 of these were ventilated, of whom 282, or 88.1%, died. Notwithstanding the authors’ warnings, these figures are quite alarming. It is unlikely that the remaining 3066 patients included a large number who were ventilated but survived. Why would the two groups have such different outcomes? It is more reasonable to assume that the clinical outcomes of the 3066 patients would have confirmed the statistics observed for the 2634 patients.
At the outset of the pandemic many reports in the mainstream media gave the impression that ventilation was critical in the treatment of covid-19. Health executives around the world scrambled to purchase as many ventilators as they could before the hospitals were overwhelmed by the expected deluge of covid cases. In Ireland the Health Service Executive (HSE) wasted millions of euros of public money on substandard ventilators that were never used:
HSE chiefs have defended the financial risks taken when purchasing ventilators at the outset of the Covid pandemic, insisting patient safety was their top priority. Chief executive Bernard Gloster and chief financial officer Stephen Mulvany acknowledged normal procurement safeguards were set aside in the scramble to secure the medical equipment as coronavirus swept Europe in early 2020. They were facing questions from members of the Oireachtas’s Public Accounts Committee on the multi-million euro costs incurred by the HSE for overpaying for ventilators or buying substandard machines from little known suppliers in China ... between March and April 2020, the HSE placed orders for a total of almost 3,500 ventilators at an agreed purchase cost of €129 million. That was almost twice the number of devices that the HSE had been sanctioned to purchase and was more than 10 times the number of additional ventilators that could be clinically used.
The HSE has said it was necessary to “over order” more ventilators than were required due to the frenzied state of the market and the number of orders that suppliers were cancelling after receiving higher offers ... the HSE received 467 ventilators from the previously unutilised suppliers, 102 of which were deemed substandard after testing. The remaining 365 were subsequently donated to the health authorities in India. ―David Young, Press Association
Bernard Gloster, the Chief Executive Officer of the HSE, blamed the massive overspend on uncertainty:
Recently appointed chief executive Mr Gloster stressed the “unprecedented context”. “The onset of the pandemic in early 2020 was a period of enormous uncertainty and health systems across the world were challenged beyond capability, particularly in the phase of what was not known and what would be needed to respond,” he said. “There was a serious excess in demand in the global healthcare products market with what were then characterised as eBay style bidding wars, normal purchasing and sourcing practices did not apply. Payment in advance was effectively mandatory. Even then with no guarantee that it will secure delivery. “Assessing requirements for volume of products, including ventilators was an impossible task with no realistic predictability models in the early months. The staff involved at the time had to deliberately over order to try and secure necessary volume of supply, knowing that cancelling later and managing the financial risk would be factors that might arise.” ―Young
It has been known for a long time that ventilation can induce secondary infections―including pneumonia and similar lung diseases―by impairing the patient’s normal defenses against infection. The rôle of ventilator-associated pneumonia, or VAP, in the initial stages of the pandemic were investigated by Catherine A Gao, Nikolay S. Markov & Thomas Stoeger of Northwestern University, Chicago:
Unsuccessful treatment of VAP is associated with higher mortality. The relatively long LOS [length of stay in hospital] for patients with COVID-19 was primarily due to prolonged respiratory failure, placing them at higher risk of VAP. ―Gao et al 1
Gao et al’s was just one of several papers widely reported on social media as evidence that ventilators were responsible for nearly all covid-19 deaths during the first wave of the pandemic:
Nearly all COVID-19 patients who died in hospital during the early phase of the pandemic were killed as a direct result of being put on a ventilator, a disturbing new report has concluded. A new analysis suggests that most patients who were forced to be hooked up to a ventilator due to a COVID-19 infection also developed secondary bacterial pneumonia. This pneumonia was responsible for a higher mortality rate than the COVID-19 infection. ―Sean Adl-Tabatabai
This characterization of the situation has been rejected by Benjamin D Singer, one of the co-senior authors of Gao et al’s paper:
The study being referenced found that a secondary pneumonia associated with mechanical ventilation contributes to a patient’s death when it doesn’t respond to treatment. But a study author said that the patients placed on a ventilator would have died without that intervention, and that COVID-19 is still the primary cause of death ... But the headline distorts the facts, a study author told The Associated Press.
“One of the major features that we found that contributes to poor outcomes is if patients develop a secondary pneumonia, meaning a pneumonia that occurs while they’re already on the ventilator for pneumonia,” Singer said. “And specifically, if that secondary pneumonia does not resolve, meaning that despite antibiotics and supportive care, the patient does not resolve their pneumonia.”
In other words, a secondary pneumonia that can’t be treated further contributes to their death. Ventilator-associated pneumonia, as it’s called, is a known issue in the field, and not COVID-19 specific:
“A patient’s lungs aren’t operating normally,” Singer said, “and a tube in the windpipe presents an opening for bacteria. But it’s a mischaracterization to say that the ventilators are responsible for the deaths,” Singer said, likening the circumstances to a patient in a severe car crash who dies despite surgery attempts; it’s the car crash that’s ultimately the cause of death. ―Angelo Fichera, Associated Press
The very same issue of The Journal of Clinical Investigation in which Gao et al’s paper was published also included an article by Sarah Jackson on VAP and the risks of ventilation:
The COVID-19 pandemic resulted in an unprecedented number of patients hospitalized in intensive care units (ICUs) because of severe SARS-CoV-2 infection. Respiratory failure in ICU patients, whether due to respiratory infection or other causes, may necessitate mechanical ventilation if oxygen levels cannot be restored with less invasive devices, such as continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) ventilators. Although ventilators can be life-saving, their use is associated with some risks, including secondary bacterial infections that cause pneumonia. Prior studies have established that patients with SARS-CoV-2 infection on a mechanical ventilator are more likely to have ventilator-associated pneumonia (VAP) compared with other ICU patients, including those with influenza. This increased risk of VAP might occur because SARS-CoV-2 infection induces such profound lung injury compared with other infectious insults. ―Jackson
In 2018 the second edition of The Ventilator Book was published. The author William Owens, MD, is the Director of the Medical Intensive Care Unit at Prisma Health Richland, in Columbia, South Carolina, and a Clinical Associate Professor of Medicine with the University of South Carolina. He is also the author of The ICU Survival Book and The Advanced Ventilator Book:
Acute respiratory failure is one of the most common reasons for admission to the intensive care unit. The majority of cases will require some sort of positive pressure ventilation, either from a mask (CPAP, BiPAP) or an endotracheal tube ... So, let’s say that a patient has a competent drive to breathe but is not quite ready for unassisted breathing. Pressure support ventilation (PSV) allows the patient to breathe spontaneously ... How much PS to provide depends on the patient. Remember, pressure support is a boost. If the patient gets tired, or if his compliance gets worse (pneumonia, pulmonary edema, etc.), he will need more PS. As he gets stronger, the PS can be dialed down. The best way to judge how much PS is necessary is to watch the patient. ―Owens 32 ... 73 ... 74
This is just one of several places in The Ventilator Book where Owens mentions ventilation in connection with the treatment of pneumonia. There is nothing unusual or questionable about using ventilators to treat patients with pneumonia.
Why, then, did so many elderly people die on ventilators in the early stages of the pandemic? Even the mainstream media noted this unexpected phenomenon:
Why Some Doctors Are Moving Away from Ventilators for Virus Patients
Some hospitals have reported unusually high death rates for COVID-19 patients on ventilators, and some doctors worry that the machines could be doing harm.
As health officials around the world push to get more ventilators to treat coronavirus patients, some doctors are moving away from using the breathing machines when they can. The reason: Some hospitals have reported unusually high death rates for coronavirus patients on ventilators, and some doctors worry that the machines could be harming certain patients. The evolving treatments highlight the fact that doctors are still learning the best way to manage a virus that emerged only months ago. They are relying on anecdotal, real-time data amid a crush of patients and shortages of basic supplies. Mechanical ventilators push oxygen into patients whose lungs are failing. Using the machines involves sedating a patient and sticking a tube into the throat. Deaths in such sick patients are common, no matter the reason they need the breathing help.
Generally speaking, 40 percent to 50 percent of patients with severe respiratory distress die while on ventilators, experts say. But 80 percent or more of coronavirus patients placed on the machines in New York City have died, state and city officials say. Higher-than-normal death rates also have been reported elsewhere in the U.S., said Dr. Albert Rizzo, the American Lung Association’s chief medical officer. Similar reports have emerged from China and the United Kingdom. One U.K. report put the figure at 66 percent. A very small study in Wuhan, the Chinese city where the disease first emerged, said 86 percent died. The reason is not clear. It may have to do with what kind of shape the patients were in before they were infected. Or it could be related to how sick they had become by the time they were put on the machines, some experts said.
But some health professionals have wondered whether ventilators might actually make matters worse in certain patients, perhaps by igniting or worsening a harmful immune system reaction. That’s speculation. But experts do say ventilators can be damaging to a patient over time, as high-pressure oxygen is forced into the tiny air sacs in a patient’s lungs. “We know that mechanical ventilation is not benign,” said Dr. Eddy Fan, an expert on respiratory treatment at Toronto General Hospital. “One of the most important findings in the last few decades is that medical ventilation can worsen lung injury―so we have to be careful how we use it.” ―NBC News, Associated Press
It was also speculated that the high mortality rate among ventilated patients may have been caused by a particularly virulent form of VAP:
A new analysis suggests that a high percentage of people who required help from a ventilator due to a COVID-19 infection also developed secondary bacterial pneumonia. This pneumonia was responsible for a higher mortality rate than the COVID-19 infection. So while COVID-19 may have put these patients in the hospital, it was actually an infection brought on by the use of a mechanical ventilator that was more likely to be the cause of death when this infection didn’t respond to treatment. ―David Nield, Science Alert
This is unlikely. What are the odds that a new and virulent strain of bacteria would emerge at precisely the same time as a viral pandemic is declared by the WHO?
Another possible explanation is simply the inappropriate use of ventilators. Doctors were deciding to ventilate patients based on misleading symptoms:
Even as hospitals and governors raise the alarm about a shortage of ventilators, some critical care physicians are questioning the widespread use of the breathing machines for Covid-19 patients, saying that large numbers of patients could instead be treated with less intensive respiratory support.
If the iconoclasts are right, putting coronavirus patients on ventilators could be of little benefit to many and even harmful to some.
What’s driving this reassessment is a baffling observation about Covid-19: Many patients have blood oxygen levels so low they should be dead. But they’re not gasping for air, their hearts aren’t racing, and their brains show no signs of blinking off from lack of oxygen.
That is making critical care physicians suspect that blood levels of oxygen, which for decades have driven decisions about breathing support for patients with pneumonia and acute respiratory distress, might be misleading them about how to care for those with Covid-19. In particular, more and more are concerned about the use of intubation and mechanical ventilators. They argue that more patients could receive simpler, noninvasive respiratory support, such as the breathing masks used in sleep apnea, at least to start with and maybe for the duration of the illness. ―Sharon Begley, STAT
In healthy patients, the oxygen saturation rate is generally between 95 and 100%. If it drops below 93%, this is generally taken as a sign of hypoxia and impending organ damage. But during the pandemic many patients presented with blood-oxygen levels below 70%.
To add to the confusion, a number of later studies have failed to bear out the high mortality associated with ventilated covid patients. Take, for example, Auld et al (2020):
COVID-19 has become one of the leading causes of death worldwide. It is estimated that 15–20% of cases require hospitalization and 3–5% require critical care. While experience with COVID-19 continues to grow, reported mortality rates range from 50–97% in those requiring mechanical ventilation. These are significantly higher than the published mortality rates ranging from 35–46% for patients intubated with H1N1 influenza pneumonia and other causes of acute respiratory distress syndrome (ARDS).
These high mortality rates have raised concerns as to whether invasive mechanical ventilation should be avoided in the context of COVID-19. To help address the growing concern that critical illness, and specifically mechanical ventilation, are associated with a high risk of death, we conducted a retrospective cohort study of critically ill patients with COVID-19 across our academic health system. ―Auld et al 799
The results of this study, however, did not reveal anything unusual about the mortality associated with the ventilation of covid patients:
Our early experience with this large cohort of critically ill patients with COVID-19 demonstrates a mortality rate of 30.9% overall, which is substantially lower than the 50–97% reported in the published literature to date (1–6). Additionally, the 35.7% mortality for the approximately three-quarters of patients in our cohort who required mechanical ventilation is also markedly lower than previous reports. These data indicate that a majority of critically ill patients with COVID-19 can have good clinical outcomes and support the ongoing use of mechanical ventilation for patients with acute respiratory failure. ―Auld et al 800–801
Far from reassuring us, this only rouses further suspicion. If ventilation is not generally associated with higher than normal mortality, then just what was going on in the early months of the pandemic, when several institutions undoubtedly observed a substantially higher-than-normal mortality? The fact that these abnormally high rates were only observed in some hospitals, while in others the mortality was comparable to that associated with influenza, is another troubling feature of this phenomenon.
The most damning claim is that the pressure settings on mechanical ventilators were being consistently set too high during the initial phase of the pandemic, causing lethal stress to the respiratory systems of elderly patients, most of whom had severe comorbidities.
A nurse working on the frontline in New York City says medical staff are killing patients by putting them on ventilators, describing the situation as a “nightmare” and “horror movie” she doesn’t want to be a part of. A woman, identified only as Sara NP, said she was a nurse practitioner not on the front lines but was addressing the issue on behalf of her friend in New York City who is working there ... Sara said her nurse friend had “used the word ‛murder’” to describe the approach being taken by medical staff at some of the hospitals in NYC ...
The nurse, according to Sara, said patients requiring more than six litres of nasal cannula―oxygen delivered through a tube in the nose―are intubated and either ventilated or given a tracheotomy. She said other options, such as a CPAP [continuous positive airway pressure] or BiPAP [non-invasive ventilation], are bypassed for a “closed system”―the ventilator ...
She said the high pressure of the ventilators causes barotrauma or damage to the lungs. ―The Chronicle
Barotrauma is the clinical name for tissue damage caused by pressure differences. But ventilator-induced lung injury is not only caused by excessive pressure:
For many years, physicians believed that ventilator-induced lung injury (VILI) was primarily due to excessive airway pressures ... Over the last two decades, however, research has shown that the major factor behind VILI is volutrauma, or overdistension of alveoli. ―Owens 57
Owens recommends the use of pressure-support ventilation as a recuperative aid, rather than as an emergency measure:
So, let’s say that a patient has a competent drive to breathe but is not quite ready for unassisted breathing. Pressure support ventilation (PSV) allows the patient to breathe spontaneously. In fact, he has no choice―there’s no set rate in PSV. Whether he breathes 4 times a minute or 40, that’s what he gets.
PSV should not be used on patients who are deeply sedated or who are receiving neuromuscular blockade (which is just common sense). It’s not the best mode for patients who are in shock, or who have high metabolic requirements, or who have severe lung injury or ARDS. In those cases, modes like assist-control are better. A/C is also better when the patient’s breathing is, shall we say, unreliable―drug overdoses, status epilepticus, neuromuscular diseases, brainstem strokes, and high cervical spine injuries all can compromise a patient’s ability to ventilate adequately.
Think of PSV as more of a “recovery mode.” Once the worst of the initial illness or injury is over, and once the patient shows that he’s able to maintain his own ventilation with a little help from the ventilator, consider using pressure support. ―Owens 73
During the initial stages of the covid pandemic elderly patients, it seems, were being put on ventilators routinely. The ventilator was being used as the first line of defence. Most of these patients had ARDS (acute respiratory distress syndrome), and therefore PSV should not have been used.
We have not yet received a satisfactory explanation of the higher-than-normal mortality among patients ventilated during the early part pandemic. Nor do we know why mortality among ventilated patients subsequently returned to normal levels. Nor has it been explained how patients could present to hospitals with blood-oxygen levels as low as 70%, or lower, while displaying no signs of distress. This is hardly a satisfactory situation.
Were ventilator pressures being set at levels too high for the majority of patients, who were elderly and usually had serious comorbidities? And if they were, was this the result of incompetence―A Knowledge Gap in Mechanical Ventilation―or was it a deliberate policy? More than three years have now elapsed since the first wave of the pandemic and no one seems to be interested in answering these questions. Why are there no official inquiries?
And that’s a good place to stop.
