Good news from the front lines

This post will attempt to answer the following questions:

1. What’s happening on the front lines?
2. How is the way doctors treat COVID-19 changing?
3. Is it working?

I just completed a week working in the ICU seeing 10-20 critically ill COVID-19 patients a day and aside from being exhausted I am quite encouraged by the progress that is being made both outside and inside the hospital. Since many of you are stuck at home you are probably wondering what’s going on here on the front lines. I must say I am getting a bit tired of hearing any variation of the phrase “the front lines” but that may be because of overuse. Further, if you’re like me, you just can’t take any more of the news media coverage which seems to have devolved from being somewhat informative to being aggravating. I thought I would give you the perspective of one front line ICU doctor after one week of treating this condition on the front lines (now I’m part of the problem). Keep in mind this is just what I saw and what I did during one week at one hospital in Baltimore. Things are probably different elsewhere and many have a different experience. Many also may disagree with my practice and things may change next week so take this all with that grain of salt.

We are not overwhelmed but we are very busy

I work at a hospital that is part of a large system that covers the Baltimore and Washington DC area. The distribution of cases and how sick the patients are has varied from hospital to hospital. Because of the size of the system we have been able to redistribute patients between hospitals to prevent any one hospital from becoming overwhelmed. What that has meant for my daily experience was that we were getting 2-5 patients from outside hospitals transferred here every day. In spite of this we have not had to start converting non critical care units into ICUs yet. We are being kept right at the limits of our capacity before activating our surge plan. This means that I was very very busy but not beyond what I or the hospital can handle using our normal setup.

The curve may be flattening

At least here in Maryland we are seeing a leveling off of new cases and hospital beds although the numbers have not started decreasing. Numbers of hospital beds and deaths reflect infections that happened a couple weeks prior. If these level off it means that interventions from a few weeks before are starting to work. Hopefully we’ll start to see a decrease in new cases soon. The government agencies are looking for two weeks of steadily declining new cases before they feel comfortable that things are really turning around. This is because those who are exposed may not develop symptoms for two weeks (see my post What is Quarantine to understand this further). Once the numbers decline for two weeks it means that people are not getting exposed anymore.

The way we treat COVID-19 respiratory failure has changed dramatically

Even though it feels like a year, just a few short weeks ago, when the pandemic was really ramping up in this country, patients who came in to the hospital with profoundly low oxygen levels were being put on ventilators early in their hospital course. These patients then had prolonged hospitalizations with multiple complications, multiorgan failure and poor outcomes. At the same time reports were coming in from hospitals with large numbers of COVID-19 patients. 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 distress from lack of oxygen. That made physicians question how to care for those with Covid-19. In particular, we have become concerned about the use of intubation and mechanical ventilators.

Anecdotal experience grew of physicians using other forms of support to maintain oxygen levels in the sickest patients. They started using a special oxygen delivery system that can provide oxygen at very high gas flow rates (aptly called high flow oxygen). They also started using CPAP. CPAP stands for continuous positive airway pressure. CPAP provides a continuous flow of air at a constant pressure through a mask that goes over the mouth and nose. This keeps the lungs “open” by preventing small areas of the lungs from collapsing allowing for more delivery of oxygen to the bloodstream. The frequent opening and close of small lung units is also known to worsen lung injury and systemic inflammation. CPAP prevents this process from happening. A rationale for CPAP in COVID 19 can be read here.

The teams employing this strategy had success in many of the patients (another example can be found here). A ventilator can save someone’s life but it can also damage the lungs if not managed carefully. The understanding of how the virus affects the lungs led us to realize that the ventilator itself may be the reason some, or perhaps most, of these patients were doing so poorly.

I used this same strategy last week. I had many patients who were very sick with very poor oxygen levels but we were able to keep them off the ventilators. Aside from not making the patients worse this strategy has many other benefits. First it prevents us from running out of ventilators (although we ran out of high flow oxygen machines at one point). Second, since we weren’t making things worse with the ventilator people were getting out of the ICU faster and we didn’t fill up and activate our emergency surge plan.

This is not to say that mechanical ventilation is not necessary, it just may not be the first step. If you oxygen levels are so low that high flow oxygen and CPAP are inadequate then there is no choice but to be put on the ventilator. Hopefully more research will be done to sort this out. The way things are going this may be different next week (or even tomorrow). An important caveat is that there is an increased risk to staff because CPAP increases aerosolization of the virus so this strategy requires adequate amounts of PPE and negative pressure systems in the patient rooms.

We have recognized and are treating the blood clotting defect caused by the virus

From very early on in the pandemic it was discovered that the body’s response to the virus creates a situation where the normal blood clotting system becomes deranged. This leads to a situation where people aggressively form clots. In one study, almost 1/3 of patients had blood clots. This was an astonishingly high number and in spite of being given prophylactic doses of blood thinners which are usually effective. .If those clots are in the lungs it could dramatically worsen oxygen levels. If they develop in the brain and heart it can be devastating. There were even reports of young people getting strokes unexpectedly.

Because of this we started treating people who are at high risk of clots higher doses of blood thinners. We estimated their risk by a combination of various blood tests and how sick they were otherwise.

Some of us are using steroids

This one is controversial and many (but not all) experts are recommending against this. It is clear that the virus leads to an overly aggressive and unregulated immune response in some people which is likely driving their deterioration. There seems to be a group that has what we call a “biphasic response”. They get sick and then get better or level off for several days before suddenly crashing. This is usually preceded by a spike in markers of inflammation in the blood. Steroid medications have been around forever and are known to inhibit this inflammatory response. In this case this may be beneficial but there are issues.

First, there is research in other viral infections that steroids also potentially inhibit the beneficial part of the immune response and may lead to higher levels of the virus in the blood. Steroids also cause an increased risk of secondary infections in addition to many other side effects. If the sudden clinical worsening and rise in inflammatory markers is from the virus itself steroids may make things worse. Alternatively, the virus could alter the immune response in a way that persists even after the virus is mostly gone. This would mean the virus is mostly gone but the immune system is overactivated. If this is the case steroids would be beneficial by inhibiting an overactive immune response without concerns of increasing viral levels.

I am definitely not alone in using steroids for these patients. I did not pioneer this treatment but even most of my own partners disagree with me. For those of you who are interested in a more detailed understanding of the argument you can check out this publication from the Society of Critical Care Medicine that summaries the data and the argument.

For anecdotal experiences beyond my own these two posts were put on Facebook in the past couple weeks:

• “We floundered for two weeks. Lots of codes, intubations and death. Maybe 15 discharges. We started steroids and discharge 250 patients. Less intubations, less codes. And the ones that ended up on vent, not as serious. CXR/CT Changes = steroids; Hypoxia on admission = steroids; Ambulatory hypoxia = steroids. This completely changed our trajectory. Steroids are a game changer. Hospitalist, SE Michigan – our group is taking care of 700 plus COVID+ patients.”
• “I’m here in New Orleans and we’ve been using it for the last four weeks. We notice a great success once we started using steroids. Do not underestimate this study. This was a game changer in our hospital. We were able to free ventilators and get elderly patient out of the hospital without needing a ventilator. Patients that were obviously crashing quickly, who we had to have end of life talks with, were able to walk out of the hospital. At no point did any of our patient worsen. These patients shed viruses 4 weeks later, with or without steroids. The virus doesn’t kill anybody, it’s the inflammation that does. Let the virus replicate however slow down the inflammation.”

My experience was the same. Early on I was hesitant and went back and forth but as I saw how well people were doing I became more convinced.

Why I’m optimistic

In one week I saw probably about 50 critically ill COVID-19 patients. I used high flow oxygen and then CPAP if they didn’t do well. I put them on steroids and blood thinners at higher doses if they were deteriorating with elevated inflammatory markers. Everyone got better and I did not put anyone on a ventilator. In fact I took four off the ventilator (they were put on in the ER before I met them).

One of the ways that the pandemic is going to end is that we are going to get better at treating patients in the hospital. If we know that we can keep the death rates down and prevent the hospitals from becoming overwhelmed we can tolerate more community spread and do not have to be as strict with our prevention measures. This all can make it easier to hold it together until the vaccine comes and we can try to get back to normal. So cheer up, I am starting to see a light at the end of the tunnel.