Ventilators may be overused

[Horatio Parker]

https://www.statnews.com/2020/04/08/doctors-say-ventilators-overused-for-covid-19/

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.

 

[Jimmy Higgins]

Meanwhile RNs are telling the ventilators to get in line. How about a pizza lunch for the ventilators?

Oh, that type of overused. Nevermind.

 

[repoman]

What is going on with hemeglobin?

 

[Jimmy Higgins]

Man, hindsight can really suck.

 

[repoman]

What is going on with hemeglobin?

https://chemrxiv.org/articles/COVID-19_Disease_ORF8_and_Surface_Glycoprotein_Inhibit_Heme_Metabolism_by_Binding_to_Porphyrin/11938173

Can anyone vet this for even basic plausibility?

If it were true, that would be very bad and hard to counter it seems.

Also, when you are in the hospital and they have that finger clamp that measures pulse and oxygen, is it oxygenated hemeglobin that it measures?

 

[bilby]

What is going on with hemeglobin?

https://chemrxiv.org/articles/COVID-19_Disease_ORF8_and_Surface_Glycoprotein_Inhibit_Heme_Metabolism_by_Binding_to_Porphyrin/11938173

Can anyone vet this for even basic plausibility?

If it were true, that would be very bad and hard to counter it seems.

Also, when you are in the hospital and they have that finger clamp that measures pulse and oxygen, is it oxygenated hemeglobin that it measures?

Yes, pretty much. It measures the saturation percentage of your haemoglobin, known as SpO₂. This is a convenient and usually fairly accurate way to measure oxygen uptake in real time. But it's routine to get an arterial blood gasses test for respiratory patients (at least outside a pandemic emergency) which gives a much more accurate result, but with a delay while the test is done.

The hypothesis discussed in the paper isn't immediately obvious nonsense to me, but I am not an expert in the field (it's been three decades since I studied molecular biology and biochemistry); However it does appear to be very preliminary and not yet well tested by other research teams (which is typical of research during a severe disease outbreak), so it's really too early to say. Published papers at this stage in an outbreak tend to be aimed at exchanging ideas that look promising, so that as many brains as possible are aware of those leads that are out there - with the understanding that some will be dead ends or red herrings.

It might be something, or nothing. If it is something, it's probably important. But it might not be anything. Lots of very smart people will be doing lots of very difficult research under significant time pressure. Some of it will turn out to be crucial. Some will be irrelevant, but will lead to astonishing results in tangentially related areas. And most will turn out to be dead ends, irrelevancies, or total bunk.

If you can tell which is which, then you will save mankind and almost certainly win a Nobel. But you can't - because that's sadly impossible.

And everything about any new pandemic in all of human history was (or is) very bad and hard to counter (with the technology and science of the time). If it wasn't, we would all be back at work by now.

 

[Derec]

Can anyone vet this for even basic plausibility?

First of all, it's spelled hemoglobin.
Second, some of it seems plausible to me (although the coevolution bit seems rather speculative). However, one caveat is that this is based on bioinformatics, i.e. transcribing the genome and computer-modelling how proteins might attach to the heme group and liberate the Fe ion. It's not observing it in real cells (in vivo) nor in a petri dish (in vitro) but purely modelling (in silico). So while interesting, it should be backed up by actual experiments.
Note also that this paper has not been published yet. ChemRxiv is a preprint server.

If it were true, that would be very bad and hard to counter it seems.

Well, most people's immune systems seem to be able to beat the virus before they even reach the lungs. In any case, the more we know about a disease the more avenues we have to fight it. So this paper, if it can be corroborated, is a good thing. The virus is what it is. Our knowledge about it increasing can only be good. One thing it shows a mechanism as to how drugs for seemingly unrelated diseases such as malaria might work.

Also, when you are in the hospital and they have that finger clamp that measures pulse and oxygen, is it oxygenated hemeglobin that it measures?

Yes, it has different absorption compared to non-oxygenated hemoglobin, so the ratio of the two can be measured by shining light through your finger.

 

[southernhybrid]

I just scanned that article. If they are putting people on ventilators with O2 sats of 93, that does sound nuts to me. I've had patients who had sat rates of 88, who were able to breathe fairly normally, although I was usually able to get an order for O2 if the rate was below 90. In fact, if I'm not mistaken, Medicare doesn't even pay for O2 unless the O2 sat is less than 90. The article didn't actually mention exactly why and when it was determined that mechanical ventilation was needed. It could be they were basing the need on symptoms other than simply the O2 sat rate. My nursing background is totally unrelated to this type of care, so I really don't know. Still, it does seem weird to me to base the need for a ventilator simply on the sat rate. It seems to me that they should be looking at a group of symptoms before making the decision to use a ventilator.

Or, it could be that many of these doctors are out of their realm of expertise during this pandemic, so those without the appropriate background are being more aggressive in the care they provide. I realize that during this crisis, doctors and nurses without the appropriate background have been asked to help. Hopefully, they have been given adequate protocols as to how to treat the worst symptoms. If not, they really need more guidance.

 

[Horatio Parker]

I just scanned that article. If they are putting people on ventilators with O2 sats of 93, that does sound nuts to me. I've had patients who had sat rates of 88, who were able to breathe fairly normally, although I was usually able to get an order for O2 if the rate was below 90. In fact, if I'm not mistaken, Medicare doesn't even pay for O2 unless the O2 sat is less than 90. The article didn't actually mention exactly why and when it was determined that mechanical ventilation was needed. It could be they were basing the need on symptoms other than simply the O2 sat rate. My nursing background is totally unrelated to this type of care, so I really don't know. Still, it does seem weird to me to base the need for a ventilator simply on the sat rate. It seems to me that they should be looking at a group of symptoms before making the decision to use a ventilator.

Or, it could be that many of these doctors are out of their realm of expertise during this pandemic, so those without the appropriate background are being more aggressive in the care they provide. I realize that during this crisis, doctors and nurses without the appropriate background have been asked to help. Hopefully, they have been given adequate protocols as to how to treat the worst symptoms. If not, they really need more guidance.

IIRC they are aggressive with ventilation in the hope of arresting the decline.

 

[Loren Pechtel]

I just scanned that article. If they are putting people on ventilators with O2 sats of 93, that does sound nuts to me. I've had patients who had sat rates of 88, who were able to breathe fairly normally, although I was usually able to get an order for O2 if the rate was below 90. In fact, if I'm not mistaken, Medicare doesn't even pay for O2 unless the O2 sat is less than 90. The article didn't actually mention exactly why and when it was determined that mechanical ventilation was needed. It could be they were basing the need on symptoms other than simply the O2 sat rate. My nursing background is totally unrelated to this type of care, so I really don't know. Still, it does seem weird to me to base the need for a ventilator simply on the sat rate. It seems to me that they should be looking at a group of symptoms before making the decision to use a ventilator.

I've measured my O2 sat at below 90 (one of those fingertip units, nothing fancy) and my response was to continue on up the mountain. Next year (maintaining distancing on parts of the trail would be impossible, the alternate, longer, route still hasn't been fully rebuilt from the 2013? fire and requires a high clearance vehicle) I'll have to try it on the highest summit around here and see what it says. A sat below 90 is a symptom, not an actual danger.

 

[4321lynx]

I just scanned that article. If they are putting people on ventilators with O2 sats of 93, that does sound nuts to me. I've had patients who had sat rates of 88, who were able to breathe fairly normally, although I was usually able to get an order for O2 if the rate was below 90. In fact, if I'm not mistaken, Medicare doesn't even pay for O2 unless the O2 sat is less than 90. The article didn't actually mention exactly why and when it was determined that mechanical ventilation was needed. It could be they were basing the need on symptoms other than simply the O2 sat rate. My nursing background is totally unrelated to this type of care, so I really don't know. Still, it does seem weird to me to base the need for a ventilator simply on the sat rate. It seems to me that they should be looking at a group of symptoms before making the decision to use a ventilator.

I've measured my O2 sat at below 90 (one of those fingertip units, nothing fancy) and my response was to continue on up the mountain. Next year (maintaining distancing on parts of the trail would be impossible, the alternate, longer, route still hasn't been fully rebuilt from the 2013? fire and requires a high clearance vehicle) I'll have to try it on the highest summit around here e and see what it says. A sat below 90 is a symptom, not an actual danger.

and here I was (and ? how many others were) imagining you slogging up those mountains on your own two feet !

 

[Loren Pechtel]

I just scanned that article. If they are putting people on ventilators with O2 sats of 93, that does sound nuts to me. I've had patients who had sat rates of 88, who were able to breathe fairly normally, although I was usually able to get an order for O2 if the rate was below 90. In fact, if I'm not mistaken, Medicare doesn't even pay for O2 unless the O2 sat is less than 90. The article didn't actually mention exactly why and when it was determined that mechanical ventilation was needed. It could be they were basing the need on symptoms other than simply the O2 sat rate. My nursing background is totally unrelated to this type of care, so I really don't know. Still, it does seem weird to me to base the need for a ventilator simply on the sat rate. It seems to me that they should be looking at a group of symptoms before making the decision to use a ventilator.

I've measured my O2 sat at below 90 (one of those fingertip units, nothing fancy) and my response was to continue on up the mountain. Next year (maintaining distancing on parts of the trail would be impossible, the alternate, longer, route still hasn't been fully rebuilt from the 2013? fire and requires a high clearance vehicle) I'll have to try it on the highest summit around here e and see what it says. A sat below 90 is a symptom, not an actual danger.

and here I was (and ? how many others were) imagining you slogging up those mountains on your own two feet !

You need a HCV to reach the trailhead. The roads top out at about 8,700' at the ski lodge--and if you want to reach the high parts the highest start location is I believe about 8,300'. (And that route goes near a cliff.) Outside the ski runs I don't think you could get above 9,000 in any motorized vehicle other than a helicopter.

 

[SimpleDon]

and here I was (and ? how many others were) imagining you slogging up those mountains on your own two feet !

You need a HCV to reach the trailhead. The roads top out at about 8,700' at the ski lodge--and if you want to reach the high parts the highest start location is I believe about 8,300'. (And that route goes near a cliff.) Outside the ski runs I don't think you could get above 9,000 in any motorized vehicle other than a helicopter.

Unless you have an "underlying condition" you shouldn't notice a decreased blood oxygen saturation at 8,700 feet, unless you are exercising heavily.

Up to 10,000 feet the FAA doesn't require supplemental oxygen. My airplane, a Lancair 320, had been modified by adding a kit to pressurize the cabin. It maintained an altitude of 8000 feet in the cabin. There was a backup oxygen system that kicked in if the cabin depressurized. The oxygen system was metered to the pressure in the cabin, more oxygen was provided the higher the altitude, the lower the pressure. The regulations allow oxygen to be delivered by cannulas, the single tube with two ports that you put below your nose, up to I think 17,500 ft.

One of the highest point in the US that is accessed by paved roads is outside of Leadville Colorodo, at about 12,000 feet with surrounding peaks over 14,000 feet. Leadville itself is over 10,000 feet and is used for high altitude training by runners, mountain climbers, bicyclists, and of course, mining engineers. Once again, there is a molybdenum and other rare earth mineral mine I have worked in, the Climax mine, the largest underground mine in the world.

This all depends on the individual's body. I was the first choice in my company to work in high altitude mines like in the Andino area of Peru where the altitude was 4300 to 4700 meters, about 14,000 to 15,500 feet, where most of our people would eventually come down with altitude sickness. I am a freak because I have spent so much time at high altitudes or because of DNA I have a lung capacity of more than 7 liters, twice as large as an average adult.

People have climbed Everest without using oxygen but it takes a whole lot of training which you can only get on the mountain.

Ventilators are over used. When I have an infection in my lungs I lay inclined with my head down to let gravity to help me get rid of the congestion by coughing it up. I also use a cough assist machine which is exactly what it says, it alternatively fills my lungs with 50 mm hg air and then sucks the air out with the same force. This combination pulls out the fluid and improves the lung function without using oxygen. Using oxygen is not the best thing to do because it fosters shallow breathing the opposite of what you want. The respiratory people in the hospitals don't like this approach because more than a couple of days of this makes your lungs quite sore, but I use this machine daily to keep the fluid from building up, so I am use to it. Besides, what do you want? To have a little pain or to die, drowning in your own congestion?

I think that they use the ventilators because they are overwhelmed. I used my system in early February when I am sure that I had Covid-19 virus, even in the hospital, but I have two private nurses who know how to do the treatments who provide an around the clock nursing care for me when I am sick and in the hospital. They are both experienced ALS nurses.

 

[Loren Pechtel]

and here I was (and ? how many others were) imagining you slogging up those mountains on your own two feet !

You need a HCV to reach the trailhead. The roads top out at about 8,700' at the ski lodge--and if you want to reach the high parts the highest start location is I believe about 8,300'. (And that route goes near a cliff.) Outside the ski runs I don't think you could get above 9,000 in any motorized vehicle other than a helicopter.

Unless you have an "underlying condition" you shouldn't notice a decreased blood oxygen saturation at 8,700 feet, unless you are exercising heavily.

I'm talking about at 10,500' and up. I said the trailheads top out at 8,700', not that I didn't go well above that. The highest summit around here is 11,916' and I have been there multiple times.

Someone jumped to the conclusion that I was talking about driving up there, I only brought up vehicles in that the one trailhead out there I would consider safe at present requires a HCV to reach.