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Doctors Rethink Use of Ventilators for Older Coronavirus Patients

The machines may not increase survival odds — and they can cause problems of their own

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COVID-19 is a health threat to everyone, but it's of particular concern for older adults: 80 percent of all deaths related to COVID-19 have been of people over the age of 65, and they make up almost a third of intensive care unit (ICU) admissions, according to the Centers for Disease Control and Prevention. Some of the most critically ill patients suffer from hypoxia, or severe oxygen shortage, and as a result are hooked up to a machine known as a ventilator to help them breathe.

But research now suggests that even with this method of treatment — which involves sedating and intubating a patient to insert a breathing tube — older COVID-19 patients face dismal survival rates. As a result, some physicians are rethinking this approach. “We know now that not everyone who presents with serious respiratory illness needs an invasive ventilator,” says Lewis Kaplan, M.D., president of the Society of Critical Care Medicine and a general, trauma and critical care surgeon at the Perelman School of Medicine at the University of Pennsylvania.

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A study published this week in The Lancet showed a high mortality rate — described to the media as “horrific” by the study authors — among older patients, particularly those with underlying conditions. The study itself looked at critically ill patients with a median age of 62 who were treated at two New York City hospitals in March and April. Looking at those over age 80 who were put on a ventilator, the authors found that more than 80 percent did not survive. By comparison, no patients under the age of 30 died at the two hospitals, and only a small number in that age group had to be put on ventilators.

In April, another study published in the medical journal JAMA looked at the outcomes of 5,700 patients hospitalized for COVID-19 in the New York area, finding that only 3.3 percent of 1,151 patients who required ventilation had been discharged alive as of April 4, with almost a quarter dying and 72 percent remaining in the hospital. This is a significantly higher death rate than what’s usually seen for patients put on ventilators for other reasons in the past, such as bacterial pneumonia or collapsed lungs.

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This doesn’t prove that the ventilators weren’t needed, experts stress. The machines were used on already seriously ill patients who may very well have died regardless of what treatment they were given. “These are hard studies to tease out because there is no control group,” explains Hassan Khouli, M.D., chair of the Department of Critical Care Medicine at the Cleveland Clinic. While the Cleveland Clinic’s own data has found higher recovery rates among patients placed on noninvasive mechanical ventilation, “those are patients who are more stable to begin with,” he explains. “We wouldn’t expect to get the same results.”

While a ventilator may increase some patients’ survival odds, experts stress that they aren’t curative: They only buy patients time. “They are meant to support and stabilize a patient having trouble breathing so that their body can recover from the underlying illness and damage done to it,” explains Natalie Yip, M.D., assistant professor of clinical medicine in the Division of Pulmonary and Critical Care Medicine at Columbia University Medical Center. One reason older adults often present with a more serious disease that requires ventilation, Yip notes, is a normal age-related decrease in lung function, which health conditions such as high blood pressure can make worse.

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Choosing high-dose oxygen instead of a ventilator

The main reason people with COVID-19 have required ventilators is that they developed a condition known as acute respiratory distress syndrome (ARDS), inflammation in the lungs that makes it extremely difficult to breathe. But there's a specific subgroup of patients known as “happy hypoxics” who may have different needs, says Lauren Ferrante, M.D., a pulmonologist and critical care physician at the Yale School of Medicine. “These are people who show up in the emergency room with terrible oxygen levels, whose X-rays reveal severe pneumonia, but are still able to talk and whose only real complaint is some shortness of breath,” she explains. For these patients, although their vital signs indicate they should be on a ventilator, there's less rush to intubate them, Kaplan adds.

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Instead, doctors now try giving these patients less invasive treatments, such as very high doses of supplemental oxygen, either through a continuous positive airway pressure (CPAP) machine, the same machine used to treat sleep apnea, or through a supercharged oxygen system known as a high-flow nasal cannula (HFNC).

A paper published on April 22 in the journal Academic Emergency Medicine found that when hypoxic patients were given these types of supplemental oxygen and positioned flat on their bellies, only about a quarter ended up requiring ventilation. Kaplan says this approach not only appears to improve patient outcomes, but has also prevented the overuse of ventilators, averting the ventilator shortage physicians had originally feared. One concern among physicians has been that these simpler forms of ventilation release aerosols, or micro-droplets of the virus that can infect health care workers close to the patient. But this is less likely to happen now, as medical professionals become more skilled with these methods and as more hospitals have the appropriate personal protective equipment.

Other potential costs: clots, infection and post-intensive care syndrome

There are other benefits to not rushing to ventilate, particularly for older adults. “When we have to put someone on a ventilator, we also have to sedate them, which carries risks, especially for seniors,” explains Abdul Khan, M.D., a pulmonologist and critical care specialist at Ochsner Medical Center in New Orleans. “Since patients are also lying immobile, they are more at risk of blood clots, and they have a higher chance of developing a secondary infection, such as urinary tract infection from a catheter or even pneumonia, because we can't suction out all your respiratory secretions as well as if you actually coughed them up.”

In addition, it's a long road back to recovery. “If an older adult comes into the ICU in respiratory distress from a winter cold virus, they usually only need a ventilator for a few days; with COVID-19 we are taking two to three weeks,” says Ferrante. “They've lost muscle strength, cognitive function, and may also now have severe anxiety, a triage of conditions that we've dubbed post-intensive care syndrome. Many will require physical and occupational therapy, and will require months before they're back to baseline."

That said, if you or a loved one are hospitalized with COVID-19 and require a ventilator — either because you are not responding to oxygen therapy or you are in such acute distress you are experiencing symptoms such as delirium due to low oxygen to the brain — getting on the machine quickly can increase your odds of survival, stresses Omar Al-Qudsi, M.D., assistant professor of anesthesiology and critical care medicine at the Ohio State University Wexner Medical Center. “A younger, more robust person may be able to tolerate low oxygen levels for longer than someone who is older and weaker,” he says. “There's a very fine balance between not rushing and waiting so long that it further endangers the patient.”

Considering potential treatments, and directives, ahead of time

It's also worth thinking about what kind of care you do want if you end up in the hospital with complications from COVID-19. “If someone is already living with a terminal illness such as cancer, for example, they may not want to be placed on a ventilator,” says Al-Qudsi. If you already have a do-not-resuscitate (DNR) order in place, realize that it is not the same as a do-not-intubate (DNI) order.

"DNR means that if you go into cardiac arrest, you don't want CPR or electrical defibrillation,” explains Al-Qudsi. But DNI goes one step further in stipulating that you don't want to be placed on a ventilator if you go into acute respiratory distress. “These are hard conversations to have, but I'd urge all people over the age of 65 to have these worst-case scenarios in mind, and decide how they would want it handled,” he says. If you do decide you want a DNR or DNI, speak to your health care provider. Keep in mind that if you change your mind, these orders are reversible.

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