One of the most interesting parts of this press release, following it on other boards, is the immediate "We already do that. Nothing new here."
That kind of reply would immediately lead me to think it was just a useless release, but then I see people posting comments along the lines of "No, we don't do that. In fact, we have a policy against doing that because of the danger of aerosolization"
For my hacker/systems wonks, this a great example of group learning happening world wide. I imagine there are many ICUs that do this, and many that forbid it. In such an environment, releases like this aren't submarines or spam; they're recurring prompts to administrators elsewhere that they might be missing something important.
I hate to sound cold, but damn this is an interesting example of how organizations learn. One commenter asked "I wonder how many of those hospitals who forbid intubation are doing it to patients with good insurance"
For the record, as far as I know this is a horrible thing to suggest. But the overall point, that large organizations have incentives that are many times removed from the actual work being done, is a good one.
This kind of conversation facilitation across borders is what the internet was supposed to be doing. I think this is the first time I've seen it working the way we had hoped. What's especially interesting to me is that many of the signals we look for in social forums, like "this is just a spam press release", "nothing new to see", or "there's some ulterior motivation here" voting up or down, etc., are actually counter-indicators and inhibitors of overall progress.
It's seminal. Having read a lot of process and innovation books in 90s and aughts, I really wish I had known to just start with the original text.
Knowledge sharing takes time. We know how to model it. This book (and others) helped me to calm down and try to hasten the process instead of wasting my energy railing and failing.
One of the most active figures in this debate has been a New York doctor named Cameron Kyle-Sidell. He frequently posts interesting sources on Twitter:
Yes, rather absurdly, I learned about him like a month ago on ZeroHedge when they started following him; he was brushed off for weeks, his message being, "Look at patient behavior, this is not actually ARDS, our ventilator strategy is probably wrong."
Crazy to think that so many doctors around the world, experts, and policy makers didn't really question the fundamental nature of the disease, and perhaps telling that it took an ER doctor in NYC posting on youtube for a month to bring it proper attention.
I don't doubt that this works well but there is a good reason that other hospitals are not using this approach. As the article mentions:
"This approach is not without risk, however. HFNCs blow air out, and convert the COVID-19 virus into a fine spray in the air. To protect themselves from the virus, staff must have proper personal protective equipment (PPE), negative pressure patient rooms, and anterooms, which are rooms in front of the patient rooms where staff can change in and out of their safety gear to avoid contaminating others."
"UChicago Medicine’s Emergency Department recently doubled its number of anterooms, thereby doubling its capacity to give ?high-flow nasal cannula to patients. The main hospital also added negative pressure rooms on two floors, making it safer and easier to take care of COVID-19 patients."
Not all hospitals have the ability to double the number of negative pressure rooms or even provide needed PPE to all caregivers.
A ventilator on the other hand allows for a HEPA filter in-line that prevents the spread of the disease within the hospital.
The article mentions 40% O2 sat to 80 or 90%; aren't the latter still really low? I'm certainly no doctor, but wikipedia[1] claims "Prolonged hypoxia induces neuronal cell death via apoptosis, resulting in a hypoxic brain injury" and suggests that 80-85% is considered severe and 86-90% moderate.
Granted, both are a hell of a lot better than 40%!
It adds, "Mild and moderate cerebral hypoxia generally has no impact beyond the episode of hypoxia; on the other hand, the outcome of severe cerebral hypoxia will depend on the success of damage control, amount of brain tissue deprived of oxygen, and the speed with which oxygen was restored."
So I guess my questions are:
* How does this stack up against an intubated ventilator, assuming one is available?
* My understanding is the patients needing respiratory support are often on ventilation for 1-2 weeks; how much damage would one expect from having severe hypoxia for that duration?
Being on a ventilator is traumatic. So much so that they generally put you under. Can you imagine waking up with a tube through your mouth and down your throat forcing you to breathe? It happens and people panic and have to be restrained. People get PTSD.
> The article mentions 40% O2 sat to 80 or 90%; aren't the latter still really low? I'm certainly no doctor, but wikipedia[1] claims "Prolonged hypoxia induces neuronal cell death via apoptosis, resulting in a hypoxic brain injury" and suggests that 80-85% is considered severe and 86-90% moderate.
Yeah, unfortunately I can't find it now, but I remember reading a "what the fuck is going on, these patients should be dead!" statement from a doctor a week or two ago about exactly that.
I wonder how they decide which patients would get the cannula instead of a ventilator?
Otherwise, intubation w/ a ventilator generally requires some form of sedation-- I wonder if that sedation has an impact on the body's ability to fight back.
From what I've read here and elsewhere, they're putting everyone they would normally put on a vent on high flow. They only move to the vent when not doing so in the near term would likely result in death. That means, among other things, that they tolerate lower SpO2 levels than they would otherwise.
First-- and I'm sure you weren't suggesting this, but I feel I need to mention-- it's extremely dangerous to pressurize a person's lungs above the surrounding environment[1]. Not to mention that pressurizing the inside of the throat could pressurize the middle ear and blow out your eardrums.
Second, I'm not a physician, I'm a physicist. What follows is for curiosity's sake.
I suspect that the goal is to maximally enrich the patient's airstream in oxygen, whenever it is that they happen to breathe in. In a patient with fluid-filled alveoli, the surface area available for diffusion of oxygen into the bloodstream is greatly diminished. Additionally, the distance that oxygen needs to diffuse before it reaches hemoglobin is increased: rather than just the lining of alveoli and capillaries, it has to first dissolve into the fluid gunk filling the space, then diffuse through the fluid, then pass through the lining of the alveolus and capillary. To top it off, water doesn't have great solubility for oxygen, and atmospheric air is mostly nitrogen anyways.
Each of these passive transport phenomena occurs at a rate that depends on the gradient (roughly...) of available O2. This concentration is greatest in the air, and lowest in the bloodstream adjacent to the alveoli, where hemoglobin binds up oxygen. One way to increase the rate of dissolution and diffusion is to increase the concentration gradient. That means enriching the airstream in O2.
The main problem with CPAP in a clinical setting is that it's not sealed and filtered like a proper ventilator, so it aerosolizes and disperses virus at high pressure. It's the same concern that they mention in this article about dispersal and the need for negative pressure rooms and more PPE. It's being used on some patients who aren't bad enough to require intubation.
Sounds like a promising strategy to manage patients, assuming the hospital has the necessary negative pressure rooms, etc. Especially since ventilators don’t even seem to be very effective. We’ve been seeing stories last few days that the large majority (88%) of folks put on ventilators in NYC, end up dying.
Be careful with that number. It's 88% of the cases that had resolved after ~4.5-5 days, which was only 25% of the cases included in the study.
If there is some bias in the study population, the overall rate can change quite a lot (for example, a possibility is that the weakest patients succumb in that period, with stronger patients coming off the ventilators after a longer period...).
That 88% number is pretty misleading. They only looked at: (number of patients who died) / (number of patients who died + number of patients discharged alive). And didn't consider the other patients on ventilators who are still alive, but still in the hospital (many likely no longer on ventilators).
Don't get me wrong, the fatality rate for intubated patients is going to be high. but probably more like 40-60%.
Hospitals are losing money on covid patients, and the more treatment they require (ICU, ventilator, medication), the more the hospital is losing. They do get paid about three times more for an intubated patient, but they lose more money too.
Hospitals make their profit off voluntary procedures like shoulder and knee surgeries and the constant flow of voluntary tests and procedures ("I just want to get this checked out"). They lose a lot of money when people spend three weeks in the ICU.
This is especially true when a huge percentage of the patients are Medicare or completely uninsured. Privately insured patients with good policies are better, but they still aren't getting rich off those people.
I have no sympathy for the hospital systems or the entire medical industry that has created a massive bureaucracy full of perverse incentives, exploitation, overbilling, and accounting games, but in this particular situation, even with the massive federal handouts, they're not making bank.
I'm an intensivist based in Sweden. From my perspective there is absolutely nothing new in this article. We have been using HFC for years if not decades.
As I understand it, what's new is that it's being used under these circumstances. The ARDS algorithm would have these patients be intubated. Instead, they're putting these patients on HFC and letting them get hypoxic, reasoning that the mixture of damage caused by the infection and the vent is what's fatal.
Edit: Also, people have been avoiding HFC for COVID-19 because of aerosolization risks.
Our* guidance has been HFNC only in negative pressure rooms because of the aersolization risk.
We've converted a huge number of beds to negative pressure in order to maximize use of HFNC. Anecdotally, I feel like it works, but would be great to see a trial.
With treatment so simple, we have effectively removed the healthcare system as a bottleneck on the rest of society.
I think we can safely reopen fully now and treat any serious cases using our existing healthcare systems in combination with this kind of new knowledge.
The longer we 'suppress the curve', when we are already far below hospital system capacity, the more economic and social damage we cause unnecessarily.
Even if we open up legally, people aren’t going to take risks that can put them in a hospital on oxygen for weeks. It’s not a pleasant experience, ventilator or not. Restaurants will not be full, conferences will still be cancelled, etc.
I’d be curious to hear counterpoints. I could be wrong. It does anyone think this will go away with a long enough lockdown? Or is there any solution other than herd immunity?
[+] [-] DanielBMarkham|5 years ago|reply
That kind of reply would immediately lead me to think it was just a useless release, but then I see people posting comments along the lines of "No, we don't do that. In fact, we have a policy against doing that because of the danger of aerosolization"
For my hacker/systems wonks, this a great example of group learning happening world wide. I imagine there are many ICUs that do this, and many that forbid it. In such an environment, releases like this aren't submarines or spam; they're recurring prompts to administrators elsewhere that they might be missing something important.
I hate to sound cold, but damn this is an interesting example of how organizations learn. One commenter asked "I wonder how many of those hospitals who forbid intubation are doing it to patients with good insurance"
For the record, as far as I know this is a horrible thing to suggest. But the overall point, that large organizations have incentives that are many times removed from the actual work being done, is a good one.
This kind of conversation facilitation across borders is what the internet was supposed to be doing. I think this is the first time I've seen it working the way we had hoped. What's especially interesting to me is that many of the signals we look for in social forums, like "this is just a spam press release", "nothing new to see", or "there's some ulterior motivation here" voting up or down, etc., are actually counter-indicators and inhibitors of overall progress.
[+] [-] specialist|5 years ago|reply
Highest recommendation for Everett Rogers' Diffusion of Innovation, first published in 1963, 5th edition in 2003.
https://en.wikipedia.org/wiki/Diffusion_of_innovations
It's seminal. Having read a lot of process and innovation books in 90s and aughts, I really wish I had known to just start with the original text.
Knowledge sharing takes time. We know how to model it. This book (and others) helped me to calm down and try to hasten the process instead of wasting my energy railing and failing.
[+] [-] joshgel|5 years ago|reply
[+] [-] christkv|5 years ago|reply
[+] [-] theobeers|5 years ago|reply
https://twitter.com/cameronks
[+] [-] not_a_moth|5 years ago|reply
Crazy to think that so many doctors around the world, experts, and policy makers didn't really question the fundamental nature of the disease, and perhaps telling that it took an ER doctor in NYC posting on youtube for a month to bring it proper attention.
[+] [-] 9oliYQjP|5 years ago|reply
https://youtu.be/Fz2gyhto-iI?t=767
[+] [-] allisterb|5 years ago|reply
[+] [-] nerdponx|5 years ago|reply
[+] [-] reticular|5 years ago|reply
"This approach is not without risk, however. HFNCs blow air out, and convert the COVID-19 virus into a fine spray in the air. To protect themselves from the virus, staff must have proper personal protective equipment (PPE), negative pressure patient rooms, and anterooms, which are rooms in front of the patient rooms where staff can change in and out of their safety gear to avoid contaminating others."
"UChicago Medicine’s Emergency Department recently doubled its number of anterooms, thereby doubling its capacity to give ?high-flow nasal cannula to patients. The main hospital also added negative pressure rooms on two floors, making it safer and easier to take care of COVID-19 patients."
Not all hospitals have the ability to double the number of negative pressure rooms or even provide needed PPE to all caregivers.
A ventilator on the other hand allows for a HEPA filter in-line that prevents the spread of the disease within the hospital.
[+] [-] firasd|5 years ago|reply
"The respiratory distress appears to include an important vascular insult that potentially mandates a different treatment approach than customarily applied for ARDS." https://twitter.com/jama_current/status/1253722428053823492
[+] [-] loeg|5 years ago|reply
Granted, both are a hell of a lot better than 40%!
It adds, "Mild and moderate cerebral hypoxia generally has no impact beyond the episode of hypoxia; on the other hand, the outcome of severe cerebral hypoxia will depend on the success of damage control, amount of brain tissue deprived of oxygen, and the speed with which oxygen was restored."
So I guess my questions are:
* How does this stack up against an intubated ventilator, assuming one is available?
* My understanding is the patients needing respiratory support are often on ventilation for 1-2 weeks; how much damage would one expect from having severe hypoxia for that duration?
[1]: https://en.wikipedia.org/wiki/Cerebral_hypoxia
[+] [-] tomohawk|5 years ago|reply
https://www.hopkinsmedicine.org/news/media/releases/ptsd_com...
If you can get the O2 up to a livable level without a ventilator so that the patient is supported enough to get well, that that is a good outcome.
[+] [-] Izkata|5 years ago|reply
Yeah, unfortunately I can't find it now, but I remember reading a "what the fuck is going on, these patients should be dead!" statement from a doctor a week or two ago about exactly that.
[+] [-] ineedasername|5 years ago|reply
Otherwise, intubation w/ a ventilator generally requires some form of sedation-- I wonder if that sedation has an impact on the body's ability to fight back.
[+] [-] Izkata|5 years ago|reply
More and more it's starting to look to me like we have two different novel viruses going around.
[+] [-] wl|5 years ago|reply
[+] [-] DenisM|5 years ago|reply
[+] [-] piannucci|5 years ago|reply
Second, I'm not a physician, I'm a physicist. What follows is for curiosity's sake.
I suspect that the goal is to maximally enrich the patient's airstream in oxygen, whenever it is that they happen to breathe in. In a patient with fluid-filled alveoli, the surface area available for diffusion of oxygen into the bloodstream is greatly diminished. Additionally, the distance that oxygen needs to diffuse before it reaches hemoglobin is increased: rather than just the lining of alveoli and capillaries, it has to first dissolve into the fluid gunk filling the space, then diffuse through the fluid, then pass through the lining of the alveolus and capillary. To top it off, water doesn't have great solubility for oxygen, and atmospheric air is mostly nitrogen anyways.
Each of these passive transport phenomena occurs at a rate that depends on the gradient (roughly...) of available O2. This concentration is greatest in the air, and lowest in the bloodstream adjacent to the alveoli, where hemoglobin binds up oxygen. One way to increase the rate of dissolution and diffusion is to increase the concentration gradient. That means enriching the airstream in O2.
[1] https://en.wikipedia.org/wiki/Barotrauma#Pulmonary_barotraum...
[+] [-] caymanjim|5 years ago|reply
[+] [-] 40four|5 years ago|reply
[+] [-] maxerickson|5 years ago|reply
If there is some bias in the study population, the overall rate can change quite a lot (for example, a possibility is that the weakest patients succumb in that period, with stronger patients coming off the ventilators after a longer period...).
[+] [-] joshgel|5 years ago|reply
Don't get me wrong, the fatality rate for intubated patients is going to be high. but probably more like 40-60%.
[+] [-] W_G_T|5 years ago|reply
[+] [-] mrfusion|5 years ago|reply
[+] [-] caymanjim|5 years ago|reply
Hospitals make their profit off voluntary procedures like shoulder and knee surgeries and the constant flow of voluntary tests and procedures ("I just want to get this checked out"). They lose a lot of money when people spend three weeks in the ICU.
This is especially true when a huge percentage of the patients are Medicare or completely uninsured. Privately insured patients with good policies are better, but they still aren't getting rich off those people.
I have no sympathy for the hospital systems or the entire medical industry that has created a massive bureaucracy full of perverse incentives, exploitation, overbilling, and accounting games, but in this particular situation, even with the massive federal handouts, they're not making bank.
[+] [-] ceejayoz|5 years ago|reply
[+] [-] unknown|5 years ago|reply
[deleted]
[+] [-] bobowzki|5 years ago|reply
[+] [-] wl|5 years ago|reply
Edit: Also, people have been avoiding HFC for COVID-19 because of aerosolization risks.
[+] [-] joshgel|5 years ago|reply
We've converted a huge number of beds to negative pressure in order to maximize use of HFNC. Anecdotally, I feel like it works, but would be great to see a trial.
*major nyc health system
[+] [-] ceejayoz|5 years ago|reply
[+] [-] forgetcolor|5 years ago|reply
[+] [-] grizzles|5 years ago|reply
[+] [-] agumonkey|5 years ago|reply
[+] [-] IlyaMoroshkin|5 years ago|reply
I think we can safely reopen fully now and treat any serious cases using our existing healthcare systems in combination with this kind of new knowledge.
The longer we 'suppress the curve', when we are already far below hospital system capacity, the more economic and social damage we cause unnecessarily.
[+] [-] atombender|5 years ago|reply
Secondly, developing respiratory distress and requiring intubation is just one of several possible outcomes.
For example, it appears that strokes due to blood clots appear to be a significant risk with COVID-19 [1].
[1] https://www.washingtonpost.com/health/2020/04/24/strokes-cor...
[+] [-] sp332|5 years ago|reply
[+] [-] empath75|5 years ago|reply
[+] [-] mrfusion|5 years ago|reply
https://thehill.com/opinion/healthcare/494034-the-data-are-i...
I’d be curious to hear counterpoints. I could be wrong. It does anyone think this will go away with a long enough lockdown? Or is there any solution other than herd immunity?