• Jon Santiago

Ventilators are life-savers, but questions loom about survival rates

Mass. doctors hopeful they’ll see better outcomes than China and other locations

MASSACHUSETTS LEADERS AND hospitals are scrambling to make sure they have enough ventilators for an expected surge of critically ill coronavirus patients. Meanwhile, the state public health department has issued guidance on how doctors might prioritize who gets the life-support machines if confronted with a shortage. But the focus on ensuring an adequate supply of the critical-care devices comes against the grim backdrop of reports elsewhere that many COVID-19 patients who are put on ventilators don’t survive.

Several small studies from China, where the outbreak began, as well as from reports northern Italy, which has been overrun by coronavirus, and Seattle point to very low survival rates for those on ventilators. In one early study from China, just 19 percent of coronavirus patients on ventilators survived. Some reports from hard-hit areas of Italy have suggested 50 percent survival.

In the US, New York Gov. Andrew Cuomo, who has drawn praise for his steady, yet frank, approach to the crisis, set off alarms last week when he said only 20 percent of those put on ventilators will ever “come off” the machines.

It is a sobering context for the all-out push here to acquire ventilators, but doctors on the front lines in Massachusetts hospitals say they aren’t convinced that the outlook for patients who require breathing life-support machines will turn out to be as bleak as some reports might suggest.

“There’s a lot of numbers out there,” said Jarone Lee, a critical care physician who directs an intensive care unit at Massachusetts General Hospital. “There are some small studies that show a very, very high mortality once you’re on mechanical ventilation. I do worry that the data is not accurate. We’ve been hopeful because we’ve been able to get people off ventilators in many ways sooner than we would have expected from just looking at data from other places.”

Jarone Lee, a critical care physician at Massachusetts General Hospital, with a ventilator in one of the hospital’s ICUs.

Patients on ventilators are sedated and have a tube placed down their throat, through the trachea, and into their lungs. The ventilator takes over their breathing function. For COVID patients, the question becomes whether their condition remains stable and their lungs can recover enough while on the ventilator for them to begin breathing again on their own.

The goal, said Craig Lilly, a critical care and pulmonary physician at UMass Memorial Health Care, “is to give them a chance to heal up.”

COVID patients who require a ventilator generally have developed a particularly aggressive form of pneumonia in which not only air sacs in the lungs are affected but blood vessel cells in the lungs are damaged as well, said Lilly. The lung damage is often so extensive that patients require as long as two weeks on a ventilator — a much longer time than doctors like to have patients connected to the machines. There are risks of infection associated with ventilators, and the longer patients are on them, the harder it can be to successfully wean them off the breathing machines.

Doctors interviewed at Massachusetts hospitals were reluctant to offer a firm number on what they think is a realistic survival rate to expect for coronavirus patients on ventilators.

Nonetheless, Lilly feels confident that UMass Memorial, which had 28 patients in its ICUs with coronavirus earlier this week, will see better results than China or Italy. “In Lombardy, they said it was 50/50,” he said of survival among patients on ventilators in that region of northern Italy.  “And we really feel like our outcomes are probably going to be better than that.”

Still, there is no glossing over the significant mortality associated with going on a ventilator. “There’s a lot of folks who end up on ventilators who probably will not make it off a ventilator, “ said Lee. The biggest factors at play in a patient’s prognosis on a ventilator, Lee and other doctors say, is their underlying health before contracting coronavirus.

“The folks that were healthy, that didn’t have a lot of other organ dysfunction before they went on a ventilator, we generally expect good outcomes for those patients,” said Lilly.

That’s why Jon Santiago, an emergency room physician at Boston Medical Center, the city’s main safety net hospital, is so worried about many of the coronavirus patients he sees.

“A lot of people are coming in with already significant underlying illnesses,” said Santiago, who is also a state representative. “The vast majority of people are poor. They have a whole host of comorbidities. A lot of them are homeless.”

Dr. Jon Santiago gives an update on Twitter on coronavirus cases at Boston Medical Center, where he is an emergency room doctor.

On Thursday, leaders of the state’s Black and Legislative Caucus called on Gov. Charlie Baker to halt implementation of Department of Public Health guidance prioritizing the use of scarce health care resources like ventilators because they say poor residents are likely to score lower based on their higher rates of underlying conditions.

“It is apparent that some severe diseases and conditions may warrant a standard of care protocol,” state Rep. Carlos González of Springfield, the caucus chairman, said in a statement. “However, utilizing points for conditions that we already know are rampant in low-income communities due to historic health disparities is unconscionable.”

Santiago said he’s having a lot of tough conversations about going on ventilators with patients and families when a prognosis seems poor, including a recent case of an older man with COVID-19. “I went to explain to them the risks and benefits and that, given his chronic medical issues, he might not ever be extubated,” he said, referring to removal of the breathing tube. The following day the patient was in the ICU but hadn’t been put on a ventilator.

“One of the saddest things in this whole epidemic is that you’re talking to people and you’re admitting people who will never see their family again — because the hospital’s not accepting visitors,” said Santiago. “You do the best you can, provide the best care you can, and you hope for the best.”

On top of the difficult issues involved with deciding to put patients on ventilators, intubating coronavirus patients is also perhaps the riskiest procedure being done in hospitals in terms of exposing health providers to the virus.

“You’re right in there,” Santiago said of the need to lean in right toward a patient’s mouth to insert the breathing tube. “It’s an intense situation in any circumstance. It’s made more intense by this COVID-19 pandemic because of the virus and the aerosolization of it, which you’re at greatest risk from when you’re intubating someone.”

Also posing a challenge to health providers as they work to ensure an adequate supply of ventilators are all the uncertainties surrounding treatment of a virus that had never been seen five months ago. There are conflicting views, for example, over the issue of whether it’s better to get patients on ventilators sooner or wait longer.

In Germany, which has had very good survival rates among those diagnosed with coronavirus, if patients can be placed on ventilators before they deteriorate, “the chance of survival is much higher,” the head of virology at a leading research hospital in Heidelberg told the New York Times. But some doctors in the US, including at Brigham and Women’s Hospital in Boston, told the health and medicine website STAT this week that they think some COVID-19 patients may be getting ventilators who could be effectively treated with other approaches.

“There’s a lot of discussion in the medical community now about the timing of when to put someone on mechanical ventilation for COVID-19,” said Lee, the MGH critical care doctor. “I think that’s all up in the air in many ways.”

While it’s important to recognize the limitations of what ventilators can do, especially for patients who already have compromising health conditions, Lilly, the UMass Memorial pulmonary and critical care specialist, worries that patients and their families might read too much into early reports from other regions of very poor outcomes on the machines.

Those “could be misleading to patients,” he said. “Patients might not elect aggressive therapy that really have a chance to survive, and that’s a real concern for us.”

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