• Richard Cree

Wishful Thinking

Updated: May 9, 2020

Sunday 3rd May 2020

COVID Figures for 2nd May

UK Deaths 621 / Total 28,131

James Cook Hospital – Total deaths – 189

All cases within South Tees Hospitals Trust - 72

James Cook Critical Care COVID cases – 12 / 5 ventilated

James Cook Critical Care non-COVID cases – 29 / 11 ventilated

Nicky is at work on one of the COVID ICUs today. We have a few more COVID patients than yesterday but some of these are re-admissions. These are people who have made an initial recovery, been discharged to the ward and then have worsened requiring them to return to Critical Care.

These patients usually have a number of things in common. They have not required intubation and ventilation but have managed on high flow oxygen systems (as endorsed by the Prime Minister recently) or Continuous Positive Airways Pressure (CPAP). This has meant they have recovered quickly from their COVID pneumonitis and have often been ready to return to the ward within a short period of time.

Unfortunately what seems to be happening is that they are then developing secondary bacterial infections, the sort that people get when recovering in hospital and deteriorate quickly. We have seen that it is taking some time for lung function to start to return to anywhere near normal in post-COVID patients and so a secondary infection is in effect, kicking them when they are already down.

Of course, not every patient is leaving the ICU before this happens. Nicky has been reviewing the same patients that I have been looking after last week. This is very convenient as it means we can hand over patients to each other and discuss the more complex cases – who said life wasn’t fun in the Cree household?

We have both been looking after a gentleman in his 60’s who had been doing very well on CPAP but is now starting to worry us. I have mentioned before that in contrast to other straightforward cases of respiratory failure, the COVID patients are spending a long time on CPAP. Normally this would worry us, as CPAP for more than a few days is often a sign that the patient needs ventilation. With the COVID patients we are finding that if we hold our nerve (and they hold theirs) they can remain on CPAP for more than a week and still recover.

This is a marked change from what was initially advised by Chinese and Italian ICU physicians who advocated early intubation and ventilation. We are now often doing exactly the opposite. They are many of us who believe that ventilating the patient earlier than is absolutely necessary is a bad thing. There is a very high mortality amongst ventilated patients and we suspect that the process of ventilation in COVID patients causes harm.

This is perhaps not surprising as we know that positive pressure via a ventilator causes inflammatory change in the lung. This is worse when higher pressures and higher oxygen concentrations are used, as is often the case in COVID pneumonitis. Under normal circumstances we breathe in using negative pressure to expand the lungs, the exact opposite of a ventilator, so stretching and over-distension of the alveoli in the lungs due to positive pressure is abnormal.

So back to our patient who had been doing well. His oxygen and CPAP requirement and his chest x-ray had been improving until two days ago when he developed a fever. We suspect he is developing a secondary infection but would like a little more evidence before we start antibiotics. If we use antibiotics when we don’t need to, we encourage the emergence of resistant bacteria, something we already have a problem with.

The other possibility is that he, like many of our patients has developed a pulmonary embolus, or a blood clot in his lungs. We are not able to transfer him for a CT scan to confirm this. Moving him in his current condition and getting him to lie flat would tip his breathing over the edge and require us to ventilate him; something we are keen to avoid for the reasons I’ve given above. Given how many of our COVID patients do have pulmonary emboli we have started him on heparin to thin his blood and help prevent further blood clots despite definitive proof.

There is still a chance that the patients like this will require intubation and ventilation but it is important to realise that this does not mean that leaving them on CPAP for the previous 1-2 weeks was necessarily a mistake.

This brings us to our second patient, a lady with COVID pneumonitis who is now doing really well. She managed 12 days on CPAP before worsening and requiring intubation and ventilation. Looking back, there has been a tendency amongst some of my colleagues to see the time she spent on CPAP as unnecessary or even harmful but I disagree. Looking closely, it would appear that her later deterioration was due to a bacterial chest infection rather than a worsening of her COVID disease. She was started on antibiotics and despite being horribly unwell, improved dramatically after a few days and is now waking up.

I have offered the suggestion that had we intubated and ventilated her initially, she may never have survived to develop the subsequent bacterial infection at all. CPAP may well have saved her life after all, we just will never know it.

I am aware that this could be seen as fanciful, silver-lining, wishful thinking but I shall be keeping an eye out for similar cases. And anyway, what’s so wrong with a bit of optimism every now and then?

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