Early in the pandemic, hospitals were worried about having enough ventilators — since that’s a critical way to treat severe breathing problems that can come with COVID-19.
Over the past few months, some western Massachusetts hospitals have been trying to rely on ventilators less.
To understand this coronavirus learning curve, it's important to understand how respiration works.
When we breathe, we inhale oxygen through the lungs. That oxygen gets distributed to our tissues through our blood cells. We also exhale carbon dioxide, which can be harmful if too much builds up.
"If either those two physiologies are disrupted — and it's life threatening — that's an indication to put someone on a ventilator," said David Serlin, head of Intensive Care at Cooley Dickinson Hospital in Northampton.
As Serlin explained, a ventilator performs those breathing functions until a person’s body is ready to take over again. And that’s often what happens with severe cases of COVID-19.
First, doctors have to figure out when a patient needs the help of a ventilator.
And second?
"We have to also think about when's the safest for the health care providers so that they don't get infected,” he said.
Doctors were concerned that traditional breathing treatments — like high-flow oxygen — would make it more likely staff might inhale the virus, whereas patients on ventilators are not breathing those particles into the air.
"With that concern, the thinking was, the faster you get people on ventilators who may end up needing that anyway, the less risk that can be posed for the health care staff," said doctor Andrew Artenstein, who oversees the pandemic response for Baystate Medical Center in Springfield.
Still, to hook someone up to a ventilator, doctors need to put a tube into their windpipe — called intubation — and that process can expose them to the virus. So Artenstein said intubating someone early, before they're in dire need, allows doctors to be more careful.
"It's like surgery,” he said. “You'd prefer to have elective surgery rather than emergency surgery.”
'An evil snake around my neck'
From the patient perspective, the ventilator can save the life of a person who can’t breathe, but it can also have serious downsides.
"What we've learned about COVID is people on ventilators tend to stay on them for a long time and sometimes they don't do as well," Artenstein said. "Even though you're able to get oxygen in their lungs, there are lots of other complications that can ensue."
Ventilators can lead to other infections, like pneumonia, since people can't naturally cough up mucus while on a ventilator. Also, after a long time sedated, a person loses muscle mass and strength.
"To me, the coronavirus is like an evil snake around my neck," said Joan Braderman, a retired film professor from Northampton.
Braderman, 70, first got severe stomach problems in early March after a trip to New York. Suspecting COVID-19, her doctor sent her to Cooley Dickinson, where she soon developed respiratory problems.
"They just came on really quickly and they were very intense," she said.
Braderman said she was put on a ventilator twice during her 11 days in the ICU. She spent six days afterwards in rehab. Today, she still gets dizzy and lightheaded, easily fatigued, and needs a walker to get around.
"Every day it is a possible disaster," she said. "You just don't know which day is not going to be a disaster."
Debbie Green, 72, was treated for COVID-19 at Holyoke Medical Center – and she remembers a doctor telling her why they would try to keep her off a ventilator.
"She basically said, 'Yeah, once you get onto the ventilator, it's like spinning down the drain,'" Green recalled. "It's like, 'Holy God.'"
'Sort of learning on the fly'
Some studies have shown that a high percentage of COVID-infected people on ventilators die – especially among the elderly, who can have cardiac or kidney failure. But that doesn't mean a ventilator caused those deaths; it's possible the patients were simply the sickest.
What became clear to doctors, according to Artenstein, is if you don’t need a ventilator, it’s better not to be on one.
"[Doctors] started to ask the question, 'Are there ways to avoid using ventilators and still have good outcomes?'" he said.
Western Massachusetts hasn’t seen the surge of COVID-19 cases that had been feared. Neither Baystate nor Cooley ever reported a shortage of ventilators, unlike hospitals in New York or Italy. But they did want to make sure their use of ventilators was judicious.
Doctors started to experiment with alternatives to ventilation — other ways to improve breathing that were also safe for hospital staff. They adjusted the setup for high-flow oxygen, putting surgical masks over patients with a nose-cannula, and encouraged some patients to lay on their stomach as a way to open up the chest wall. Some hospitals also put these patients in rooms with negative air pressure to reduce virus particles in the air.
"Like everywhere, we're sort of learning on the fly," Serlin said. "There was a lot of collaboration among hospitals and a lot of learning. So we weren't waiting six months for the next article to come out."
Debbie Green’s doctors at Holyoke Medical Center never put her on a ventilator. She remembers getting oxygen through her nose, and — after she got home — lying on her stomach. Two months later, she said she still experiences panic, fear and fatigue — plus occasional vertigo and headaches. But she felt like her breathing came back relatively quickly.
"I would say [in] three weeks I was breathing like I normally do," Green said. "So I thought that was marvelous."
Both Baystate and Cooley Dickinson said the percentage of people on ventilators dropped slightly over time, although they couldn’t say by exactly how much.
Neither Artenstein nor Serlin follow patient cases after they leave the hospital, so they don't know whether being on a ventilator has corresponded to better or worse long term outcomes.
But while intensive care COVID-19 cases are now in the single digits at both hospitals, they're glad to have a range of treatment options if caseloads increase again.
