Head of intensive care unit at Thompson discusses what type of COVID-19 patients wind up in the hospital, why ventilators are not used as much and whether ICUs are prepared to handle the omicron wave of patients
By Chris Motola
Q: The public policy focus with regard to COVID-19 has been laser-focused on the vaccines. But we want to talk to you about treatments for people with COVID-19 who are hospitalized. How has treatment evolved over the last two years?
A: Thankfully, we have a lot more information about COVID. With regard to the far end of the spectrum, the severe and critical illness, it really has a lot to do with a sub-population. A lot of it has to do with the virus strain, but perhaps even more so with the patients and their comorbidities: their age, any other illnesses they may have. The vaccines play a role in how likely someone is to develop critical illness. But different than most pneumonias, COVID takes some time to ramp up. Sometimes with very few symptoms in the beginning and then somewhere between seven to 14 days people very rapidly become extremely ill, with the major issue being oxygenation. So people may be at home with a typical flu-like illness but then suddenly have a lot more respiratory distress. Or, even scarier, not have much respiratory distress, but their oxygen numbers are life-threateningly low.
Q: I take it that’s when many patients come to the hospital?
A: We’ll often see people come into the ER around the start of needing oxygen. And then suddenly on the hospital floor using a couple liters of oxygen—even a healthy individual without existing lung disease. Within a day or two some of them may need the maximum amount of oxygen we can supply through non-invasive means. Over time we’ve learned about different medicines that are helpful. That probably started a little more than a year ago. Some of it is based on general treatments of acute respiratory distress syndrome. There’s also some effort in the early phases to prevent viral replication. There’s been some marginal data on remdesivir. But it hasn’t had strong outcomes, particularly with the critically ill. We also use anti-inflammatories to try to mitigate the immune system’s over-exuberant response to the virus. In some patients, there’s a very strong inflammatory response that goes beyond just controlling the virus and starts damaging the lungs.
Some of the strongest data is around steroids like dexamethasone and there’s been investigation into some others that are used to treat autoimmune diseases. If patients are having rapidly accelerating oxygen problems, we’ll apply these medications to try to prevent progression to respiratory failure and the need for ventilation.
Q: I wanted to touch on that because early on in the pandemic, the ventilator became a symbol of, short of death of course, the worst-case scenario. There were well-publicized ventilator shortages in New York City. We don’t hear about them as much lately. Are we not ventilating as many patients?
A: It’s understanding the illness better. In the initial phase of the pandemic in the spring and summer of 2020, there were a lot of unknowns. There wasn’t the same understanding of how an individual’s illness might progress. Then there was the winter 2020 surge during the north’s viral respiratory season. Now, going back into this year we have staffing and fatigue issues. But you’re right, in the “unknown phase” the rapidly accelerating hours or days of oxygen requirements, it was a matter of understanding the patient’s condition and resource allocation. There are only so many ventilators in an area or hospital. There’s also a complicated transition of getting someone onto a ventilator. You have to put them to sleep with medications that actually stop them from breathing. So you have a limited amount of time to transition them onto the machine. So there’s some danger there. So there’s been a discussion about when to do it and we’ve become more comfortable watching patients’ illness evolve, intervening with treatments and preventing the need for mechanical ventilation. The other side of that is that if a patient is receiving the maximum amount of oxygen with a high-flow nasal cannula that’s pumping 40, 60, 80 liters of oxygen into their lungs—it’s like having your head out the window on I-90, so it’s a massive airflow holding their lungs open—getting them from that onto a ventilator can be very delicate. So to circle back around to your original question, we’re ventilating fewer people now, but the people we’re ventilating are extremely sick.
Q: I’ve heard some pretty wild stories about how low people’s O2 have gone and able to come back from it. Is that a quirk of COVID-19?
A: There are a number of illnesses, other pneumonias, flu, that can create a severe drop in oxygen. What’s unique to COVID is how it can go from something about on par with a typical cold then rapidly—and more frequently—suddenly have that happen. Another unusual aspect is that people can have this severe inflammatory state, but it’s only affecting their lungs. So other organs may be less affected in the initial phases of the illness. The human body is an amazing machine that can compensate. So if your heart, kidneys and muscles are working well, your body can compensate until the wheels come off. Your body can tolerate low oxygen levels for a period of time, but underlying conditions can make it harder to compensate.
Q: How stressed are our ICUs from COVID-19 in your experience?
A: It’s a perfect storm. COVID usually takes about twice as long to treat as typical pneumonia. We’ve got a new variant, omicron, with a lot of unknowns. We’re going into winter in New York. And we were already low on staff in summer, but a lot of hospitals are working with 20%-30% staffing vacancies. FF Thompson has thankfully doing well with physicians, nurse practitioners, physicians assistants, but seeing another surge coming is demoralizing and exhausting. We’re not at our wit’s end, but it’s impressively difficult when all these issues come together.
Q: If you’ve just gotten a COVID-19 diagnosis what can either they, or doctors, do to decrease their chances of needing treatment at a hospital?
A: That’s a great and hard question. There have been a number of studies looking into how to stop progression into hospitalization. There are some more formal medications, which require help from some kind of medical provider, like monoclonal antibody infusions. There are two medications that are in the hands of the FDA, I believe, that are intended to stop progression. As far as things you can do without intervention: make sure you’re maintaining good hydration and nutrition and managing any underlying illnesses you might have. There are some questions about whether vitamin D and zinc help. They certainly don’t hurt; the data is not so clear. And monitor your illness so you know when to get help.
Q: What does recovery generally look like for severe and critical COVID-19 patients? How are they doing months later? Are there many reinfections?
A: There are reinfections, but they’re typically milder. Whether they’re vaccinated or have had previous exposure, most people have developed some degree of protection. That can vary depending on how much disability and damage they may have had from a previous infection. Most patients make a complete recovery in lung function, but there are some who have scarring in their lungs or other organs. Critical patients who have gone through the paralysis we induce for mechanical support can take months to truly recover. It can be a life-changing event. Overall, we’re seeing the survivability of this illness is getting better. Age and underlying functional status affect it, of course. Healthy people who are nevertheless on heavy amounts of oxygen, it can actually be borderline shocking how quickly some of them can come off oxygen. So it’s a very wide range. But we’re trying to be better about critical care recovery and follow-up.
Lifelines
Name: Justin M. Weis, M.D.
Position: Pulmonary critical care physicianl director of the intensive care unit; president of medical staff at FF Thompson. Associate professor of clinical medicine.
Hometown: Musscatine, Iowa
Education: University of Iowa Carver College of Medicine
Affiliations: FF Thompson Hospital; Strong Memorial Hospital; Highland Hospital
Organizations: American Thoracic Society; American College of Chest Physicians
Family: Wife (Emily), son (Jack)
Hobbies: Horseback riding, sailing, outdoor activities