Written by Physician’s Weekly Blogger, Skeptical Scalpel
Although at the time I wrote this over 33,000 people had died from COVID 19 infections worldwide, the numbers of patients dying in intensive care units and on mechanical ventilation is unknown.
We have some early published data on percentages which vary widely. A paper from China involved 710 Covid-19 patients; 52 were admitted to an ICU. Of the 22 who eventually required mechanical ventilation, 19 (86%) died. Another early study reported 31 of 32 (97%) mechanically ventilated patients died.
Medical ventilators awaiting use
I posed the following question on Twitter: “What is the mortality rate for [COVID-19] patients who require mechanical ventilation?” and received answers ranging from 25% to 70% from people who have personal knowledge of outcomes in their hospitals.
Probably the best published information we have so far is from the Intensive Care National Audit and Research Center (ICNARC) in the UK. Of 165 patients admitted to ICUs, 79 (48%) died. Of the 98 patients who received advanced respiratory support—defined as invasive ventilation, BPAP or CPAP via endotracheal tube, or tracheostomy, or extracorporeal respiratory support—66% died.
Compare that to the 36% mortality rate of non-COVID patients receiving advanced respiratory support reported to ICNARC from 2017 to 2019.
An article in The Guardian said this about the ICNARC study, “The high death rate raises questions about how effective critical care will be in saving the lives of people struck down by the disease.”
We know nothing about the survival rate of COVID-19 patients who have undergone cardiopulmonary resuscitation.
Why do we need to know the mortality rate of patients who are on mechanical ventilation or suffer cardiac arrest?
If the number of critically ill patients exceeds the current supply of intensive care beds and ventilators as occurred in Italy, it would help intensivists to triage. And if CPR is ineffective in these patients, we should not be subjecting caregivers to the risks involved in resuscitation.
The possible need for ventilator triage is no longer theoretical, and the ethical issues are being discussed by hospital committees and others. For an in-depth look at the problem, I recommend this article from Undark, a non-profit digital magazine. If we run out of ventilators, “American medical teams, too, will soon face the hardest possible decisions over who lives, and who dies, when not everyone can be treated.”
Hospitals need to have policies in place before that crisis occurs.
Thanks to everyone on Twitter who contributed to the discussion. Stay safe.
Skeptical Scalpel is a retired surgeon and was a surgical department chair and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times.For the last 9 years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 3,700,000 page views, and he has over 21,000 followers on Twitter.
SkepticalScalpel
Protocols say not to treat for CAP empirically with antibiotocs. No steroids either. And no nebulizer. So whats’s left? O2 then mechanical vent. or bipap. They assume the pneumonia is not bacterial why? 50-75% of covid is asymptomatic so there is zero reason to believe that these patients do not have CAP with secondary asymptomatic Covid. Treat them as such.
In my large district general hospital, NON of the ventilated patients has so far survived. Medical and nursing staff on ITU feel very sad and almost clinically depressed. I feel for them.
In covid19 treatment, if reaching the stage which necessitates the use of the ventilator is 80% fatal, we should concentrate on treatments that avoid reaching that stage.
Each day, I read anecdotes of hospitals shifting toward less extreme methods of treating Covid-19 patients in the later stages of the disease (when blood oxygen levels have fallen into the 70s and below). This includes putting patients on their stomachs instead of their backs and using cannulas and CPAP masks instead of ventilators and induced comas. Is there any data on the mortality rate of very sick patients who were not put on ventilators?
Hello,
I am not in the medical field and I do not have a lot of experience with a family member being in the ICU or having Covid-19. In wanting answers about my dad’s condition, because I’m getting VERY little info from the VA he’s in, I stumbled across this page and it seems that you’re giving a fair amount of realistic info about mortality and I appreciate that I have found this page.
I have many questions, and I know this is not a substitute for his actual medical doctor’s advice but again I’ve only been able to speak to nurses who have only been able to give me his current stats and beyond that, they said I should talk to the doctor, whom I cannot get in touch with.
My dad is 75, history of embolisms in legs and lung. Has been stable and controlled after surgeries to get those under control. Has cardiac history (unknown diagnosis) but high bp which is also being controlled with medications. He is considered obese (bmi 40).
He was admitted to the VA on Friday last week with mild chest pain and severe gastro issues (vomiting and diahrea). No temp. They did a CT to rule out the possibility of embolism and it came back as unchanged from previous CT’s. Because his stats and O2 were stable, they sent him home, despite a diagnosis of viral pneumonia on Sunday (this past weekend). He was swabbed upon admission and his results came back positive for covid19 on wednesday afternoon. Between sunday and Wednesday this week, he continued to experience severe gastric distress, sore throat, not eating, severe dehydration, and breathing issues to the point that he need to be transported to the VA via ambulace.
He was admitted to ICU immediately and now has a stable fever and his pulseox is maintaining at 92 with high nasal oxygen and fever of 100.4. He’s still having severe gastric issues. They placed a central line last night and hoped to hydrate him better last night. They have him on his current bp and blood clotting meds along with quaraquine and zithromyacine. This is all the info that I have at this time.
I cannot see him because of the virus and have not been able to get any ino beyond what the nurses have shared which is all I have shared here.
What i want to know is what type of care plan he might have?
How will I know if the care plan is working?
What is his long term prognosis?
If he recovers, how will this affect him?
What would be their determining factors in him needing intubation?
I am so frustrated and overwhelmed and I can’t get any clear answers. If anyone can help answer anything, including mortality, just so that I can try and mentally prepare myself, I would be so grateful.
Thank you
As a Nurse Practitioner (24yrs), and before that an ICU nurse in a teaching hospital, who cared for many ventilator patients, I am intrigued by the string of comments. I agree that once a person’s oxygen saturation falls below 90% (while on high FiO2) there is not much left to do but place them on mechanical ventilation, that is if you don’t want to watch them die in front of your eyes. If the space in the alveoli becomes to wide (due to fluid accumulation secondary to the Civid-19 infection) to allow sufficient diffusion, then (sometimes) even the added pressure afforded by mechanical ventilation is not enough. Despite all the ventilator settings being maxed out, you watch them spiral downward and die. I’ve seen this in numerous individuals, many with comorbid conditions, but sometimes in previously young healthy individuals. Is is so sad to watch. I believe the those doctors and ICU nurses (and respiratory therapists) are doing the best they can in a difficult situation. Kudos to all those staff. When this pandemic calms down or resolves I believe there should be monuments erected in their honor. Just like the military does, a system of commendation awards should be given to those who went extraordinarily above the usual call of duty, such as working double shifts when no one was available to step in, or taking on extra high number of patient loads. In my past days in the ICU we typically had just 2:1 (patient/ ICU nurse) ratios. I suspect that those involved in the current pandemic are taking on a much higher patient load. They are angels disguised in human form. God Bless them all.
Would liquid ventilation increase survival?
The greatest vaccine lab in the world is your own immune system! Covid is no match. Instead of sitting on your hands waiting for the self annointed saviors the pharma industry to save us all, just take the steps to fortify your own immune system. Get proper nutrition, i dont care if you are veg or nonveg, but you must eat cruciferous veg, mushrooms, garlic and onions! Get enough sunshine for vitamin d and exercise. Your immune system will protect you.
So everyone who died was simply malnourished in micronutrients?
Man oh man, the USA is so screwed.
obesity, hypertension, and diabetes seem to be high comorbidities with hospitalized covid-19 patients so diet has a significant connection to covid-19 health.
Your immune system is precisely what goes haywire in ARDS and kills you.
THANK YOU for asking the obvious and painful but also necessary question which we as a community have been overly hesitant to approach.
I’m wondering if it’s possible that we’re taking a subset of patients who have a ZERO chance of survival, and putting a tube down their throat, a tube in their stomach, a tube in their bladder, a tube in their butt, a line in their wrist, and a central line their neck, and degrading their final moments of life, while also putting the doctors and nurses taking care of them at risk for death, while also using resources that could be used for other people who may actually survive this disease.
JUST watched CNN. A Connecticut critical care Doctor just indicated with Covid19, survival of intubated patients is a GRIM 20 %. Can this % be possible?
You are right to question however you asked the wrong question. The right question is whether ventilators are actually the reason people are dying? That answer is YES. Ventilators which usually help people breathe, are actually spreading covid within the lungs and also drying out the essential mucous membrane which serves as a protective barrier. Doctors should be aggressively clearing the lungs as opposed to drying them out. Gov Bozo of NY will not listen and is now going to turn a disaster into a catastrophe!
The reason patients are intubated and ventilated is that they are still desaturating
Below 90% SpO2 on 6L oxygen – so if they are not ventilated they will very likely die as not being adapted to low oxygen saturation’s they de compensate and die from respiratory failure . If vented they have a 50/50 chance of survival .
Proning on vent support probably helps ventilation perfusion mismatching . It’s a desperate scenario whatever way you cut it as the lungs are stiff and non compliant . There are. No glib answers …
In Ireland at the beginning of this outbreak they were putting older people into ICU units with little or no hope of survival. This indeed was the case, they then decided to ICU the people they thought would have a better chance of survival and the figures for survival in the ICU facility changed and more were surviving. The Irish authorities keep changing the goalposts and it’s impossible to decipher anything from their figures because the baseline keeps changing. Why is this? Possibly to make their efforts look better can be the only answer.
Yes. Most of the people on vents are older people with multiple health conditions. We’re not talking about healthy young adults with an acute bacterial infection that will be easily treated. But people who are already old and sick and frail, and so are very likely to die, whatever is done. (Or if they survive, their quality of life will be severely affected.) Instead of more ventilators, perhaps we need more living wills, and more doctors willing and able to honestly explain likely outcomes, so educated choices can be made. I think most people, given the choice, would prefer to die at home surrounded by loved ones, than in an ICU surrounded by strangers in space suits. I know I would.
Here is the REAL deal based on real math, since mortality rate is a RATE which is based on MATH:
as of 4/7/2020 at 18:26 GMT, there have been 1,411,099 cases reported to Worldometers website. Of those cases, 81,044 have ended in death, and 300,759 have recovered. This means that 1,029,296 are still sick, which is 73%. This means that your Math can go either way at this point, but the drive shows that of the 381,803 cases that have ended in either death or recovery, 21% have ended in death. This number has been STEADILY increasing every week. That means, that there is a very real possibility that 21% or more of the current 1,029,296 could end in death, or another 216,152 people gone. Like I said, though, that is like calling a baseball game’s final score in the middle of the 2nd inning.
Having more information may also hold clues to this seemingly high mortality rate. Age of patients, general health condition to include underlying conditions, and duration of illness before ventilation was necessary would be a good start.
I completely agree. I hate to be a conspiracy theorist, but do you think it is possible that this kind of information is being intentionally withheld? I don’t know if it is, but I do wonder. I feel like hospitals must be reporting a lot of information to the state/federal government and I wonder why we’re not seeing it.
I am a PhD student in DAOM program in Virginia. I also worked as a Clinical patient care pharmacist for 25 years in a major teaching hospital system in Philadelphia, PA.
When the reports from China came out in January, I knew it was the respiratory ventilator that was the culprit creating such a high mortality rate.
Viruses are 100 to 500 times smaller than bacterias. It is a well known fact that the failure rate with respirator is about 44% +/- .
When using a respirator, In case of a viral attack, it is not just the oxygen that gets pumped into the blood stream, but the coronavirus as well which causes sepsis. Without antibodies, Virus plus RBC causes hemagglutination or blood clots. This can lead to heart attack, pulmonary embolism, stroke, multi-organ failures, and host of other problems if the patient survives.
China and Korea was able to quickly overcome COVID-19 by using Classic Chinese herbal preparations , Ma Huang Tang and Ma Huang Xi Xin Fu Xi Tang for the Chinese populations as well as acupuncture to revive the patients.
Shang Han Lun ( SHL) is a classic text written by Zhang Ji in 150 C.E. to 219 C.E. SHL has extensive description on how to treat (wind-cold) a flu. During the the wheezing or shortness of breath of the invasion of the wind pathogen in the lung, Ma Huang Tang is the best prescription for this symptom. Ma Huang Tang powerfully opens the Lung by circulating the qi of the lungs and opening the pores and sweating out the pathogen through the skin.
In TCM everything in life is based off of the “5 Elements” even medicine.It worked for thousands of year, why not go back to the roots.
ANIMAL STUDIES
Most of the corona virus studies are done in the field of veterinary science through out the world. Mothers pass the corona virus to the offsprings causing adverse effects on puppies, calves, pigs, horses, kittens, and other animals. There are vaccines for animals.
Most of us have animals as pets. There is a possibility that most of the American population will have corona virus weather we have symptoms or not.
My friend owns 5 horses, two cats and a dog.
Do you think most American will depart with their animals?
Acupuncture and sweating it out? LOL, you are a bad troll. This sounds rather dumb.
Dear Yun, Chinese herbal remedies and acupuncture are not the solution to a global pandemic. Thank you for confirming how many animals your neighbour owns.
Best wishes
Dave
For those who are wary of Yun’s wacky “qi” theory, the way Ma Huang (Ephedra) helps covid patients is that it significantly widens the lung airways, making it easier for covid patients to breathe & cough up the gunk that’s accumulating in their lungs & slowly suffocating them. Unfortunately I haven’t seen any reputable English language studies proving its efficacy, but it’s early days and western scientists are uncomfortable with studying TCM due to all the psuedoscience its tied up in.
Just wanted to ask about this, I heard it is because the virus kicks the iron out of the blood and the blood cannot hold onto oxygen to take it from the lungs to the rest of the body, so eventually the organs start shutting down from lack of oxygen, ventilators don’t help. Maybe blood transfusions with good blood and strong white blood cells would help fight the virus long enough and keep the organs going long enough for immune system to get a second wind?
new ideas have to be thought of.
prayers to all, be safe
ANY REPUTABLE MEDICAL JOURNAL REFERENCE?
Dear Skeptical Scalpel , or anyone willing to ease my curious mind, please excuse my uneducated and limited use of words here as I don’t speak the medical language, and already broken the rules, instead of leaving a reply, I’m asking a question, I. I’m certainly no doctor nor do I claim to have any medical knowledge in the field, I’m just an average citizen on lockdown with time on my hands and trying to think outside the box in regards to the news that some doctors and nurses are facing mask shortages and reusing them, my sister is a nurse in New Zealand, preparing for the first wave, while she remains positive and dedicated to fighting this virus and saving lives, I, on the other hand, am naturally worried for her and our people. I can’t wrap my head around the fact that there is a shortage, and not in abundance, so back to how I accidentally stumbled upon this physiciansweekly.com site ( Bookmarked for life now ) so blindly, I’m searching for solutions, safe alternatives, thinking, wondering if lightweight backpack oxygen tanks would guarantee not inhaling any droplets, I know it sounds ridiculous, but don’t judge, surely there can’t be a worldwide shortage on these.. and I ENDED UP HERE, one page back I just learned that this oxygen that saves lives, could just as easily kill you, leading me to pop this question on you about the above mentioned subject, and a spare of the moment one too, with good intentions, not intending to offend anyone, is it true that, Inappropriate oxygen use in patients at risk of type 2 respiratory failure (T2RF) can result in life-threatening hypercapnia (higher than normal levels of carbon dioxide in arterial blood), respiratory acidosis, organ dysfunction, coma, and death? I heard that some new nurses are being thrown into the deep end, with little, if any real-life experience in that department. Could death by inexperience/error be an outcome? adding somewhat, if any, to the Mortality rate of COVID-19 patients on ventilators? Maxine from New Zealand North Island, where the panic and fear, for now, seems worse than the Pandemic.
Maybe we should expand the availability and use if ECMO ( basically a heart lung bypass pump). Theoretically this may be less physical trauma to the already damaged lung tissue.
Maxine – To answer your first question, portable oxygen tanks (actually 20% oxygen as pure oxygen is toxic) : impractical here due to their heavy weight, bulky size and limited capacity. A practical solution would be a battery powered pump and particulate filter built into a hood or mask – these are commercially available and in regular use in industry. Cost is not too high, BUT they need some degree of maintenance (recharging batteries, replacing filter and cleaning). Protection is likely to be up to 10 times better than ordinary N95 respirators. Hygiene factors and of course cost may be reasons that they are not in wide use in this situation.
Mate you just don’t get it . When you are desaturating despite high oxygen levels being administered , treatment has to scale up to intubation in order to Control rate of inspiration and expiration and tidal volume .
And type II respiratory failure patients with chronic emphysema can die from oxygen treatment because it switches off their hypoxic drive to breathe . They run on high C0 2 levels and low O2 and are adapted to it over time . High levels of oxygen administered can switch off their drive to breathe which has adapted to responding to high levels of CO2 instead of low levels of O2 as a trigger for breathing .
But as a percentage of the Covid populace they are small and are unlikely to live long enough to get to a ventilator in any case if they get Covid given their overall condition.