Bag Breathing Helps Flu; Ventilators And Oxygen Probably Kill

[md_a]

Lancet Image) Look at the lactate dehydrogenase levels in 98% of non survivors. Their cells appear to be hypoxic, excess glycolysis

 

[ecstatichamster]

Great find ...where is the url.

 

[Blossom]

Could just be that those put on ventilators were the most severely ill and would have deteriorated regardless, hard to judge without controlled studies.

I wonder if there's any evidence that people with "mild respiratory ailments" are being put on ventilators before it is necessary and thus deteriorating because of this, or is medical staff generally discerning enough to only put people on ventilators when its certain they would die without it?

The current WHO/CDC recommendation is to intubate when a person who is covid-19+ needs more than 5 liters of oxygen via nasal cannula which is approximately 35-40%. With most other situations we are not that aggressive but I keep hearing it reinforced that these people decompensate/crash rapidly. I haven’t seen this first hand yet but it’s newer to my community. When I write about these things I’m only sharing information about what I’ve learned and experienced so far as a front line worker and I’m not necessarily agreeing or disagreeing with the way the situation is being handled.

 

[md_a]

Great find ...where is the url.

https://www.thelancet.com/action/showPdf?pii=S0140-6736(20)30566-3

 

[S.Seneff]

The current WHO/CDC recommendation is to intubate when a person who is covid-19+ needs more than 5 liters of oxygen via nasal cannula which is approximately 35-40%. With most other situations we are not that aggressive but I keep hearing it reinforced that these people decompensate/crash rapidly. I haven’t seen this first hand yet but it’s newer to my community. When I write about these things I’m only sharing information about what I’ve learned and experienced so far as a front line worker and I’m not necessarily agreeing or disagreeing with the way the situation is being handled.

Was it the same procedure with a pneumonia before this virus ?

 

[Blossom]

Was it the same procedure with a pneumonia before this virus ?

No. We used high flow humidified oxygen/air blend (Airvo, Vapotherm, Optiflow) and bilevel noninvasive mechanical ventilation (bipap s/t, AVAPS) as a bridge to try to avoid intubation. The recommendations are more aggressive for covid-19.
Edit: The 5 liters recommendation has been increased to 6 and now other interventions are being mentioned. The updates are daily at this point.
Coronavirus Clinical Collaboration

 

[md_a]

From KMUD Herb Doctors - Altitude July 2013 :

HD: So why are hospitals so concerned, especially in emergency rooms, you know, they test your oxygen saturation by putting this meter over your fingertips and then they give you oxygen to breathe?
RP: Well, for one thing, I’ve tested those things on my finger and everyone feels really good when they have a 99% saturation, but I’ve noticed that when I am feeling really the best I can get mine down to 89%. And I have thought about that a lot, and watched the different conditions that cause it, and hyperventilating will cause the saturation to go up and having just cold fingers will make the oxygen go up. If you are not using the oxygen, it doesn’t do you any good to have your haemoglobin saturated if you’re not using it. So those finger meters aren’t really very informative unless you know what temperature your fingers are at.

 

[md_a]

From an infectious disease doctor dealing with this is NYC. here is what his response was.... We have no idea how many people are infected without sx. There is no way to say 85%
It doesn't look like most people who are sick are old. Corey has all 40-60yos intubated in the ICU
It is IMPOSSIBLE to give someone pure oxygen. No one gets oxygen unless there is pulse oximetry is low (under 95%). If above they are generally discharged. People are at first given nasal oxygen which can only deliver up to 28% oxygen (we normally breath 21%). Even putting on a mask they can only deliver up to 40% because higher flow oxygen spreads the virus to health care workers. The majority of people on ventilators are given 40% oxygen. The goal is always to get patients to breath the lowest % of oxygen they can tolerate cause it is well known to the health care community that oxygen free radicals are bad for the lung, carbon dioxide level is tightly regulated by the body to keep the ph at 7.40. If Ph changes too much the heart stops. This is what is behind co2 levels.

 

[Blossom]

From an infectious disease doctor dealing with this is NYC. here is what his response was.... We have no idea how many people are infected without sx. There is no way to say 85%
It doesn't look like most people who are sick are old. Corey has all 40-60yos intubated in the ICU
It is IMPOSSIBLE to give someone pure oxygen. No one gets oxygen unless there is pulse oximetry is low (under 95%). If above they are generally discharged. People are at first given nasal oxygen which can only deliver up to 28% oxygen (we normally breath 21%). Even putting on a mask they can only deliver up to 40% because higher flow oxygen spreads the virus to health care workers. The majority of people on ventilators are given 40% oxygen. The goal is always to get patients to breath the lowest % of oxygen they can tolerate cause it is well known to the health care community that oxygen free radicals are bad for the lung, carbon dioxide level is tightly regulated by the body to keep the ph at 7.40. If Ph changes too much the heart stops. This is what is behind co2 levels.

I agree with most of this. A 2 liter nasal cannula is about 28% but you can go higher. Where I live we usually only give oxygen to a normally healthy person if they drop below 92% and below 90% for those with chronic lung disease. We can give 100% oxygen but definitely try not to give more than absolutely necessary and try other means to increase it especially if a person requires more than 60%.

 

[ecstatichamster]

I would be in bad shape without bag breathing. It is a life saver. I remember talking to my moms doctor about CO2. Got nowhere. She died a few days later on oxygen.

 

[Tristan Loscha]

I am experiencing some chest tightness. Bag breathing or Frolov device or pauses always helps.

The worst thing I could do was get oxygen or be “ventilated”. I don’t need any of that, my point is that would kill me and probably accounts for most of the so-called COVID-19 deaths.

Related:



Is ventilator-associated pneumonia in trauma patients an epiphenomenon or a cause of death?
Louis J Magnotti, Martin A Croce, Timothy C Fabian
Surgical infections 5 (3), 237-242, 2004
Background: Ventilator-associated pneumonia (VAP) is a common infection among patients in trauma intensive care units (ICUs). It has been suggested by different investigators that VAP is an indicator of injury severity and not necessarily associated with mortality. Crude mortality rates approximating 20% have been reported for trauma patients with VAP. Most studies have involved the most severely injured patients, making it difficult to determine the relative contribution of either VAP or injury severity to death. If VAP is independently associated with mortality, this relationship should be most evident in less severely injured patients. We studied patients with less severe injuries (Injury Severity Score, ISS < 25) to determine the impact of VAP on outcomes.
Methods: Patients admitted to the trauma ICU with ISS < 25 were identified from the trauma registry of a level I trauma center. Patients with penetrating injuries and those who died within 48 h of injury were excluded. Pneumonia was diagnosed using quantitative cultures of bronchoalveolar lavage effluent (≥ 105 colony forming units/mL). Risk factors for VAP, including age, transfusions with 24 h of admission, brain injury, and chest injury severity were analyzed. Logistic regression analysis was then performed to determine independent factors for death.Results: There were 15,492 blunt admissions over a 5.5 year study period who survived >48 h. Of these, 5,860 (38%) were admitted to the ICU, and 4,111 (70% of ICU admissions) had ISS < 25. The incidence of VAP in this group was 8%. Patients with VAP were older (47 vs 39 years), had more transfusions within 24 h (2.5 vs 0.9 units of red blood cell concentrates) and had greater injury severity by ISS (16.7 vs 12.6 points), GCS (Glasgow Coma Scale) score (11.8 vs. 13.7 points) and chest AIS (Abbreviated Injury Scale) (1.7 vs 0.9 points; all p < 0.001). Overall mortality was 4%. Mortality was 16% in patients with VAP compared to 3% in those without VAP (p < 0.0001). Logistic regression analysis identified transfusions, age, and VAP as independent predictors of mortality. Other descriptors of injury severity (ISS, GCS, or chest AIS) were not associated with death.
Results: There were 15,492 blunt admissions over a 5.5 year study period who survived . 48 h. Of these, 5,860 (38%) were admitted to the ICU, and 4,111 (70% of ICU admissions) had ISS , 25. The incidence of VAP in this group was 8%. Patients with VAP were older (47 vs 39 years), had more transfusions within 24 h (2.5 vs 0.9 units of red blood cell concentrates) and had greater injury severity by ISS (16.7 vs 12.6 points), GCS (Glasgow Coma Scale) score (11.8 vs. 13.7 points) and chest AIS (Abbreviated Injury Scale) (1.7 vs 0.9 points; all p , 0.001). Overall mortality was 4%. Mortality was 16% in patients with VAP compared to 3% in those without VAP (p , 0.0001). Logistic regression analysis identified transfusions, age, and VAP as independent predictors of mortality. Other descriptors of injury severity (ISS, GCS, or chest AIS) were not associated with death.
Conclusions: Ventilator-associated pneumonia is independently associated with death in less severely injured trauma patients. This demonstrates the need for effective diagnostic techniques so that adequate therapy may be initiated. Prevention of VAP in less severely injured trauma patients should increase survival.






Artificial Ventilation itself is a common cause of Pneumonia.
So,SARS2 Pneumonia aggravated by different-cause mediated Ventilation associated Pneumonia.
A double Whammy.

 

[Blossom]

Related:



Is ventilator-associated pneumonia in trauma patients an epiphenomenon or a cause of death?
Louis J Magnotti, Martin A Croce, Timothy C Fabian
Surgical infections 5 (3), 237-242, 2004
Background: Ventilator-associated pneumonia (VAP) is a common infection among patients in trauma intensive care units (ICUs). It has been suggested by different investigators that VAP is an indicator of injury severity and not necessarily associated with mortality. Crude mortality rates approximating 20% have been reported for trauma patients with VAP. Most studies have involved the most severely injured patients, making it difficult to determine the relative contribution of either VAP or injury severity to death. If VAP is independently associated with mortality, this relationship should be most evident in less severely injured patients. We studied patients with less severe injuries (Injury Severity Score, ISS < 25) to determine the impact of VAP on outcomes.
Methods: Patients admitted to the trauma ICU with ISS < 25 were identified from the trauma registry of a level I trauma center. Patients with penetrating injuries and those who died within 48 h of injury were excluded. Pneumonia was diagnosed using quantitative cultures of bronchoalveolar lavage effluent (≥ 105 colony forming units/mL). Risk factors for VAP, including age, transfusions with 24 h of admission, brain injury, and chest injury severity were analyzed. Logistic regression analysis was then performed to determine independent factors for death.Results: There were 15,492 blunt admissions over a 5.5 year study period who survived >48 h. Of these, 5,860 (38%) were admitted to the ICU, and 4,111 (70% of ICU admissions) had ISS < 25. The incidence of VAP in this group was 8%. Patients with VAP were older (47 vs 39 years), had more transfusions within 24 h (2.5 vs 0.9 units of red blood cell concentrates) and had greater injury severity by ISS (16.7 vs 12.6 points), GCS (Glasgow Coma Scale) score (11.8 vs. 13.7 points) and chest AIS (Abbreviated Injury Scale) (1.7 vs 0.9 points; all p < 0.001). Overall mortality was 4%. Mortality was 16% in patients with VAP compared to 3% in those without VAP (p < 0.0001). Logistic regression analysis identified transfusions, age, and VAP as independent predictors of mortality. Other descriptors of injury severity (ISS, GCS, or chest AIS) were not associated with death.
Results: There were 15,492 blunt admissions over a 5.5 year study period who survived . 48 h. Of these, 5,860 (38%) were admitted to the ICU, and 4,111 (70% of ICU admissions) had ISS , 25. The incidence of VAP in this group was 8%. Patients with VAP were older (47 vs 39 years), had more transfusions within 24 h (2.5 vs 0.9 units of red blood cell concentrates) and had greater injury severity by ISS (16.7 vs 12.6 points), GCS (Glasgow Coma Scale) score (11.8 vs. 13.7 points) and chest AIS (Abbreviated Injury Scale) (1.7 vs 0.9 points; all p , 0.001). Overall mortality was 4%. Mortality was 16% in patients with VAP compared to 3% in those without VAP (p , 0.0001). Logistic regression analysis identified transfusions, age, and VAP as independent predictors of mortality. Other descriptors of injury severity (ISS, GCS, or chest AIS) were not associated with death.
Conclusions: Ventilator-associated pneumonia is independently associated with death in less severely injured trauma patients. This demonstrates the need for effective diagnostic techniques so that adequate therapy may be initiated. Prevention of VAP in less severely injured trauma patients should increase survival.






Artificial Ventilation itself is a common cause of Pneumonia.
So,SARS2 Pneumonia aggravated by different-cause mediated Ventilation associated Pneumonia.
A double Whammy.

Yes it’s a big deal and impeccable oral care and keeping the head of the bed elevated at least 30 degrees can decrease it significantly.

 

[S.Seneff]

From an infectious disease doctor dealing with this is NYC. here is what his response was.... We have no idea how many people are infected without sx. There is no way to say 85%
It doesn't look like most people who are sick are old. Corey has all 40-60yos intubated in the ICU

I see study aroud showing that 75 percent of americans are metabolically ill.
To know the asymptomatic, you just have to make test poll like opinion poll with 1000 people are done daily no ? They want to know or not ? Perhaps its a little bit more complicated that a simple opinion poll but I will be surprise if something like that could not be done.

 

[md_a]

Both COVID-19 and HAPE exhibit a decreased ratio of arterial oxygen partial pressure to fractional inspired oxygen with concomitant hypoxia and tachypnea. There also appears to be a tendency for low carbon dioxide levels in both as well. Radiologic findings of ground glass opacities are present in up to 86% of patients with COVID-19 in addition to patchy infiltrates. Patients with HAPE also exhibit patchy infiltrates throughout the pulmonary fields, often in an asymmetric pattern and CT findings reveal increased lung markings and ground glass-like changes as well. Widespread ground-glass opacities are most commonly a manifestation of hydrostatic pulmonary edema. Similarly, elevated fibrinogen levels in both conditions are likely an epiphenomenon of edema formation rather than coagulation activation. Autopsy results of a COVID-19 fatality revealed bilateral diffuse alveolar damage associated with pulmonary edema, pro-inflammatory concentrates, and indications of early-phase acute respiratory distress syndrome (ARDS). HAPE itself is initially caused by an increase in pulmonary capillary pressure and induces altered alveolar-capillary permeability via high pulmonary artery hydrostatic pressures that lead to a protein-rich and mildly hemorrhagic edema. It appears that COVID-19 and HAPE both discretely converge on ARDS. In light of this, a countermeasure that has been shown to be effective in the analogous condition of HAPE is Acetazolamide. Acetazolamide has a myriad of effects on different organ systems, potently reduces hypoxic pulmonary vasoconstriction, improves minute ventilation and expired vital capacity. Other therapeutics to consider that are also directed towards decreased pulmonary pressure include Nifedipine and Phosphodiesterase inhibitors.
Acetazolamide, Nifedipine and Phosphodiesterase Inhibitors: Rationale for Their Utilization as Adjunctive Countermeasures in the Treatment of Coronavirus Disease 2019 (COVID-19)

 

[md_a]

Interpretation
In acutely ill adults, high-quality evidence shows that liberal oxygen therapy increases mortality without improving other patient-important outcomes. Supplemental oxygen might become unfavourable above an SpO 2 range of 94–96%. These results support the conservative administration of oxygen therapy.
https://www. Interpretation In acutely ill adults, high-quality evidence shows that liberal oxygen therapy increases mortality without improving other patient-important outcomes. Supplemental oxygen might become unfavourable above an SpO 2 range of 94–96%. These results support the conservative administration of oxygen therapy..com/journals/lancet/article/PIIS0140-6736(18)30479-3/fulltext

 

[md_a]

There are a substantial number of clinical trials concerning the efficacy of mask CPAP that can be used to defend the position that this therapy ought be developed into what is considered routine and expected treatment of acute respiratory insufficiency. The literature is particularly strong for its use in COPD and pulmonary edema. Successful use has also been reported with asthma, PCP pneumonia, neuromuscular weakness, post-operative respiratory distress, and traumatic lung contusions. The use of NIVS in acute respiratory failure is associated with prompt improvement in acid-base balance as determined by arterial blood gases obtained within the first few hours. Any patient with acute respiratory distress significant enough to result in more than mild accessory muscle use should be considered for this technique. Off-loading the respiratory muscles early in the presentation of acute respiratory failure, and supporting respiration while waiting for medical therapy (bronchodilators, steroids, antibiotics, diuretics, or nitrates) to have their effects, can potentially result in more rapid improvement and a lower incidence of intubation. All Emergency Departments should have rapid access to at least one mode of Non-invasive Ventilatory Support. If you do not have access to a BiPAP machine, mask ventilation can be easily accomplished using a standard ventilator by simply substituting a facemask for an endotracheal tube as the interface between patient and ventilator. However, for optimal performance, a later generation ventilator is required ( i.e., Puritan Bennett 7200, Siemans 900c, Siemans 300 ).

In summary, the use of NIVS should be considered early in the course of moderately severe acute respiratory failure. It is clear that use of NIVS is well tolerated and is associated with improved gas exchange and avoidance of intubation in appropriately selected patients with acute respiratory failure. It is simple and convenient to use, and has the potential to decrease both morbidity and costs when compared to standard invasive mechanical ventilation. Any patient with significant accessory muscle use, hypoxia, or respiratory acidosis could potentially benefit from its use. If you do not yet have easy access to CPAP or BiPAP in your Emergency Department, I would encourage to obtain it.
Preventing intubation in acute respiratory failure: Use of CPAP and BiPAP

 

[Giraffe]

View attachment 17190
Sorry, I don’t know the source but it doesn’t look too good for surviving invasive mechanical ventilation if this is correct.

page 7 of
https://www.thelancet.com/action/showPdf?pii=S0140-6736(20)30566-3

All sorts of oxygen therapy were predictive for bad outcome. Data taken from table 2.

 

[Zilean]

Seems like some of you are confusing correlation with causation. Simply because someone receives a treatment and ends up dead does not mean that treatment is adding to the risk of death. What this tells us is that we need to know more about the non-survivors - e.g. did they receive a treatment too late? Are there other unobserved variables (yes, most likely) that influence the outcomes? No researcher with self-respect would derive strong conclusions from univariate analyses. The study suffers from endogeneity issues and is only a teaser - not a study we should base much of anything on.

 

[Collden]

There are a substantial number of clinical trials concerning the efficacy of mask CPAP that can be used to defend the position that this therapy ought be developed into what is considered routine and expected treatment of acute respiratory insufficiency. The literature is particularly strong for its use in COPD and pulmonary edema. Successful use has also been reported with asthma, PCP pneumonia, neuromuscular weakness, post-operative respiratory distress, and traumatic lung contusions. The use of NIVS in acute respiratory failure is associated with prompt improvement in acid-base balance as determined by arterial blood gases obtained within the first few hours. Any patient with acute respiratory distress significant enough to result in more than mild accessory muscle use should be considered for this technique. Off-loading the respiratory muscles early in the presentation of acute respiratory failure, and supporting respiration while waiting for medical therapy (bronchodilators, steroids, antibiotics, diuretics, or nitrates) to have their effects, can potentially result in more rapid improvement and a lower incidence of intubation. All Emergency Departments should have rapid access to at least one mode of Non-invasive Ventilatory Support. If you do not have access to a BiPAP machine, mask ventilation can be easily accomplished using a standard ventilator by simply substituting a facemask for an endotracheal tube as the interface between patient and ventilator. However, for optimal performance, a later generation ventilator is required ( i.e., Puritan Bennett 7200, Siemans 900c, Siemans 300 ).

In summary, the use of NIVS should be considered early in the course of moderately severe acute respiratory failure. It is clear that use of NIVS is well tolerated and is associated with improved gas exchange and avoidance of intubation in appropriately selected patients with acute respiratory failure. It is simple and convenient to use, and has the potential to decrease both morbidity and costs when compared to standard invasive mechanical ventilation. Any patient with significant accessory muscle use, hypoxia, or respiratory acidosis could potentially benefit from its use. If you do not yet have easy access to CPAP or BiPAP in your Emergency Department, I would encourage to obtain it.
Preventing intubation in acute respiratory failure: Use of CPAP and BiPAP

Seems CPAP and BiPAP have been considered in many places but ultimately are not being used because they increase the risk of spreading the virus, difficult trade-off.
CPAP Machines Were Seen As Ventilator Alternatives, But Could Spread COVID-19

 

[md_a]

On the other hand, there is no evidence that viral pneumonia from CoV-2 with invasive ventilation takes a better course. Rather, it can be expected that too many patients will be intubated too early in the current phase and especially taking into account established rules of emergency and intensive care medicine. Spontaneous breathing with and without ventilation support should be maintained as long as possible and taking into account known criteria of medical care. The importance of non-invasive ventilation therapy should also be taken into account when the government purchases and distributes ventilation devices in the current crisis.

Only when the saturation falls significantly below 90% should NIV or high-flow therapy be started, especially if the respiratory rate increases, as it indicates that the respiratory pump is beginning to tire. In hypoxemic insufficiency, ventilation is usually given too early on the IS and too much oxygen is given. This accelerates the development of ARDS (lung failure), because high ventilation pressures damage the alveoli and induce inflammation, which is then lacking in the defense against infections. Oxygen concentrations in excess of 50% in the inspiratory air also lead to a considerable radical load in the lungs, which also triggers an inflammatory reaction. However, these values can practically not be achieved with a nasogastric tube or admixture with the NIV.

The transfer to the IS should be made dependent on the individual case. According to clinical experience, many patients outside of IS can be treated with an NIV. This is the primary preferred form of ventilation for viral pneumonia. Experience has shown that a large number of patients with SARS-CoV-2 pneumonia only need temporary breathing support. The ventilation of these patients outside of IS protects valuable resources and thus helps to avoid secondary damage due to lack of space for the typical intensive care patients.

Much of it was published in 2005. At that time, it was recommended to stock up on pandemics with antibiotics, ventilators, protective masks, etc. Unfortunately, not many hospitals implemented this in Germany at the time, so that bottlenecks could now arise. On the other hand, the NIV has now established itself widely in hospitals (especially in the lung clinics), so that more ventilators are available here than before, which simplifies care outside of IS.

Dr. med. Gunter Frank, born in 1963 in Buchen im Odenwald, is a general practitioner in Heidelberg and a lecturer at the St. Gallen Business School. Sterben Coronapatienten auch an falscher Beatmungstechnik?