On Wednesday, STAT News published an influential story asking whether ventilators are being overused for Covid-19 patients. The United States is facing a dire shortage of ventilators for coronavirus patients. In that context, a complex debate within critical care medicine has become a matter of urgent public interest. How many ventilators are needed is already a politicized issue: Donald Trump and his son-in-law and adviser Jared Kushner have opined, seemingly baselessly, that New York doesn’t need as many ventilators as Governor Andrew Cuomo and his experts predict. “If ventilators are actually not the best solution to this problem we’re wasting a whole bunch of time and effort,” tweeted journalist Dave Dayen, author of The American Prospect’s Covid-19 blog, Unsanitized, in response to the STAT story. “Do Ventilators Help?” asked National Review.



The “yes ventilators” versus “no ventilators” frame is an overly simplistic take on a complex debate within critical care medicine. Some doctors think that a subset of Covid-19 patients would do better if they went on a respirator later, or not at all. That’s a far cry from saying that ventilators are “not the best solution” or that efforts to increase the ventilator supply are a waste of time. The debate over when to intubate, however, also has tricky ethical dimensions.

One pressing issue is whether ventilators will be allocated on a top-down basis by hospitals, hospital systems, or public officials—or whether bedside physicians will retain control over these decisions. The argument for top-down allocation is that it increases fairness and allocates resources more rationally. The Holy Grail is to find a list of objective criteria that predict who is most likely to benefit from a ventilator. But Dr. Lisa Moreno, president-elect of the American Academy of Emergency Medicine, who treats patients with severe Covid-19 at her hospital in New Orleans, told me that we simply don’t know enough about this new virus to reduce these decisions to algorithms. The fact that someone is young, thin, and healthy doesn’t necessarily mean they’re a better candidate than someone who’s older, obese, or suffering from a preexisting condition like diabetes. This disease affects people so differently that someone who looks good “on paper” may not be the strongest candidate for ventilator support.

When deciding whether to put a Covid-19 patient on a ventilator, Moreno says she takes into account various factors, including how well they’re breathing and how clearly they’re thinking (an indication of whether their brain is getting enough oxygen). “This has nothing to do with their age and even, in some cases, not necessarily to do with their underlying condition,” Moreno said.

Early in the pandemic, frontline health care providers in China argued that rapidly deteriorating patients should be intubated if their oxygen saturation levels fell below 93 percent and less invasive measures couldn’t bring these saturation levels back up. However, as the pandemic progressed, it became clear that many patients with severe Covid-19 remained functional and comfortable (at least by the standards of critically ill people) with oxygen saturation levels much lower than 93 percent. Now some doctors are rethinking the 93 percent threshold. Maybe some patients are better off sticking to less invasive ventilation methods that can’t push their oxygen saturation levels quite as high, but which can spare them the trauma that mechanical ventilation inflicts on their lungs.