"The patients in front of me were unlike any patients I've ever seen. Clinically they look more like high-altitude sickness than pneumonia. The real illness may be a disfunction of the oxygenation of the blood. Doctors still need ventilators to treat patients but they should reflect on the treatment strategy because this is an entirely new disease"

Dr. Cameron Kyle-Sidell, Maimonides Medical Center, New York, March 31, 2020

During the early weeks of the COVID-19 outbreak, there was a lot of discussion about ventilators. In the beginning, people discussed the need for more ventilators in hospitals or the attempts to repair malfunctioning ventilators. In March is was estimated that although 960,000 patients in the US might need a ventilator, only about 200,000 machines were available. People are still talking about ventilators, but this month, the discussion has changed. A recent study published in the Journal of the American Medical Association reported that almost 90% of COVID patients placed on ventilators in New York between March 1 and April 4 died. The report shows that the mortality rate of those aged 65 and over was 97% and for those aged 18 to 65 was 76%. It's reported that generally 40% of patients with severe respiratory distress die while on ventilators. Over twice as many COVID patients are dying while intubated on a ventilator.

Ventilators are used in hospital ICUs to move air into and out of the lungs when a patient's breathing is compromised. COVID attacks the respiratory system and some patients who are infected struggle to breathe. A few weeks ago it was routine to place COVID patients on ventilators to keep them breathing and according to Governor Cuomo, it’s been common for COVID patients in New York to be on ventilators for 10-15 days. In comparison, patients with bacterial pneumonia are typically placed on ventilators for a few days and the majority recover. Image: Fluidda

Doctors have been working under the assumption that some COVID patients develop acute respiratory distress syndrome (ARDS) and that the best approach for treating these patients is with ventilators. Some ICU doctors are questioning whether standard respiratory therapy protocol for ARDS is the best approach for treating patients with COVID pneumonia and if respiratory therapy is doing more harm than good. Doctors are calling for a review and possibly a revision to guidelines for treating COVID patients in the ICU.

Note: Normal oxygen saturation rate is 95% -100%. When oxygen saturation rate drops below 93% it is usually seen as sign of potential hypoxia. Prior to the COVID pandemic, when the oxygen level dropped below 93%, doctors typically used noninvasive devices such as face masks with tubes to supply oxygen.

Some ICU doctors say that COVID-19 is challenging core tenets of medicine and question if they are treating the virus correctly. Source New York Times

“I realized as soon as I saw the first CT scan that this had nothing to do with what we had seen and done for the past 40 years”

Dr. Luciano Gattinoni, guest professor, Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Göttingen in Germany, and renowned expert on ventilators to Reuters April 23, 2020

In March, Luciano Gattinoni, MD, one of the world's leading experts on ARDS reported that COVID does not lead to a typical ARDS, that intubation was leading to additional lung damage, and that overall the treatment was not having much success. In a letter published in the American Journal of Respiratory and Critical Care Medicine and a letter soon to be published in Intensive Care Medicine, Luciano Gattinoni, MD, and his colleagues at the Medical University of Göttingen in Germany, question whether protocol-driven ventilator use for patients with COVID could be doing more harm than good. They suggested that that instead of high positive end-expiratory pressure, perhaps doctors should use the lowest possible pressure and gentle ventilation to minimize damage to the lungs. Dr. Gattinoni describes two variations of COVID, Phenotype L and Phenotype H, each of which require different treatments.

Panel A: CT scan acquired during spontaneous breathing. Patient receiving oxygen with Venturi mask.

Panel B: CT acquired during mechanical ventilation at end-expiratory pressure at 5 cmH2O of PEEP.

Image: Luciano Gattinoni, MD

Patient Response to Respiratory Treatment

Dr. Albert Rizzo, chief medical officer at the American Lung Association reported that higher-than-normal death rates of COVID patients on ventilators have been reported in US.

In a paper in The Lancet on two studies in China, 97% and 86% of patients on ventilators died.

Researchers in Wuhan reported that, of 37 critically ill COVID patients who were put on mechanical ventilators, 30 died within a month.

In a small study this month in Annals of Intensive Care, doctors who treated COVID patients in China found that the majority of patients needed only nasal cannula.

In February doctors in South Korea reported that critical COVID patients respond well to oxygen therapy without a ventilator.

In a study in Seattle 6 of the 7 COVID patients older than 70 on a ventilator died, and only 36% of those younger than 70 survived.

In a study published by JAMA this week, doctors in Italy reported that 90% of 1,300 critically ill patients with COVID were put on a ventilator. One-quarter died in the ICU; 58% were still in the ICU, and 16% have been discharged.

Higher-than-normal death rates of COVID patients on ventilators have been reported in the UK. The UK issued a new report based on 4,690 COVID patients in the ICU in England, Wales, and Northern Ireland. Overall there was a 51.6% death rate, 65% death if on a ventilator in the first 24 hrs, young people age16-49 years 23.6% death rate.

Acute Respiratory Distress Syndrome (ARDS)

Many people became aware of ARDS for the first time after watching a YouTube video made by Dr. Cameron Kyle-Sidell, a critical care doctor treating COVID patients at Maimonides Medical Center in New York. (scroll down to watch the video). In this video he says that after treating many patients with COVID, he formed the impression that the real illness may not be typical pneumonia or ARDS, but disfunction of the oxygenation of the blood. He said that patients that he's treating are showing symptoms as if they were at high altitude without time to adapt. He said that clinically his patients look more like they are experiencing decompression pulmonary sickness or high-altitude pulmonary edema (HAPE) than acute respiratory distress syndrome (ARDS). When he started treating COVID patients in the ICU, Kyle-Sidell and his colleagues were under the impression that they were treating pneumonia, so they followed the given protocols and best practices.

Dr. Kyle-Sidell thinks that COVID lung disease is not a pneumonia, and should not be treated as pneumonia. He says that it appears to be a viral induced disease resembling high altitude sickness. He said that its as if tens of thousands of people are on a plane at 30,000 feet and the cabin pressure is slowly being let out and they are slowly being starved of oxygen. He says his patients look like people dropped off at the top of Most Everest without time to acclimate to the altitude. He says that if doctors continue to treat patients as though they are experiencing respiratory failure when they are actually experiencing oxygen failure it will cause great harm to thousands of people.

Dr. Cameron Kyle-Sidell describes treating COVID patients in the ICU

The following are comments that Dr. Kyle-Sidell made in a recent interview with John Whyte, MD, MPH, chief medical officer at WebMD.

"In the past, we haven't seen patients who are talking in full sentences and not complaining of overt shortness of breath, with saturations in the high 70%. It's just not something we typically see when we're intubating patients. With COVID patients, when we put a breathing tube in, they tend to drop their saturations very quickly; we see saturations going down to 20%. I've literally seen a saturation of zero on a monitor, which is not something we ever want and something we actively try to avoid. And yet we saw it, and many of my colleagues have similarly seen saturations of 10% and 20%. It's just something that we are not used to seeing."

"Some COVID patients in ICU have blood oxygen levels so low they should be dead. But they’re not gasping for air, their hearts aren’t racing, and their brains show no signs of blinking off from lack of oxygen."

Dr. Cameron Kyle-Sidell, Maimonides Maimonides Medical Center, New York, March 31, 2020

"This originally came to me when we had a patient who had hit what we call our trigger to put in a breathing tube, meaning she had displayed a level of hypoxia of low oxygen levels where we thought she would need a breathing tube. Most of the time, when patients hit that level of hypoxia, they're in distress and they can barely talk; they can't say complete sentences. She could do all of those and she did not want a breathing tube. So she asked that we put it in at the last minute possible. It was this perplexing clinical condition: When was I supposed to put the breathing tube in? When was the last minute possible? All the instincts as a physician—like looking to see if she tires out —none of those things occurred. It's extremely perplexing. But I came to realize that this condition is nothing I've ever seen before. And so I started to read to try to figure it out, leaving aside the exact mechanism of how this disease is causing havoc on the body, but instead trying to figure out what the clinical syndrome looked like."

According to a recent article in the New York Times, COVID patients are put into a medically induced coma before being placed on a ventilator. Many patients are sedated from ten days to two weeks. Older patients who do survive COVID risk permanent cognitive and respiratory damage from being sedated for weeks on a ventilator. Some doctors have suggested that COVID patients could receive simpler, noninvasive respiratory support, such as breathing masks, and other doctors have reported success using ECMO. Dr. Kyle-Sidell's message is: doctors still need ventilators to treat patients but they should reflect on the treatment strategy because this is an entirely new disease. His message has been passed through hospitals and homes across the US and has made it's way to government. On April 8th, New York Governor Andrew Cuomo was asked about the high percentage of COVID patients not coming off ventilators during his live COVID update (30.36 in the video).

This article was written by Margaretta Colangelo and Dmitry Kaminskiy.

Margaretta Colangelo is Co-founder and Managing Director of Deep Knowledge Group. She is Co-founder and Managing Partner of Deep Knowledge Ventures, Longevity Capital, and AI Pharma Capital. She is Co-founder of Longevity Bank, Aging Analytics Agency and Deep Knowledge Analytics. She is Co-founder and CEO of Jthereum an Enterprise Blockchain technology company. Margaretta serves on the Advisory Boards of the AI Precision Health Institute at the University of Hawai‘i Cancer Center and the Longevity AI Consortium at King's College London. Margaretta is based in San Francisco.

Dmitry Kaminskiy is Co-Founder and General Partner of Deep Knowledge Group. He is Founding Partner of Deep Knowledge Ventures, Longevity Capital, AI Pharma Capital. He is Co-founder of Aging Analytics Agency, Deep Knowledge Analytics, and Neurotech Analytics. He is the Head of International Development of the Secretariat for the UK All-Party Parliamentary Group for Longevity, Managing Trustee of the Biogerontology Research Foundation, and serves on the Advisory Board of the Longevity AI Consortium at King's College London. Dmitry is based in London.

Deep Knowledge Group is an international consortium of commercial and non-profit organizations focused on the synergetic convergence of DeepTech and Frontier Technologies including AI, Longevity, FinTech, GovTech, and InvestTech. Deep Knowledge Group's subsidiaries and associated organizations include Deep Knowledge Ventures, Longevity Capital, AI-Pharma Capital, Longevity Bank, Longevity FinTech Company, Deep Knowledge Analytics, Aging Analytics Agency, NeuroTech Analytics, Biogerontology Research Foundation, Longevity Swiss Foundation, Longevity International UK - Secretariat for the UK All-Party Parliamentary on Longevity, and the Longevity AI Consortium at King’s College London.