Ventilation: on the machine or not?

Ventilators are considered essential for the treatment of patients in the corona crisis. At the same time, the form of therapy has a number of side effects. What does this mean for patients and doctors?

Diagnosis Covid-19: Patients with a particularly severe course of the disease are usually ventilated. However, the measures do not guarantee that the patient will survive in every case

© Getty Images / Taechit Taechamanodom

The discussion about who should and should not be ventilated flares up again and again in the Corona crisis. There is still great concern that ventilation places in hospitals could become scarce as the spread accelerates.

For this reason, professional societies have issued recommendations for doctors as to what may and may not be used as a criterion in an emergency. Experts advise risk patients to think about the emergency beforehand.

Health risk from ventilation

The corona virus, but also the treatment, can have very different effects on people. "There is no such thing as an instruction manual for all cases," says Guido Michels. He is the chief physician of the clinic for acute and emergency medicine at St. Antonius-Hospital in
Eschweiler. Each individual case must be assessed individually. What Michels means by this becomes clear when you look at the serious course of the disease.

If the virus causes severe pneumonia, the inflammation may cause too little oxygen to get into the blood. Patients are connected to ventilators. That carries risks.

In addition to the viral disease, a bacterial infection in the lungs can develop through the tubes. A second pneumonia, so to speak. The risk is higher in patients who are weakened by previous illnesses.

In addition, too much pressure during ventilation can burst the lung structure. The high proportion of oxygen with which the patient is ventilated could also damage the lung tissue. The muscles of the diaphragm, the main breathing muscle, can break down.

Sometimes it takes longer to heal

From the point of view of experts, artificial ventilation, such as that given to Covid 19 patients with very severe courses, does not necessarily cause permanent damage to the health of the lungs. "We have no data that suggest that it actually results in permanent damage," says the President of the German Society for Pneumology and Respiratory Medicine (DGP), Michael Pfeifer.

It is true that there are patients for whom the healing process takes longer after artificial ventilation, for example. But this has to be confirmed in the coming months.

Other forms of severe lung disease in which the patient had to be artificially ventilated had shown that the lungs could recover very well - provided that there were no previous damage, said Pfeifer.

"The fear that is discussed again and again that ventilation per se must lead to permanent damage is certainly not justified." The alternative would be not to ventilate the patient in a severe course - but this would likely mean death.

Measures are not a guarantee of survival

However, if there are complications or side effects from mechanical ventilation, there would be an increased risk of death, says Michels. With the start of artificial ventilation, weaning must therefore also be considered directly.

The Deutsches Ärzteblatt reports, citing a British study, that only every third patient who was ventilated in the intensive care unit in Great Britain could be discharged alive. Other studies also show that ventilators are no guarantee of survival for a long time. Should mechanical ventilation be the last resort
be?

"That would be a big mistake," says Pfeifer of the DGP. If invasive therapy is started too late, it simply means higher mortality.

There is no database yet

Sensible and correct ventilation can therefore increase the survival rate, said Torsten Bauer, Deputy President of the DGP. That emerges from experiences with past illnesses. The data for Covid should be available in the coming months, it said.

"For Corona, the necessary data to be able to make reliable statements is only just emerging," confirms Frank Heimann, Chairman of the Federal Association of Pulmonologists and Sleep and Ventilation Medicine. The experience of the ventilation team and the available resources currently play a particularly important role in treatment.

Recommendations of the professional associations should only serve as background information for the discussion in individual cases - and not "as a check list", says Lukas Radbruch, President of the German Society for Palliative Medicine. Ultimately, the doctor decides which therapy to offer and which not.

Alternative ventilation methods

The decision as to whether risks or benefits outweigh the risks is not black and white, says Radbruch. Another treatment option is non-invasive ventilation. "This is being discussed among ventilation specialists. The risk of damaging the lungs is lower with this method," says Heimann.

However, this form of ventilation is associated with higher personnel costs because the patient is often awake. Some also feared more droplet production and thus a greater risk of infection.

However, the DGP makes it clear in a recommendation that fear of infection should not be the primary reason for intubation. Rather, sufficient protective clothing is necessary here in the clinics.

Watch for the right moment for intubation

The pulmonologists of the DGP gave recommendations for the treatment of seriously ill Covid-19 patients on Friday. For example, good monitoring of the sick is important, as the situation can escalate in a few hours to the point where intensive medical treatment is necessary.

In addition, it is crucial to find the right time for invasive ventilation with intubation and artificial coma. If ventilation started too late, the patients would have a higher mortality rate. However, intubation should only take place if there are indications that the organism is no longer able to maintain the functions of the lungs and gas exchange on its own.

"Many now do not want to think about death and dying."

Radbruch advises people and especially high-risk patients to think in advance about what they want in the acute situation and whether they want to be ventilated.

For example, with the help of a living will or an emergency form. It determines which treatments are to be carried out in an emergency and which are not. Radbruch often observed resistance to this conflict in old people's homes: "Many now do not want to think about death and dying."

"If you had such an emergency plan, it would be a great help in the clinics," says Michels. The emergency physician therefore suggests that regional palliative networks develop these emergency plans together with retirement and nursing homes. For each resident it can be clarified how to proceed in a specific emergency. People who do not want to be ventilated, for example, could then receive palliative care.

Fear of death from suffocation

Corona patients, who no longer have any prospect of a cure, mainly suffered from shortness of breath, says Radbruch. "That often triggers fear." In addition, there is confusion, restlessness and coughing, and sometimes diarrhea. Some patients complain of muscle pain, "as in
a strong flu that hurts your whole body ".

In palliative care, morphine is used to counteract the symptoms. The patients then no longer feel short of breath. Ventilator patients in the hospital are kept in an artificial coma with medication and also do not experience any shortness of breath. "Nobody has to suffocate in hospitals. And neither in nursing homes," assures Michels.

Radbruch asked individual nursing homes how people with Corona died there. He was reported to have not suffocated. It could be different for people who do not receive medical care and, for example, die at home.

To die in company

According to a representative survey by the Berlin Institute for Population and Development, above all people want to die pain-free, well cared for, close to the familiar, socially integrated and self-determined. The survey was carried out in April 2020 as part of the study "On a mortal word".

Radbruch knows these wishes from his work. He heads the Center for Palliative Medicine at the Malteser Hospital in Bonn and the Clinic for Palliative Medicine at the University Hospital Bonn. There people who are dying can receive unlimited visitors.

The German Interdisciplinary Association for Intensive Care and Emergency Medicine has also recommended it for corona patients in the intensive care units - while observing the protective measures. "Above all, it is important that people are given the opportunity to express what they want in an emergency," says Radbruch.