Ventilators Don't Cure COVID-19. What Happens When People Come Off Them? | Opinion

As the COVID-19 crisis unfolds in sections, it appears that the question of whether there will be enough ventilators available for everyone that needs one has been answered.

There will be.

Credit goes to a number of governmental and private entities that helped our country's health care providers avoid having to make similar—horrible—choices that had to be made in other countries about who gets a ventilator and who doesn't. These kinds of decisions are filled with the kind of value judgments that keep those of us in health care awake at night.

But now we must pivot to a new issue—and perhaps one that will unfold more slowly and be more vexing: What happens to people who require a mechanical ventilator to be kept alive, both in the short- and long-term?

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We can make some inferences based on studies that have evaluated the long-term effects in a similar patient population. The lung condition that can occur in COVID-19 patients is known by doctors as the acute respiratory distress syndrome (ARDS), which is an acute lung injury with many different causes, including infection, trauma, sepsis, and post-surgical and massive blood transfusions.

Mortality due to non-COVID-19 ARDS generally is around 25 percent, much lower than that seen in COVID-19 patients who are on a ventilator. Depending on what dataset one examines, the statistics examining survival if mechanical ventilation is required are sobering. Although some of these data include COVID-19 patients still being ventilated, and therefore incomplete, it appears across a few geographic locations that a high percentage of ventilated patients die of this disease.

In a recent study published in JAMA of patients treated at New York area hospitals, 88 percent of ventilated COVID-19 patients died. One important limitation was that the study mortality data assessed only patients who had died or were discharged. Patients still being ventilated were not included, meaning that the mortality number could go up or down, depending on this group's ultimate outcome. Another analysis looked at 98 ventilated patients in the U.K. and reported only 33 who were discharged alive. The numbers from Wuhan, China, are even grimmer. Only three of 22 ventilated patients survived. Studies of ventilated patients in Italy report similarly dismal results.

And what do we know about ventilated ARDS patients who survive?

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Again turning to the historical ARDS literature, studies have consistently shown that those who survive remain at risk for mortality and long-term health complications, which includes not only lung problems but also post-ARDS syndrome neuropsychological effects, including cognitive difficulties and higher incidences of mental health disorders, like depression and anxiety. These complications are not transient in many cases, with some studies showing persistent effects out to five years post-ARDS.

Leaving aside other health effects that do not involve the lung, pulmonary dysfunction is manifested in three ways: one, by radiographic changes, specifically pulmonary fibrosis which is a scarring lung disease; two, by pulmonary function changes which indicate functional impairment; and three, by a reduction in six-minute walk distances, which is a measure of exercise capacity. In multiple studies, all have been shown to be below normal in patients who have survived ARDS, and these effects have endured in studies that have followed patients for up to five years.

Just as we need a strategy to care for patients in the acute phase of COVID-19, we also need one to address the chronic phase.

Patient COVID-19 ventilator
Ventilator tubes are attached to a patient suffering from COVID-19 on the Medical Intensive Care Unit floor, MICU, at the Veterans Affairs Medical Center on April 24 in the Manhattan borough of New York City. Robert Nickelsberg/Getty

Long-term mortality after ARDS survival is primarily influenced by the presence of co-morbidities, just as survival with COVID-19 in the acute phase is. In addition to managing these risk factors, there are a few measures that should be taken with this patient group. First, regular follow-up visits with a lung specialist should occur. Second, these visits should include radiographic and functional assessments of this at-risk population, including regular measurement of lung function, CT imaging, oxygen saturation testing and six-minute walk tests. By doing this, pulmonologists can identify those patients who are not recovering.

Relatively few of these patients will progress to the point of needing a lung transplant, but patients and practitioners would do well to keep transplantation in mind if a post-ARDS patient develops progressive lung failure. Initial cases of lung transplants in recovering COVID-19 patients have already been reported in China. These preliminary reports are concerning for a variety of reasons, not the least of which are that China is not a country that has exhibited a high level of proficiency in lung transplantation—or, for that matter, an acceptable ethical standard, given its history of using organs procured from prisoners.

As our acute management of COVID-19 patients improves and effective therapeutics are developed, we should see fewer patients who develop ARDS, but patients and health care providers should be mindful of the long-term effects of this severe lung injury. Let's start planning the care of this group now.

David Weill, M.D., is principal and founder of the Weill Consulting Group, a biomedical consulting firm. He is the former director of the Center for Advanced Lung Diseases and the Lung and Heart-Lung Transplant Program at Stanford University Medical Center. He recently completed a memoir entitled Exhale: Healing, Hope, and a Life in Transplant. Learn more about him at DavidWeillMD.com.

The views expressed in this article are the writer's own.

Ventilators Don't Cure COVID-19. What Happens When People Come Off Them? | Opinion | Opinion