Do COVID-19 Vent Protocols Need a Second Look?

Hello. I'm Dr. John Whyte, Chief Medical Officer at Web MD, and welcome to Coronavirus in Context. Today, we're going to talk about whether or not we're managing coronavirus correctly, and do we need to think about a change in our treatment regimens.

And my guest is Dr. Cameron Kyle-Sidell. He's a physician trained in emergency medicine and critical care, and he practices at Maimonides in Brooklyn, New York. Welcome, Dr. Sidell.

Thank you very much. Thank you for inviting me.

So you've been talking a lot about the number of patients, the percentage of patients, actually, that are dying on ventilators. When did you first notice this trend?

You know, so in preparation of opening, what was, you know, going to be what became a full COVID positive intensive care unit, you know, we kind of scoured the data just to see what was out there.

And obviously, um, you know, those that have experienced it before us, uh, primarily the, you know, the Chinese and the Italians, you know, it was hard to find exactly, you know, what the rate of, you know, what we call successful excavation, meaning someone was put on a ventilator and then taken off.

And that data is still hard to find, and I imagine there's a lot of people still on ventilators. Um, but from the data we have available, it appears to be, you know, somewhere between 50% and 90%. And it seems that most, reports or most, published data, you know, puts it around 70%. So, you know, that's a very, very high, percentage in general, when one thinks of a medical disease.

And you've been talking on social media. Um, you say you see things that you've never seen before. What are some of those things that you're seeing?

Um, you know, so when I initially started treating patients, you know, I was under the impression, as most people were, that I was going to be treating acute respiratory distress syndrome that, you know, was similar in some sense, to the, you know, ARDS that I saw as a fellow.

Um, and as I started to treat these patients, I did. I witnessed things that are just unusual. And I'm sure doctors around the country are experiencing this. And, you know, it's not -- in the past, we don't see patients that are, talking in full sentences and not complaining of overt shortness of breath with saturations in the high 70s.

It's just not something we typically see. Um, you know, when we're intubating some of these patients, that is to say, when we're putting a breathing tube in, they tend to, drop their saturations very quickly. And we see saturations going down to 20, to 30.

And typically, one would expect some kind of, um, reflexive, um, response from the heart rate. Um, which is to say, usually, we see tachycardia. And if patients go too low, then we see bradycardia. And these are things that, you know, we just weren't seeing.

And, you know, I've seen literally a saturation of 0 on a monitor, which is not something we ever want, and something we actually actively, uh, try to avoid. And yet, you know, we saw it. And many of my colleagues, similarly, have seen, you know, saturation of 10 and 20.

And, you know, our whole practice is aimed, when we try to put breathing tubes in, is to avoid this very situation. Now, uh, these patients tend to desaturate extremely quickly. Um, and so these, uh, these situations have occurred. And still, you know, what we're seeing, that there was no change in the heart rate is just unusual. It's just something that we are not used to. So that's--

Are you suggesting that this is more like, a high altitude sickness? Is that right?

Um, so --

-- of our own home that we're talking about?

Yeah, so -- so what I was trying to find -- you know, the patients in front of me are unlike any patients I've ever seen. And I've seen a great many number of patients, and I've treated many diseases. And you get used to seeing certain patterns. And just, the patterns I was seeing did not make sense. Now, this originally came to be when we had a patient who had hit what we called our trigger to put in a breathing tube, meaning she had displayed a level of hypoxemia, of low oxygen levels, where we thought she would need a breathing tube.

And most of the times, when patients hit that level of hypoxia, they are in distress. And they can barely talk, and they can't say complete sentences. And she could do all of those. And she did not want a breathing tube. And so she asked that we put it in at the last minute possible. And it was this perplexing clinical condition -- when I was supposed to put the breathing tube, when was the last minute possible?

And all the instincts as a physician -- you know, we're looking to see if she, you know, so-called tires out, if she's getting too tired. None of those things occurred. It's extremely perplexing. But it just -- I came to realize that this condition is nothing I've ever seen before. And so I started to try to read, and try to figure out what's -- and leaving aside the exact mechanism for how this disease is causing havoc on the body, but just trying to figure out what the clinical syndrome looked like.

Talk a little bit about the data from Italy, and --

Yeah.

-- Gattinoni. Were you aware of what was going on in Italy before you noted these observations? Or did that come after the fact?

So that came a little bit after. And I wasn't aware -- you know, I can't even remember the exact timeline. But in my reading, I sort of came upon decompression pulmonary sickness, which is, you know, essentially the bends -- when divers dive and come up too quick, which seemed to have some kind of a mirror picture, clinically, as these patients. And then, you know, in discussions with other people, it came up that, you know, they do similarly appear, clinically.

And this is not to say that the pathophysiology underlying it is similar, but clinically, they have -- they look a lot more like high altitude sickness than do pneumonia. And Gattinoni, you know, he published something on March 20th, which was about two days before I opened the ICU. And I don't know that I read it then, but somehow it got passed around. And, you know, in my mind, by the time I read what he was saying, I'd come under the impression that this just wasn't the usual ARDS that we were used to seeing.

It was a high compliance disease, which every pulmonologist, and anyone managing a ventilator, can see. That's not a question. And so then when I read his stuff, where he's suggesting that the management strategy that we use is essentially somewhat flipped, at least in these high compliant patients, it just became more clear that if we operate under a paradigm whereby we are treating ARDS in these high compliant patients, we may be not operating under the right paradigm.

How have you changed your protocols, then?

CAMERON KYLE-SIDELL: So to be honest, you know, I've run into a great deal of resistance within my institution, which is not to say that anyone is trying to stymie progress at all. These are the protocols that are, you know, in every major hospital, and minor hospital. I mean, you know, we generally --

We talked about it in your videos. You're against a long standing dogma. So what's been the response from your clinical colleagues, as well as hospital administrators?

So to be honest, in the ICU, I started to try to, you know, run -- not my own protocols, but to treat patients as I would have treated my family under -- with different goals, which is to say a ventilation. However, these didn't fit the protocol. And the protocols is what the hospital runs on, with the respiratory therapists, with the nurses. I mean, you know, everyone is part of the team.

And so, actually, we ran into an impasse where, you know, I could not -- I could not morally, in a patient-doctor relationship, I could not continue the current protocols, which again, are the protocols of the top hospitals in the country. But I could not continue those. And obviously, they couldn't have someone -- you can't have one doctor just doing their own protocol. So I actually had to step down from my position in the ICU.

And so now I'm back in the ER, where we are setting up slightly different ventilation strategies. But fortunately, we've been boosted by recent work by Gattinoni, which actually was formally published today, which does outline the best evidence-based and at least expert recommendations for changes in what were our overall protocols.

Quickly, can you tell us what are some of those changes that you're going to make?

First, I'll describe sort of what Gattinoni is saying, which is that really what we're seeing in ARDS are two different phenotypes -- one in which the lungs display what you call high compliance, low elastance, and one in which they have low elastance and high compliance. And so really what that is, to say simply for people who are not, you know, pulmonologists, is that if you think of the lungs as a balloon -- typically, when people have ARDS or pneumonia, the balloon gets thicker. So not only do you lack oxygen, but the pressure and the work to blow up the balloon becomes more. And so one's respiratory muscles become tired as they struggle to breathe. And so patients need pressure. What Gattinoni is saying is that there's two different, essentially, phenotypes -- one, in that sense, where the balloon is thicker, which is a low compliance disease. But in the beginning, they display high compliance, which is to say that -- imagine if the balloon is not actually thicker, but thinner.

And really -- so they suffer from a lack of oxygen, but it is not that they suffer from too much work to blow up the balloon. So as far as how we're going to switch, is we're going to take our approach differently from the traditional ARDSNet protocol, in that we are going to do an oxygen-first strategy. Which is to say, we're going to leave the oxygen levels as high as possible. And we're going to try to use the lowest pressures possible to try to keep the oxygen levels high.

And so that's the approach we're going to do, so long as the patients continue to display the physiology of the low elastance, high compliance disease.

Do you feel that somewhere, the world made a wrong turn in treating COVID-19?

CAMERON KYLE-SIDELL: I don't know that they made a wrong -- I mean, it came so fast. You know, I think that one thing we benefit from is that the Chinese and the Italians were hit first, and they were hit hard. And I cannot imagine -- I mean, really, New York is being hit so hard. It's hard to switch tracks when a train is going a million miles an hour. And I think, in that sense, we benefit from their shared experience. And I think it's important that we listen to that experience.

But I do think that it starts out with knowing, or at least accepting, the idea that this may be an entirely new disease. Because once you do that, then you can accept the idea that perhaps all the studies on ARDS in the 2000s and 2010s, which were large, randomized, well-performed, well-funded studies -- that perhaps none of those patients in those studies had COVID-19 or something resembling it.

And so it allows you move away from a paradigm in which this disease may fit. And unfortunately, you kind of have to walk somewhat into the unknown.

I think you're advocating something a little different. So what are the consequences of you being wrong, albeit well-intentioned? What if you're wrong?

You know, at this point, I would say, you know -- I mean, you know, right now we have some of the greatest experts in the world giving their opinions now. By that, I mean the Italians and Dr. Gattinoni, which is suggesting this. So, you know, I certainly could be wrong. And really, what more I'm asking for is not even an immediate change in the ventilation strategy, because, I'm critical care trained. I'm not pulmonary trained.

And I'm not as experienced as, you know, many around the country, and many in my own hospital. But what I would like to see is all these great minds get together. And if they can accept this notion that perhaps we need to switch paradigms, and they're able to better create a path forward that fits the disease, I would gladly follow them. And so, really, what I'm asking, and what I'm requesting, is that all the experts in the field get together and perhaps come up with some fresh recommendations.

Now you've been active on social media, as I mentioned. Are you a whistleblower?

I've never -- this is sort of my first foray into social media. I don't know that I'm a whistleblower, because I don't know that anyone was trying to purposely do any harm. I think that, you know, all the physicians involved, and all the nurses, and everyone writing protocols -- you know, everyone, I believe, is working as fast and as hard as they can with utter good faith and pure intention.

You know, I think that, for me, I saw something clinically that didn't make sense. And seeing that New York is about 10 days ahead of the country, you know, I just felt compelled to get that information out.

Has speaking up impacted your professional career?

I mean, I don't know yet. You know, I don't know. In one sense, I feel -- I have not felt qualms about it. You know, I -- for whatever reason, you know, I trained in critical care. And I was an ER doctor. You know, and I think part of that allowed me to see it a little bit better, because if you just received these patients in the ICU, on breathing tubes, it's very hard to see this physiology. And you know, I was running around the hospital from the ER, to the floors, to the ICU.

And I saw them in all stages of this disease. And I think part of it is when you see them in all those different stages, you're able to see that something, physiologically, doesn't make sense. And so in a way, I do feel that somehow -- you know, somehow my training, and my position, and being in New York City, you know, allowed me to see this. And so I have not felt any conflict about coming forward, per se.

And I don't know what it will do for my career, you know. But I hope that, you know, people know that I'm not doing this with any kind of -- I'm not trying to stymie anything, or to -- you know, it's really, I'm doing what I think is right.

What are the two things that we need to be doing right now, in your mind, to really kind of address the mortality?

You know, well, that's a good -- to go back to your question of -- yeah, if I am wrong. You know, doctors right now -- and these are my colleagues. We are desperate now, in the sense that everything we are doing does not seem to be working. So we've reached a point that most other -- in other diseases, we have not reached, where many physicians are willing to try anything that may help, because so little seems to be helping.

As far as what we can do, you know, one of the reasons I hope to speak up, and I hope people at the bedside speak up, is that I think that there is -- there may be a disconnect between those who are seeing these patients directly, who are sensing that something is not quite right, and those brilliant people and researchers and administrators that are writing the protocols and working on finding answers.

So I think that -- you know, if the first thing to do is if we can admit this is something new, I think it all starts from there. And I think that we have the kind of scientific technology and human capital in this country to solve this, or at least have a very good shot at it. So that's the first.

And I think the second thing is that whatever collaboration we can do with those who came before us. And by that, the Chinese, and the Italians, and the Egyptians, and whoever else has experienced this -- anything we can learn from them, you know, I think we need to open up and be ready to receive their help.

Well, Dr. Kyle-Sidell, I want to thank you for speaking up and sharing your story with us.

Thank you very much. I appreciate you allowing me to speak.

And now I want to thank you for watching "Coronavirus in Context." I'm Dr. John Whyte.