Answering Your Questions About COVID-19 Treatment And ICU Stays

Stan Bunger
June 30, 2020 - 1:36 pm

    As we continue to navigate these unprecedented times, KCBS Radio is getting the answers to your questions about the coronavirus pandemic. Every morning at 9:20 a.m. Monday-Friday we're doing an "Ask An Expert" segment with a focus on a different aspect of this situation each day.

    Today, we're gonna focus on the disease itself and treatment, with a focus on ICU's with Dr. Angela Rogers, pulmonary critical care specialist at Stanford Healthcare who has been leading a critical care task force among Stanford Healthcare and dealing with this disease from the frontlines.

    So here we are, about three and a half, four months into this thing. Can you just talk to me for a moment about how you feel and your colleagues feel about where we are today?

    It's a good question. I would say in many ways, the last three to four months of being an ICU  doctor has been the hardest times of many people's lives. I can certainly say I feel very lucky to be in the Bay Area where we've had an amazing community response to keep our numbers down. We have not had nearly the surge that was had in New York, for example. But it's still been an unprecedented time of thinking about a new disease. How do we treat it? Do we treat it like we've treated other infectious diseases, other respiratory failures, or do we adapt to very rapidly emerging information? So it's been a real time to come together as a community to try to do our best to care for patients when we're not sure how to do that.

    Yeah that brings up a question I wanted to ask about the sort of silos that exists in any medical environment. People are specialists, they know what they know really well. But here's a case where nobody knew much of anything about this thing.

    Right. I would say that you're right that in general medicine is very siloed, but I have been amazed by the medical community's ability to work together here. I would say that's true within our critical care community, meaning anesthesiologists, ED doctors, neurologists, hematologists, infectious disease, pulmonary critical care medicine, nursing, respiratory therapy. Really everyone has worked together to try to very quickly figure out what's working well and what's not working and adapt to change quickly. 

    We've also been very humbled about what we know and don't know, because we don't have a lot of really solid clinical data about how to treat patients, and so reaching out to other communities that were harder hit, for example New York, or in the early days even Italy, China. What do other people know about how to do this? And is the level of evidence high enough that we should change our standard practices? 

    So we've had a critical care task force as you mentioned here at Stanford that at the height of things in early March and April, was meeting three times a week. We still have met every week for an hour to look at new things. You know, there are reports of blood clots or reports of when to do a tracheostomy. How do we handle delirium I know is a question that some of your readers were asking. So we meet as a large group of up to 50 people and discuss and come up with protocols and then share them with the community.

    Let's get to the questions then, which have been sent in by our listeners to Let's get to the first one here: what defines a case of COVID? I've heard that cases are skyrocketing in parts of the state and country, does that mean a positive test with a person suffering from a least one symptom or do the numbers include people who have tested positive but are asymptomatic?

    That's a good question. As you know, I'm an ICU doctor and that question might be a little bit out of my field. My interpretation is that those are positive tests. You asked about how things are better now than they were in early March, and one of the things is that we do have much more testing. So, you know, in March and April, there were people that had a little bit of symptoms but were okay enough to stay home and they were basically being told in early March, you just need to stay home, isolate for 14 days, assume you have it, but we don't really know. We're very lucky now in the Bay Area that there are a lot of places where people can get walk up testing whenever they care to and we have adequate testing now. And so if people have symptoms or had a concerning exposure, they're able to get tested so in our area our positives are less than 5%. 

    But you're right that the numbers across California of positive tests, especially emanating, I would say, out of Southern California, the numbers are really, really going up as the state has reopened quickly.

    And there's a question here about people who are at home, they're not sick enough to need to be in the hospital. Is there a well-developed protocol for then? This question wants to know guidelines regarding meds or breathing exercises or oxygen levels in the blood that might require a change in the treatment.

    That's a great question. Right now, there are no outpatient therapies for COVID-19 that I'm aware of. Certainly a really important thing if you're feeling just a little bit sick, but not that sick, is to isolate yourself. Always wear your mask, stay home as much as you possibly can. Obviously if you're feeling worse, come to an emergency room or call your doctor, but for the most part, it's really isolation. 

    There are clinical trials happening. There are clinical trials absolutely recruiting here at Stanford for outpatients and so, thinking about whether you'd be willing to be in a clinical trial to help future patients as well and potentially gain some benefit, those trials are happening. So I do think we'll know more in three months than we know now, just like now we know a lot more than we did three months ago. So the short answer to your question is there aren't specific therapies that have been proven to help outpatients. But there are things being tested: anti-inflammatories, antivirals in the outpatient setting.

    What determines when someone gets moved from a regular hospital bed to the ICU?

    So patients are admitted if they either need oxygen already or look sick either by labs or just physical exam when people come to the emergency room or to their doctors office, they'll get admitted to regular hospital wards. On the regular hospital wards, you're able to get two to three liters or up to five liters of oxygen, so kind of a modest amount of oxygen, although if you need oxygen you'd still be classified as having severe COVID disease.

    Once you get over about five liters of oxygen, we tend to move patients to the intensive care unit where you have very close nursing monitoring and can get a breathing tube if you need it, or high flow oxygen. So it's really the oxygen levels and how the patient is looking that determines the need to go to the intensive care unit. Sometimes patients with COVID-19 have other complications; heart rhythm problems, seizures, that kind of thing. And those patients will tend to come to the ICU too, but the biggest thing with COVID-19 and what I see a lot of your questions are about, have to do with breathing and the potential need for a breathing tube and mechanical ventilation.

    And that's obviously something that terrifies people just in the abstract. Maybe you could walk us through what that process is like? When that decision is made, how does it get made that someone needs intubation?

    Yeah, so intubation and the need for mechanical ventilation - a machine kind of taking over and giving you more oxygen and doing the work of pushing air into your lungs so that your body doesn't have to suck it in the way that we normally breathe - has been around for more than 50 or 60 years. And it's really a life saving therapy for people whose lungs are not able to do the work of bringing oxygen in and clearing carbon dioxide. We use it routinely for surgeries, we use it for people with bad pneumonias, acute respiratory distress syndrome for any other reason, other bad infections, flu. There are a lot of reasons that we use mechanical ventilation and COVID-19 is in many ways similar. 

    When the oxygen gets low or the carbon dioxide starts to rise, the patient is working really hard and you can tell they just can't keep that up, it's time to put a breathing tube into your throat and let the machine do the work for you to buy time until the patient can recover.

    So the next question kind of gets into the specifics: what's the average length of time from intubation to successful excavation? And secondly, are you seeing pulmonary fibrosis, neurological, cardiac or renal damage associated with post-COVID syndrome, as is being discussed as a potential subsequent diagnosis in the United Kingdom?

    COVID-19 pneumonia is quite severe for a lot of patients. So there are regular bacterial pneumonias, or most flus we see patients needing the breathing tube often for less than five days, it can be a pretty short course. Typical in COVID-19 are much longer intubations, we're seeing that across the United States as well that people just are on the breathing tube for a really long time with this disease, much longer than we're used to with other diseases. Although, you know, sometimes flu can be really bad and people need ECMO, really advanced life support for many weeks. So in COVID-19 on average, people are mechanically ventilated for a long time. 

    When people are mechanically ventilated for a long time they tend to have more complications, meaning other bacterial infections, risk for kidney injury. When people are sick for a long time on the breathing tube, it's not the breathing tube fault that they're sick, but really a sign of how bad their infection is. And it puts them at risk for other other complications as well. For most people who get what's called acute respiratory distress syndrome, or ARDS, which is the lungs filling up with fluid and a lot of systemic inflammation, most people can fully recover from that and are left without major lung scarring. But the consequences of being an intensive care for two or three weeks like this can be substantial. A subset of patients will develop lung scarring and many of those patients actually won't make it out of the hospital. A few patients probably do have some lung scarring longer term who do survive. And we know that just being sick in ICU, having the tube in your throat, some patients can be pretty awake but many of our patients are sick enough that they need to be deeply sedated to keep their lungs safe and then they have a lot of problems of delirium and confusion and can have longer term consequences of things like post traumatic stress disorder, depression, anxiety. We know that when you're in ICU for more than two weeks intubated, up to 1/3 of our patients will have those kinds of complications. 

    So I know there's a lot of focus in the press about exactly how many patients die of COVID-19 and we're really glad that our rates of mortality are far lower than what were initially heard in early March. We were hearing out of China that up to 80% of people needing a breathing tube were dying; we're definitely not seeing those rates in the United States or certainly here in the Bay Area, where we didn't experience a major surge. But even without death, there are a lot of long term consequences to ICU stay. So people need to be aware of that. As a community, we still need to try everything we can not to spread this virus and to decrease the number of people getting sick, because even for young people, there can be long term consequences.

    If ICU's become overwhelmed, will doctors still be able to take steps to deal with ICU delirium?

    Yes, ICU delirium is something that we deal with in every patient who is on the mechanical ventilator. We try our best to minimize the sedating medications that contribute to that. Delirium is partly probably also because people do have a lot of information, they're just really sick. And so in the same way that the kidneys are inflamed and the lungs are inflamed, the brain is probably inflamed too. So we have therapies that we try to do to minimize that and to get people off those medications and, frankly, off the mechanical ventilator as soon as we can.

    I think again, California's response to COVID-19 has been really good and Dr. Cody in our county of Santa Clara has been really amazing about trying to keep us from having a major surge where hospitals are overwhelmed. It is hard to care for patients with COVID-19, they're very sick. And so the ideal is not to let you ICU's get so full that you can't give the number one best care to every patient. And again in our area we've been really lucky to not have that happen, so that's absolutely our goal. We definitely feel confident here at Stanford that we can offer care to people with the community who have COVID, and also to those who come in with other critical illnesses. We're actually concerned that people have been putting off their routine care because they were avoiding hospitals for all those months, so it's important to take care of yourself. And the county and the region has really worked hard to come up with systems to try to smooth things so that everyone can get the care that they need.

    Of COVID-19 patients that require ICU, what percentage recover? And how long, on average, are they in the ICU?

    So I would say again, it's very clear that mortality rates are far lower than the 80% that we were hearing in March. You know, there are lots of different publications out there across the United States about different rates. Certainly in our area here in the Bay Area, I would say that the rates are closer to 1/3 or so, I don't know the exact number at the various hospitals but it's much lower than 80%. But still a substantial number of people we're not able to save despite every therapy that we can offer.

    Why are deaths going down while cases are going up? How much of this is because of the availability of testing? And is it good for herd immunity that more young people are getting COVID-19? 

    That's a savvy question by your reader. Absolutely, I think that part of the reason that mortality rates are going down is that in the early days we just didn't have nearly enough testing capacity to test people with mild disease. If you look at the numbers in the United States - I don't remember what today's numbers are - but we know that 125,000 people have died in the US of COVID-19. We know that for sure and we know that the mortality rates across other countries as well are close to 1%. So you can assume that 12 million people had COVID-19, so many more than were reported. There just wasn't enough testing in the early days. So now there is enough testing and so it makes sense that the mortality rates are falling.

    In terms of herd immunity, I think that our public health experts are telling us that we're nowhere near herd immunity. And to get to herd immunity, it's really gonna have to be something upwards of 70% of people. And trying, somehow, for herd immunity is an error because it would lead to again a surge situation where hospitals were overwhelmed, many people dying who don't need to. I think one of the things we've learned since March is that  masking, when people are out in the community, is actually quite effective in keeping numbers low and there's a tremendous effort by health care and science to try to come up with a vaccine. And so I don't think that there is anything good about the surging numbers that we see of young people getting it. 

    I think if young people are having it, then they will by definition pass it on to their elderly relatives that they come into contact with. We know COVID-19 spreads before people are sick. So I see the surging numbers as just an absolute negative. And also keep in mind that young people are getting desperately ill. We've absolutely cared for people in their twenties and thirties that needed mechanical ventilation for three weeks. I think young people have a lot of assurance that they should do well, and that's a good thing. As a mom of young kids, I feel good to know that if by chance they get sick or even get it from me, they're very likely to do well. But young people need to do their part as members of this community and wear their mask and not congregate in large, large groups.

    Before we let you go let me just run something by and get your reaction to it. I've been looking this morning at the positivity rate. It's a seven day rolling average, and these are numbers from the Kaiser Family Foundation. Here in California, it's pretty close to 6% of all test come back positive. In Texas right now, it's 14%. In Arizona it's 24%. In Nevada, right next door to us, it's 15%. Do these suggest to you that there's that much more disease or that there aren't enough tests for people who are not walking around feeling really sick.

    That absolutely suggests that there's not enough testing. You know, the CDC months ago came up with very clear guidelines for what is the positivity rate that suggests that there's adequate testing that people can do contact tracing, et cetera. We're hearing in the news about long lines and inadequate testing in Texas and the last thing you want, right, is long lines of people who think they might have COVID-19 to be standing around waiting for their tests and potentially exposing each other, right? It's a nightmare situation. So as a country we have to do our part to not spread things and wear our masks.

    And again, I feel very lucky in the Bay Area that we have great public health infrastructure and we need to listen to what they tell us to do, which is still to be trying our best to social distance to prevent the kind of disasters that are coming in other parts of the nation from coming here.

    This interview has been edited for clarity.