What your doctor is reading on Medscape.com:
APRIL 28, 2020 — Over 48 hours, eight patients arrived at the COVID-19 unit in Neustadt, Germany — four from an overwhelmed hospital in Strasbourg, France, and four who were transferred from other hospitals across Germany. All were critically ill, deeply sedated, and receiving lung-protective ventilation. It was clear to Gerhard Laier-Groeneveld, MD, a pulmonologist specializing in respiratory failure, that for all eight of his new patients, the long-trusted ventilation protocol wasn’t working. So, he made a controversial call.
He ordered that positive end-expiratory pressure (PEEP) be set to zero, inspiratory time to 1.4 seconds, pCO2 to less than 35 mmHg, and that tidal volume be increased to at least 800 mL. The regimen runs in direct contrast with widely held ventilation strategies and current guidance on COVID-19 treatment.
Within 20 hours of passive ventilation, one of the French patients, a woman who had been intubated for 14 days, was able to be extubated. Another was extubated on the second day. The remaining six are doing well in the ICU but are too weak to breathe on their own for more than a few hours, owing to the fact that they arrived under such heavy sedation. After 2½ weeks without any deaths, Groeneveld decided to share his strategy via Medscape Consult, a crowdsourced social media platform where clinicians share and discuss real cases.
“COVID-19 is not ARDS [acute respiratory distress syndrome],” Groeneveld posted. “And it does need a different strategy of ventilation,” he added later in an interview with Medscape Medical News. Although his patients were hypoxemic, CT scans showed pneumonia “with some homogeneous air space consolidation that does not respond to PEEP or prone positioning,” he wrote. Physicians from all over the world responded, thanking him for his advice and asking for clarifications.
It’s now been 4 weeks since the first patients arrived from France, and still there there have been no mortalities at the Neustadt COVID-19 unit. But many physicians are wary of abandoning decades of research-backed practices for this new approach in the face of a little-known virus. Still, Groeneveld insists the current protocols are inadequate, even dangerous, for treating COVID-19. And he’s not alone.
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Groeneveld posted to Consult just days after Luciano Gattinoni, MD, and his colleagues wrote an editorial arguing that COVID-19 has two distinct phenotypes, type L and type H. Type H, which is similar in pathology and treatment to ARDS, was only present in 20% to 30% of their 150 patients. Gattinoni argues that for the remaining 70% with type L, standard ventilation protocols are not productive and may even create injuries that cause COVID-19 to progress. The difference, Groeneveld says, between Gattinoni’s approach, detailed in a recent JAMA editorial, and his own is that Groeneveld believes passive ventilation is the best course of treatment for all patients, even ARDS-like type H.
A physician on the front line in New York City has also questioned ventilation protocols because he found that COVID-19 symptoms could often present more like high-altitude pulmonary edema (HAPE) than ARDS. However, clinicians with experience treating both HAPE and COVID-19 have pushed back on this observation and have argued that the comparison between the diseases is potentially risky.
Other experts say it’s too soon to abandon ventilation strategies that have been established through years of clinical trials. “Regardless of whether COVID-19 beha