The importance of ventilators should not be questioned

It is rare for us to pay any notice to what is published in the Daily Mail. However, their article titled “Is this proof ‘life-saving’ ventilators are actually deathtraps?” is so devoid of science, and so potentially dangerous, that it must be responded to.

The central premise of the article is that invasive ventilation (i.e. having a tube inserted through your nose or mouth to your lungs to make an tight seal, then having a machine breathe for you) is not the right treatment for very unwell patients with Covid 19, and that this is causing a high death rate. The article appears to be based on the twitter thread of an American doctor, Cameron Kyle – Sidell. He is reported to have “Broken ranks with the medical establishment” in calling for doctors to rethink whether our old protocols for treating severe lung disease are applicable with the current patients. This is not in any way breaking ranks with the medical establishment. There are constant discussions and research going on at local, national and international level to look at how to modify our treatment of extremely ill patients with Covid, and modifications to guidelines are occurring on a constant basis. This period, at the coal face at least, is an example of evidenced based medicine at its very best. 

The article would lead the reader to believe that ventilation is a treatment that is specifically used for pneumonia. This is not true. Intubation (i.e. “putting in a tube”) and ventilation is used as part of a stepwise ladder for many serious illnesses. The article also, dangerously, claims that developing “yellow, mucousy, gunk” in the lungs is a definitive sign of Coivd infection. This is both not true, as very many chest infections will cause an increase in thick secretions from the lung, and also irresponsible to claim, as it could result in millions of people with minor chest infections leaving isolation to get urgent medical attention as they are concerned they have Covid due to the presence of coughing up yellow mucous.

The article reports from several studies that many people who go onto a ventilator end up dying. This is unfortunately true. However, this is not specific to patients who have Covid; whenever somebody goes onto a ventilator they are at risk of dying. This is because, for health staff to put patients onto a ventilator, the patient must already be very unwell and not responding to less invasive treatments. Therefore, the claims in the article that many patients treated with less invasive breathing support tend to get better is getting cause and correlation confused: Patients who improve with less invasive treatments are, by definition, less sick and so less likely to die, than patients who end up being ventilated.

The article claims that the answer is to give patients either high flow oxygen or Continuous Positive Airway Pressure, also known as CPAP. Both of these techniques fundamentally involve pushing air and oxygen into the lungs to hold them open and stop them collapsing down. This is analogous to trying to blow up a balloon: when the balloon is fully deflated, it is hard to get the balloon to begin to inflate. However, once there is some air in the balloon, it is quite easy to get it to inflate more. CPAP holds the lungs in a state where they always have some air and pressure contained within them, to make it easier for the body to then inflate the lungs more and breath.

This is a very well established technique which is widely used in many different specialities for unwell patients. However, there are two problems with this argument. Firstly, if somebody is being ventilated then they are already being given CPAP plus additional intermittently higher pressure to make the patient breathe in, before dropping back to CPAP pressure to allow the patient to breathe out. Therefore, the argument presented in the article that CPAP is able to penetrate these thick secretions in a way that ventilators can not is ridiculous; if there was something special about CPAP, then ventilated patients would get an identical benefit when breathing out. Also, this argument requires the logical jump that low pressures can get through the secretions, but high pressures can not.

The other problem with CPAP and high flow oxygen in the current pandemic is that both systems involve blowing gases into the patient. To prevent the patient’s lungs over inflating and puncturing, there needs to be a way for gases to come back out of the patient. Unlike on a ventilator, where the breathing in and out is on a closed system, CPAP and high flow oxygen therapy both involve the patient breathing out into the room. This means that the virus from the patient’s lungs will be spread throughout the room, posing a serious risk to the staff caring for the patient and anyone else in the environment. One could argue that this could be dealt with by equipping all staff with airtight suits so they are completely isolated from the patient’s environment. However, the Daily Mail article makes no reference to this risk; following the plan laid out in the article would likely lead to even higher rates of infections and death among healthcare staff.

The final argument that the article makes is in favour of a therapy called “proning”. This fundamentally involves lying a patient on their front for prolonged periods, which helps to open up the lower parts of the lungs. They argue that this is much easier in a patient who is wearing a simple oxygen mask than in one who is ventilated. The article is correct, this is an effective therapy. Currently it appears to be one of the best approaches we have in improving the condition of patients in the short term. It is too early to tell whether it has long term benefit. Because it is effective, it is also one of the most commonly used techniques in patients who are most unwell with Covid 19; the article is arguing for something that is already happening. The article is also correct in saying that the process is easier in patients who are not on a ventilator. However, this is a nonsensical argument. It is clearly easier to prone somebody who is awake, alert, conscious and cooperative than somebody who is in an induced coma on a ventilator. Proning is currently being used regularly in patients who are simultaneously ventilated, paralysed, have central lines and are on heart – lung machines; need for proning is not in anyway an argument for not ventilating people.

So if the article is full of errors, misunderstandings of the science and outright falsehoods throughout, there is the question of why it was published. We currently have a shortage of intensive care beds, ventilators and many other pieces of equipment. The reason for this is due to political decisions of successive governments. There have been repeated warnings by healthcare staff, the trade unions and progressives for many years that we have no capacity to deal with a major crisis. The last few weeks have shown that this wasn’t just complaining for political benefit, or making up scare stories, but was a genuine and accurate appraisal of how things were in a under supported health service. Now that we have been proven right, the government and their allies in the right wing media are desperately trying to distract attention from what is going on. What better way to silence those who were calling for more capacity and support than by leading people to believe that, had the health service been given the equipment it asked for, it would have led to misuse of the equipment and more deaths? This is a cynical, unscrupulous attempt by the Daily Mail to gaslight the public into thinking that better resourcing would lead to bull headed NHS staff following outdated practices that would lead to more deaths. They should be condemned for their poor understanding of the science, and they should be condemned for the hypocrisy of making cheap political points while calling for us to all back the government and dampen down dissent.

CPB Health Commission