Bengaluru/New Delhi: A recent instance of high mortality among ventilator-ridden Covid-19 patients at Bangalore Medical College and Research Institute (BMCRI) has made it increasingly clear that their role in treating patients has taken a back seat.
Of 90 patients who were intubated on ventilators at the government-run facility until 13 July, only one survived.
The patients who died were aged between 20 and 70 years, and all of them either had comorbidities or were shifted to the hospital during the last stages of their illness, hospital authorities said.
“80 per cent of the patients died within four to six hours of reaching our hospital. They were already intubated from outside. They had severe comorbidities like heart diseases, acute hypertension, diabetes, chronic kidney diseases, coronary artery disease and some patients were also on dialysis when they came to us,” Dr C.R. Jayanthi, director-dean of BMCRI, told ThePrint.
A senior doctor with government-run Victoria Hospital said: “Several patients are taken to private hospitals and when it comes to putting them on a ventilator, they are diverted to Victoria hospital or BMRCI. Many do not want to take responsibility for these patients.”
High mortality among Covid-19 patients on ventilators is, however, not unique to the BMRCI alone.
A hospital in Patiala reported last month that all its 12 patients on ventilator had died. In Delhi, former dean of Maulana Azad Medical College, Dr Deepak Tempe, told The Indian Express last week that 85 per cent of patients put on ventilator in the national capital had died and doctors are “reluctant” to use them.
While there are no nationwide statistics yet on the survival rate of patients on ventilators, it is becoming clear that ventilators do not really help in curing critical Covid-19 patients.
High mortality among ventilator users ‘common’
When cases of the novel coronavirus first began to climb in March, ventilators were thought to be the need of the hour, given the fact that Covid-19 attacks the lungs.
A tally of the country’s ventilators in April came to about 40,000. The government then allocated Rs 2,000 crore from the PM CARES Fund towards the production of 50,000 indigenously made, low-cost ventilators.
“The rush for ventilators that we saw some months before was to prepare for the worst-case scenario. This worst case scenario hasn’t been realised, but we still need ventilators. ICUs are better equipped this way,” said Dr Anil Gutroo, professor of medicine at Lady Hardinge hospital in New Delhi.
A ventilator requires a tube to be inserted into the patient’s throat, so that oxygen can flow freely into the lungs. This is called intubation. When a patient requires this kind of ventilation, their lungs are usually too weak to perform their most basic function — absorb oxygen and release carbon dioxide. The ventilator functions as a “pump” that mimics this function.
The number of active Covid-19 cases in the country stands at 3,58,692. Of these, less than 1.94 per cent patients are in ICUs, 0.35 per cent are on ventilators and 2.81 per cent on oxygen beds. So far, 25,602 patients on ventilator have died, putting the mortality rate in the country at 2.5 per cent, according to government data.
Several doctors and pulmonologists agree that once patients are put on a ventilator, high mortality is “common” and “unsurprising”.
“High mortality among patients on a ventilator is very common,” said Dr Sai Praveen Haranath, a pulmonologist with Apollo Hospital in Hyderabad.
“People who are on a ventilator cannot breathe because their lungs are too damaged to do so. When a disease advances to this level, generally there is high mortality, especially when there are other complications or comorbidities,” said Dr Haranath.
This isn’t to say that all those on a ventilator will die, but the chances are higher if the patient has an underlying illness or other health complications, he added.
Patients who die of Covid-19 tend to be in a vulnerable age group, and develop Acute Respiratory Distress Syndrome, or a cytokine storm (an overactive immune system response).
Ventilators have thus become the last resort, and are reserved for only two to three per cent of patients, who reach the critical stage of the Covid-19 illness.
“Before a patient is put on a ventilator, typically every other method of improving their oxygen levels is tried. The first is oxygen supplied through a nasal cannula. Most patients respond to this and get better. If this doesn’t work, a High Flow Nasal Oxygen (HFNO) therapy is used. Then we try a non-invasive ventilator, and only if this fails, is an invasive ventilator used,” said Dr Gutroo of Lady Hardinge hospital.
Use of experimental drugs helped
Dr Sudharshan Ballal, chairman of Manipal Hospitals in Karnataka, said that those who are intubated come to the hospital when they are severely affected by the virus. But outcomes of survival can depend on different factors. Ballal, for example, has noticed that those on HFNO tend to survive more.
“We have a multi-pronged approach where we treat using conservative or supportive measures by giving them oxygen and help them maintain their vital signs. We also give our patients high flow nasal oxygen and in extreme or late cases, intubation is done,” Dr Ballal said, adding that those using high flow oxygen “have been able to survive and recover well”.
Epidemiologist Giridhar Babu says the timing of providing treatment — including intubation — is critical.
What has also helped is the emergence of experimental drugs.
“We saw extremely high mortality before we started using experimental drugs like remdesivir and tocilizumab,” said Dr Dhiraj Malik, medical superintendent of Saroj Specialty Hospital, a private Covid-19 facility in Delhi.
He also said that about 50 per cent of its patients on ventilator have survived so far, while the other half has succumbed to the illness.
“When a patient dies, it’s mostly because they have comorbidities. But what helps is proper and careful ventilator support.”
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