Respiratory Therapist Speaks Out
about Covid and Mechanical Ventilation
by Betsy Thomason 2021
In 2019, covid introduced the world to respiratory therapists and their work managing folks connected to mechanical ventilation. In 2020, during the height of the spread of coronavirus, a pop-up covid hospital in the New Jersey Meadowlands, just west of New York City, begged me to come out of retirement for $70/hour, about twice the average hourly wage. I declined, feeling that the best use of my 25 years of experience with ventilators in hospitals and home care is to share my knowledge and point of view with the public.
The purpose of this article is to explain ventilator basics, as related to people with severe covid. This may help you as you navigate the medical world on behalf of a loved one, or even yourself.
Mechanical ventilation is designed to do the breathing work for people with extremely disabled lungs, usually because of damaged lung tissue, as in chronic obstructive pulmonary disease (COPD); or extreme weakness of the surrounding muscles, as in neuromuscular conditions, such as muscular dystrophy, post-polio syndrome, or amyotrophic lateral sclerosis (ALS). The ventilator pushes air into the lungs and then pauses for expiration (one breath); then pushes another bolus of air into the lungs, over and over again, 24/7.
The lungs of critically ill covid patients are connected to the ventilator in one of three ways: with a tube inserted up their nose, or into their mouth, or via a surgically created hole in their neck, below their voice box. All three eliminate the possibility of speech.
There is, however, a difference between the “usual” use of mechanical ventilation and this covid-related mechanical ventilation. The major difference is that the blood of many critically ill covid patients lacks hemoglobin — iron to which oxygen attaches in the blood. While the ventilator continues to push in the bolus of air, creating the rise and fall of the patient’s chest, the blood is unable to accept the gift of oxygen. This may account for the low success rate of mechanical ventilation for people with covid.
Preliminary research documented in Pub Med Central at the National Center for Biotechnology Information (NCBI) suggests an underlying reason for the failure of mechanical ventilation in covid patients: “We speculate that in covid-19, beyond the classic pulmonary immune inflammation view [pneumonia], the occurrence of an oxygen-deprived blood disease, with iron metabolism dysregulation [dysfunction], should be taken into consideration.” (1.)
Here’s my interpretation:
Severe covid is basically pneumonia, accompanied by: 1) a lack of hemoglobin, the oxygen-carrying particle of the blood, as well as 2) dysfunction of iron metabolism in the tissues. In the first case, due to the lack of hemoglobin, the blood is unable to transport oxygen. In other words, the blood cannot support life. In the second, the dysfunction of iron metabolism in the tissues may cause blood clots, resulting in pulmonary embolism (PE) and/or deep vein thrombosis (DVT) — both potentially deadly. Simply stated, there is not enough iron in the blood and too much iron in the tissue; but scientists can’t say why.
Here’s the essential question:
Can ventilators truly support the life of critically ill covid patients?
Let’s take a look at what the experts report in one medical journal:
The American Journal of Respiratory Critical Care Medicine (AJRCCM, one of several journals published by the American Thoracic Society and publicly available online) in January 2021 reported a meta analysis of 69 studies that included outcomes for 57,420 adult covid patients using invasive mechanical ventilation. Simply stated, the fatality rate for folks younger than 40 was 48%. The fatality rate for folks over age 80 was 84%. (2.)
Initially, this information suggested to me that invasive mechanical ventilation is pointless in a vast majority of covid cases. But there is a problem with this information. While we, the public, try to understand these critical medical issues, the medical community deals with multiple issues and conflicting data and definitions that lead to misconstrued conclusions. For example, in the February 2021 issue of AJRCCM, the editors recanted and downgraded the previous month’s covid ventilator death rate statistics mentioned above. Even prior to this, AJRCCM editor Hannah Wunsch, MD confessed in a July 2020 editorial that the medical community needs to learn how to report complex information with improved clarity and intention. (3.)
Now the medical community is reaching for another high-ticket item—extracorporeal membrane oxygenation or ECMO. Simply stated, this machine removes blood from the body via a tube placed in the neck. Then the machine adds oxygen to the blood, and pushes the blood back into the body. These machines have been part of open-heart surgery for decades, but are not in great supply. Now in the covid marketplace, the demand for ECMO is high; the supply low.
Here are some medical ethics questions: Who decides who receives the high-priced equipment and associated supplies, and the trained personnel? Who even wants it? Are medical devices always used in the patient’s best interest? Are we pushing the inevitable—death—into an unsustainable future?
There are thousands of microbes in our world; some we can’t live without; others have the potential to cause great harm. How can you balance this and prevent disease? Your immune system is what keeps you healthy. From my vantage point as a healthy health professional and an active septuagenarian, it is my own immune system that allows me to live independently, disease-free, and to enjoy life. Thus, my daily task is to care for my immune system. I focus on my outbreath for energy as well as for management of pain and stress, and I include daily doses of nutritious food, water, exercise, restful sleep, and joy. Lots of joy.
What is your approach to the covid conundrum?
About the author:
Betsy Thomason, a Vermont resident, began writing in the 1970s as a stringer for a community newspaper in northern New Jersey. Her articles have also appeared in specialty magazines for small business, respiratory therapists, and the outdoors. She is the author of Just Breathe Out—Using Your Breath to Create a New, Healthier You (North Loop Books, 2016).
Betsy Thomason, 2766 #1 Windham Hill Road, West Townshend VT 05359
1. PubMed Central at National Center for Biotechnology Information; Clinics and Practice, May 19, 2020; 10 (2):1271:
2. American Journal of Respiratory Critical Care Medicine. January 1, 2021. 203(1):54-56.
3. https://doi.org/10.1164/rccm.202004-1385ED Wunsch, Hannah, MD; Editorial: July 2020; American Journal of Respiratory and Critical Care Medicine: Mechanical Ventilation in COVID-19: Interpreting the Current Epidemiology