Illustration: Xinmei Liu

Six Months In

Why More Covid-19 Patients Are Surviving the ICU

Intensive care has risen to the challenge of 2020. Here’s what has changed.

This story is part of “Six Months In,” a special weeklong Elemental series reflecting on where we’ve been, what we’ve learned, and what the future holds for the Covid-19 pandemic.

Matt Morgan, MD, an intensive care doctor at the University Hospital of Wales, in the United Kingdom, vividly remembers his first Covid-19 patient. It was a busy day at his hospital, and the patient was so ill upon arrival at the intensive care unit (ICU) that they needed life support almost immediately.

Back then, in late March, Morgan knew that Covid-19 had already caused havoc in Italy and begun spreading in the U.K. Morgan, who is also Wales’ lead for critical care research, had expected the disease would reach his hospital, but it was only when he and his team began treating patients infected with SARS-CoV-2 that they realized how serious Covid-19 can be.

“It’s fair to say in those early days we thought Covid was a lung disease,” he says. The virus is now known to cause problems in other organs, including the heart, kidneys, and brain. In some cases, patients who survive are left with long-lasting symptoms.

That first patient Morgan treated spent a long time in intensive care — but the attention they received there meant they survived.

Around the world, ICU physicians like Morgan have battled Covid-19 doggedly from day one, even as some ICUs have been stretched to or beyond capacity. Responding to the pandemic has meant adopting new procedures, such as isolating patients from their families and adapting to changing guidelines regarding the use of personal protective equipment (PPE). Hospital staff have worked interminable hours. Some have died from Covid-19 themselves. And many have watched patients slip away while others have pulled through.

Now, six months into the pandemic, there is growing evidence that the Herculean effort made by ICU staff has made a real difference in Covid-19 survival rates, which have significantly improved for intensive care patients since the start of the pandemic. One study in the journal Anaesthesia found that Covid-19 death rates in ICUs around the world had fallen from more than 50% in March to around 40% at the end of May. That is still roughly double the mortality one would expect from cases of viral pneumonia in intensive care, which again indicates how dangerous a disease Covid-19 is. But the improvement is clear — and it has happened relatively quickly. How did it come about?

Trying drugs, rethinking ventilators

For one thing, some intensive care staff have been involved in trials to find out whether certain drugs can help severe Covid-19 patients pull through. Three drugs in particular have gained attention: remdesivir, dexamethasone, and hydrocortisone. The latter two, corticosteroids, have been shown to cut the risk of death in critically ill patients by a third.

ICU doctors who spoke to Elemental all mentioned the importance of these pharmaceutical treatments. And yet none of these drugs is a miracle cure. Doctors working in ICUs think other factors have also been important, including what other treatments they offer to patients, and when.

Take ventilation, for instance. When someone whose lungs have been ravaged by Covid-19 is struggling to get enough oxygen into their blood, ICU staff can choose from various interventions to try to help them. One technique is high-flow oxygen therapy, which involves blowing oxygen up a patient’s nose via tubes. Another option is to use a CPAP machine, which provides oxygen via a tight-fitting face mask. These are relatively noninvasive methods — but early in the pandemic, many ICU physicians avoided using them because they feared they could help spread the virus around hospital rooms, potentially infecting staff.

Nuala Meyer, MD, professor of medicine at the Hospital of the University of Pennsylvania, recalls that in the first few weeks of the pandemic, she and colleagues more commonly opted for ventilator systems instead. Although air flow can be carefully controlled with these devices, ventilators are more invasive. They require putting patients into chemically induced comas and inserting tubes deep into their airway. This can cause complications, and it may be harder for patients to recover once they are taken off such systems.

As the pandemic unfolded, it became clear that appropriate PPE actually did do a sufficient job of protecting health care workers from the aerosolizing effects of less invasive therapies. It was one reason why ventilators were used less over time.

“One of the more dramatic changes is being less worried about that spread,” Meyer says. That had benefits for patients, too: “If you can avoid the ventilator, you avoid sedatives, and maybe there is a benefit there,” she adds.

It’s a balancing act, though, Morgan says, because it can also be detrimental to keep a patient on less invasive methods should they prove ineffective. The patient only becomes more exhausted, and switching to the ventilator at that point can be even more of an ordeal for them.

Overall, though, the consensus among ICU staff seems to be that being able to opt for CPAP or high-flow oxygen therapies is a good thing. In time, clinical studies may prove that this has had an impact on mortality.

“In a strange way, yes, of course it was a new disease and loads to learn, but that’s kind of what we do every day.”

Proning

It has also become more common for ICU doctors to put patients in what’s called the prone position, where they lie on their front rather than on their back. In this position, the patient’s lungs are slightly freer to expand and absorb more oxygen, which is crucial for those with Covid-19 pneumonia.

“Usually we had withheld it for the more severe patients,” says Meyer, who explains that over time it became customary to ask patients in the ICU to “self-prone,” so long as they were not in shock or had low blood pressure, for instance. In many of these cases, oxygen levels improved. “I think that allowed us to not escalate to the ventilator,” she adds.

Some small studies have found an association between proning and improved outcomes, but no large clinical trial has yet verified this — though one is currently underway.

Yet another example of altered treatments is the practice of reducing blood thinners for patients on ECMO life support systems, which continually extract blood from a patient’s body, remove carbon dioxide, introduce oxygen, and then pump it back in. Anecdotal evidence shared on Zoom discussions has supported the hypothesis that lowering blood thinners in such patients can stop fatal bleeding in the brain.

Global communication

Things have evolved so quickly during the pandemic that there hasn’t been time to review ICU practices via medical conferences or studies backed up by long-term clinical trials. Physicians have had to move much more quickly, all while trying to maintain high standards of safety for patients.

One way they’ve managed to do this is by talking to each other. Across the globe. The emergence of Covid-19 was followed by a blossoming of electronic communications between ICU physicians. Doctors and nurses routinely found themselves attending Zoom conference calls, chiming in on Twitter discussions, scrolling through email chains, and getting plugged into WhatsApp groups with their counterparts at other hospitals worldwide. Via these outlets, they have shared valuable insights about what approaches seem to be working.

“It’s been great to have a whole host of other units at our fingertips,” says Liz Thomas, MD, a consultant in intensive care medicine and anesthesia at Stockport NHS Foundation Trust in the U.K. town of Stockport and chair of Women in Intensive Care Medicine. Thomas is referring to a WhatsApp group used by around 250 ICU staff from around the U.K. that sprung up during the pandemic as a portal for knowledge sharing.

The group allows staff to check up on medical guidelines, share treatment approaches, and swap notes about the distribution of medical equipment around the country, so a particular ICU can find out when to expect a new shipment of ventilators, for example.

Patient communication and support

Technology has helped tackle other problems as well—perhaps most significant, the issue of separation created when patients with severe Covid-19 are moved to isolation rooms. Catherine Bonham, MD, an intensive care doctor at UVA Health in Virginia, says that at her hospital, staff have tried to reduce the number of visits they need to make to patients inside these rooms. They have repositioned some ventilator controls outside the door, for instance. Staff initially found it difficult to read information on monitors by patients’ bedsides when viewing them through the window to the room. One even brought in a pair of binoculars so they could make out the small numbers on the devices from afar.

“We had to get extra screens that made the numbers literally bigger so you could see them just looking through the glass,” Bonham says.

Not being able to allow family members into Covid-19 units for visits has been the biggest upheaval — something Morgan describes as “alien” for ICU staff. Bonham agrees: “Part of being an intensive care doctor or provider is that you are always both minding your patients and minding their family,” she says.

Over time, ICUs have begun offering tablet computers to patients who are well enough to use them so they can have video calls with their families. Thomas notes that a charity donated 16 such tablets to her ICU for this very purpose.

At other times, doctors and nurses have had to step in themselves. They’ve held the hands of dying patients and tried to make them as comfortable as possible. Morgan remembers one patient whose condition had deteriorated so much that they would not recover. He called their family via phone to tell them the news.

“They asked, ‘Please, can you play their favorite song?’” he says. So he did.

“It’s those kinds of things we carry with us into the future.”

Many stories like this one have unfolded in intensive care units over the past few months. And yet the data shows that things continue to improve for patients who find themselves requiring that level of critical care. All of the above efforts have played some role. Meyer also points out that in some hospitals, including hers in Pennsylvania, fewer patients seem to be requiring treatment in ICUs at the moment, lowering the load on staff, which has likely also helped.

Ultimately, intensive care as a field is no stranger to taking on sudden challenges. Morgan points out that the very concept of an intensive care unit arose during a different viral epidemic — the polio outbreak of 1952.

An ICU physician is trained to respond with little or no notice, sometimes experimenting with treatments and, on occasion, bringing crisis situations under control. So perhaps it is not surprising that ICUs have been flexible enough to adapt in the ways described above. But it is inspiring.

As Morgan puts it: “In a strange way, yes, of course it was a new disease and loads to learn, but that’s kind of what we do every day.”

Freelance science and technology journalist. Based in Northern Ireland.

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