Is ventilation the best way to treat serious COVID-19 cases, or is it a brutal but necessary intervention? Patients on ventilators could need better therapies. 

Patients on ventilators have been the media’s go-to footage and photographs during the COVID-19 pandemic. Unable to breathe on their own, those with severe infections need ventilation to buy time for their immune systems to beat the disease.

But is it a truly merciful intervention, or a harsh necessity that may do more harm than good for some? Most importantly, what can we do to avoid the need for ventilation? 

Are Patients On Ventilators Doomed?

In an April 2020 paper, a total of 5700 hospitalized COVID-19 patients were studied. Sixty percent were men, and their average age was 63. Most had other illnesses too: 56.6 percent had hypertension, 41.7 percent were obese, and one-third had diabetes. Of all patients, one in seven were treated in intensive care.

Their average age was a little higher at 68, and they were slightly more likely to be men. As of April 4, 2020, only 3.3 percent of those given ventilation left the hospital alive. Twenty four and a half percent died, and the other 72.2 percent were still in the hospital. This means that of all closed cases, just under 12 percent had survived. 

However, later studies paint a better picture. A May 26 paper reports a much smaller 35 percent death rate for patients who needed ventilators. This makes it comparable to other cases of acute respiratory distress syndrome (ARDS). Why was the death rate much lower?

Since the pandemic began, doctors’ knowledge around which patients should be intubated and how to manage blood clotting have improved. They also began to implement the practice of lying patients on their stomach to breathe easier. Unfortunately, medical experts don’t think we will ever reach perfection. “It’s never going to be 10 to 20 percent. Let’s not kid ourselves,” says Leora Horwitz, an NYU professor. “The people who are sick enough to be put on ventilators, they’re really sick.”

With that in mind, what are some ways to support the body’s innate healing capabilities, and how does the use of a ventilator affect them? 

The Harmful Effects Of Ventilation

The duration of ventilation affects mortality risk. Prolonged ventilation, defined as a period of at least three weeks, is linked with a one-year mortality risk of 52 percent. It is also associated with a poorer quality of life. Fortunately, almost all of those who survive after three years report being back to normal.

Complications of prolonged ventilation include gastrointestinal ulceration from reduced blood flow; neurological problems from sleep disturbances and sedation; and swallowing dysfunction from prolonged gag reflex stimulation. Even after just 18 hours of ventilation, muscle wasting in the respiratory system appears, which lengthens the amount of time needed on a ventilator.

The physiological effects of ventilation involve increased oxidative stress; lowered antioxidant capacity; and changes to gene expression that impair our respiratory muscles’ ability to repair themselves. It only takes six hours for these to appear.

Melatonin Production

When it comes to immunity, one harmful consequence of spending time in an intensive care unit (ICU) is its effect on sleep cycles. A survey found that 59 percent of patients reported trouble sleeping during their hospital stay, compared with 24 percent at home. More objective measures of polysomnography (PSG) and melatonin levels also found abnormal circadian rhythms and reduced melatonin production.

The disruption of the melatonin cycle is most likely caused by a combination of factors in the ICU. Constant lighting and noise, alongside the stresses of being seriously ill and hooked up to machines prevent patients from truly relaxing and may interfere with their body’s “knowing” when it’s nighttime.

Dysregulated melatonin production cycles are linked with delirium, a sadly common consequence of mechanical ventilation. It may also be partly caused by sedative drugs used to control agitation in the ICU. With continuous sedation, the natural rhythm of melatonin production can be completely abolished. Sedation can cause or increase the severity of delirium, and may not even be a “necessary evil.”  Simply adjusting the ventilator setting to improve patient comfort is more effective. 

Pneumonia

Another common but serious complication is ventilator-associated pneumonia (VAP). Other ICU-acquired infections, such as those in the skin and urinary tract, only have a mortality rate of one to four percent. In contrast, VAP has a mortality rate ranging anywhere from 20 to 50 percent and can be higher when high-risk microbes are involved.

Part of the problem is that ventilation suppresses the functions of innate immunity. Normally, barriers in the throat, coughing, and mucus production, and its movement out of the lungs help to remove viruses such as the coronavirus. Additionally, white blood cells protect us from these sources of infection, but this is all compromised by ventilators. 

Acute Lung Injury

Ventilator-associated lung injury (VALI) can result from excessive pressure during positive pressure ventilation. Barotrauma, meaning pressure-induced damage, causes air leak syndromes such as broncho-pleural fistula, interstitial emphysema, and pneumothorax.

Diaphragmatic dysfunction may be caused by ventilation too, which can be worsened or triggered by steroids and drugs that cause paralysis. Unfortunately, the gentler, less invasive CPAP, and BIPAP machines are discouraged from use because of fears they may increase virus spread. 

Ways To Support Patients On Ventilators – Or Keep Them Off

The best way to prevent complications from ventilation is to shorten the time they’re needed, or prevent severe infections. 

Melatonin

One way is to replace lost melatonin, which is not only a sleep hormone but also an anti-inflammatory and antioxidant. It protects against lung injury and Acute Respiratory Distress Syndrome (ARDS) caused by infections. In critically ill patients, melatonin reduces anxiety and use of sedatives, while improving vessel integrity and sleep quality.

A study of seriously ill participants found that melatonin reduced the risk of delirium by 59 percent, compared with the control group. Among the elderly patients in medical wards, melatonin cut delirium by 75 percent, but no difference was found among the older patients in surgical wards. 

Stem Cell Therapy

One upcoming treatment that has recently been shown to reduce time on ventilators is stem cell therapy. Although already-published trials were only powered for safety, not efficacy, one study found that stem cells cut days in the ICU from an average of 10.3 to 8.1, and days on a ventilator from 12.9 to 9.2. Severe cases only spent eight days on ventilators, compared with 14.6 in their placebo group. They also had 11.4 days outside of the ICU during the 28-day study period compared to 5.9 days.

Other stem cell therapies developed by other companies have recently shown similar promising results. As stem cells work by reducing inflammation and increasing tissue regeneration, they could work against a broad range of infections, not just COVID-19. 

N-Acetyl Cysteine And Other Supplements

A controlled clinical trial involving 262 mostly-older adults demonstrated that taking 600mg of N-acetyl cysteine (NAC) twice daily significantly reduced the risk of flu. It also shortened the time they were stuck in bed if they did get sick. What’s telling about the power of our immune systems is that the treatment and placebo groups had similar seroconversion rates. This means they were exposed at a similar frequency, as they developed antibodies at similar rates.

However, just 25 percent of infected people in the NAC group developed symptoms, compared to 79 percent of placebo volunteers.  Of course, there are other natural remedies that may help control RNA viruses, such as coronaviruses and influenza. These include lipoic acid, at 1,200-1,800mg daily; spirulina at 15g daily; selenium, at a dose of 50-100 micrograms; glucosamine, at 3,000mg; and zinc at 30-50mg. 

Ventilation is a far from perfect intervention, and we must work to the best of our current abilities to help patients on ventilators heal. However, to achieve this, we need a free flow of knowledge. While new developments in allopathic critical care are much welcomed, we also need information on ventilator complications and holistic therapies.