Those of us who have placed COVID-19 ICU patients on mechanical ventilation know that this is not a process that is going to resolve overnight. Patient with decompensated congestive heart failure with pulmonary edema? Better in 24-48 hours. Aspiration pneumonia in a young kid who partied a little too hard? Better in a few days. COPD exacerbation in a mild player? Steroids, nebs, supportive care and then extubated in 24-48 hours. COVID-19 patient who has failed the other modalities such as supplemental oxygen and high-flow nasal oxygen? Better check your sedation inventory and tell the family to prepare for the marathon rather than a sprint. We all know that these patients spend a while on mechanical ventilation and struggle at predicting when they are going to come off safely.
I stress to the families that this is going to be extremely rough. On those cases in whom I did not recommend a focus on comfort measures to avoid intubation in the first place (an example being my 213 year-old patient with metastatic cancer and end-stage COPD), the first thing I mention is that the odds are not in their favor. In my practice, over 50% of patients who are placed on mechanical ventilation succumb to the complications of the virus for which I already created content as to the five reasons patients die of COVID-19. Some institutions have published better numbers but the real world would not be too proud of their numbers and hence we don’t share how things really are.
What the majority of us have seen include patients rapidly deteriorating as soon as they are placed on mechanical ventilation. It’s quite challenging to set them up on the ventilator without the assistance of heavy sedation and paralytics in some cases. I explain to the families that this need for heavy sedation and paralytics is detrimental to their recovery. That no matter how robust they were prior to intubation, the immobility, use of corticosteroids, as well as the plain and simple duration of mechanical ventilation will inevitably make it so that they do not go directly home after their liberation from mechanical ventilation. We are looking at at least a week on the vent.
Under traditional circumstances, most intensivists use a general rule of thumb where we start contemplating a tracheostomy on days 10-14 of mechanical ventilation. Both you and I know that many intubated COVID-19 patients are still not on vent settings low enough to where this procedure can even be safely performed. It is not my plan to review what the vast majority of us are seeing in our clinical practice, but I make sure to break this down early to the families of my patients so they know what to expect. The best-case scenario includes a discharge to a short-term rehabilitation facility after discharge. Not to mention that these patients also have their baseline co-morbidities to throw another wrench into the equation.
The study that I am using as a citation for this post was published on 31 March of 2021 in the Journal of Intensive Care. Hat tip to the authors. This was a retrospective paper that looked at 118 patients who survived their time on mechanical ventilation. Great job at this institution for having saved these 118 patients. Thankfully, I have not had a total of 118 patients on mechanical ventilation at my shop for the duration of the pandemic to date. They looked at a number of different functional scores including mental status, ICU mobility scale, and others to come to their conclusions. I am not going to take a deep dive into these scores as it gets pretty dense and you could read it for yourself as this article is free. To be completely honest, I think the results they published are better than what we are all seeing at our respective institutions.
You see, it’s hard to come clean with the real world data of real-world institutions because we know our institutions are going to be judged. We may not look good in the eyes of other shops which may, or most likely do not have favorable outcomes compared to ones own shop. We may have some trepidation regarding the outcomes of our own COVID ICU patients. I know when an Ivory Tower institution published that their mortality rate on mechanical ventilation was 30%, many of us in the social media world admitted to each other that 30% would be a fantastic number at our respective institutions.
But regardless of survival, one has to wonder about quality of life. If grandpa can never leave the nursing home after being completely independent, would it all be worthwhile? I know these types of circumstances have to be 100% individualized, but we need to consider it strongly. The functional status of survivors of mechanically ventilated ICU COVID-19 patients is something that strongly needs to be considered. In this paper, 27% were discharged home with homecare, 71% were discharged to a rehabilitation facility, and 2% were discharged to either an LTAC or hospice. Before we get all excited about the fact that 21% of patients ended up going directly home, the authors admitted that many patients who should have gone to a rehabilitation facility elected to go home against recommendations. In addition, 50% of patients were discharged with supplemental oxygen.
The authors went further into looking at all the follow-up appointments that needed to be made. Imagine the challenges to get these patients in and out of their cars, or arranging transportation to their physicians’ offices when they’ve gotten so beat up after beating COVID. It wouldn’t take much to see how they will need help from cardiology, vascular medicine, pulmonology, endocrinology, and neurology. The authors did not disclose the duration of mechanical ventilation, ICU length of stay, nor hospital length of stay of their patients. This limits how we can use these data for our ICU patients with COVID who have been on mechanical ventilation but are grateful that these data were collected and shared with us in the first place.
All in all, the point of going through this was to explore the importance of discussing with patients as well as their families the harsh reality of what the patient will have to work through should they survive their time on mechanical ventilation after beating COVID-19 in the ICU. This could certainly assist with transitioning to palliative care in the appropriate scenarios. 94% of patients went into battle fully functional and it appears that less than half of them were discharged being fully functional. Also, if you consider the mortality of in-hospital cardiac arrests in COVID patients being 89.9%, it injects some additional reality into all this.
Citation
Musheyev B, Borg L, Janowicz R, Matarlo M, Boyle H, Singh G, Ende V, Babatsikos I, Hou W, Duong TQ. Functional status of mechanically ventilated COVID-19 survivors at ICU and hospital discharge. J Intensive Care. 2021 Mar 31;9(1):31. doi: 10.1186/s40560-021-00542-y. PMID: 33789772.
Link to Article
Link to FULL FREE PDF
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