03-15-2020, 12:09 AM
RE: CPAP use for Coronavirus mitigation & severe pneumonia
Please do not think that I'm trying to argue here, or that I disagree with the things that you said. Rather, I'd like us to consider switching the way in which we think to address a completely new situation that is now likely to come upon many of us during this pandemic. The problem is that people are GOING to get desperate for solutions as the healthcare systems become overwhelmed. It's GOING to happen.
We already have a study posted that seems to indicate that CPAP indeed did provide some effective treatment for pneumonia (HERE) at least by "forestalling the need for intubation" (ventilation).
Quite frankly, in an emergency (which is exactly what we have now), and especially as this pandemic gets worse and worse, for the purposes of this thread discussion, I really don't care about what CPAPs, bilevels and non-invasive ventilators were originally intended for, nor do I care that under "normal" circumstances, some doctor believes them to be ineffective for treatment of pneumonia. We still have doctors today that believe that Auto-CPAPs should be set up at 4-20 on the pressure and they say "Let the machine do it's work!" We all know that's stupid advice in most every case. Using these machines for their intended purpose only is all well-and-good for NORMAL times, when there are enough hospital beds, when there are enough ventilators to go around, and when hospital staff is plentiful, rested and healthy. I agree with that assessment for normal times.
But, we have moved into ABNORMAL times now. Please re-read Post #6 (HERE). Conventional, careful, cautious thinking is not what this thread is all about. To think that we're talking about normal times like we have all the resources of a modern hospital, trying to find the optimal method for treating a pneumonia patient is to have a misunderstanding of the intention of this thread. What this thread is talking about is more like the "meatball surgery" experienced in a MASH unit, where you're forced to do the best you can with what you've got.
This thread is about thinking outside-the-box, and (like sheepless), if my family member has coronavirus and they move into the serious stage of pneumonia with no possibility of being hospitalized or being put on a ventilator, then I'm going to do my dead level best to give them a fighting chance as best I can, including using a CPAP machine to at least partially help with getting more air pushed into their lungs. At that point, does it really matter that they might be "uncomfortable"? Does it matter that they might have an elevated degree of central apnea events?
Is that not exactly what a ventilator is trying to do? (Push pressure into an inflamed, fluid-filled lung)? So if we can do some degree of that with CPAP, Bi-Level or ASV, you're saying that it will do no good whatsoever to someone who's dying?
The patients we're talking about in this possible scenario are not going to survive anyway without hospital treatments, unless we come up with a radical method for dealing with the pneumonia with what we have on hand, at home. So why not at least explore the possibility for using these machines for a small degree of mitigation here for a future dangerous time when we have no alternatives?
We're not talking about "comfort", we're talking about saving a loved one's life. If they have severe pneumonia, they're not going to be comfortable anyway.
Okay good. Now let's go from there. The question then becomes: how can we use our current machines to increase airflow into the lungs, but in a way that the negative effects will not outweigh the positive effects?
Okay, you said "most people"... that seems to indicate that there are some people who could be prepared to use enough pressure support to overcome the centrals. So this is good, perhaps we can help some people, then.
Again, in this thread, we're not talking about "the most appropriate ventilator". We're instead talking about a worse-case scenario - (working with what we have on-hand).
As far as the issue of eliminating or reducing fluid in the lungs, way back in 1918 they dealt with that very issue by putting the patient in the prone position (face down) with a pillow or some other soft object elevating their middle section (with their head lower than their stomach) so that the pillow pushed up against the bottom of the lungs, and gravity helped fluids flow out of the bottom of the lungs and into the upper respiratory tract, whereupon the patient would cough some of the fluids out of their system. In this case, a nasal mask or nasal pillows would be the preferred method so that the mouth was free to cough up fluid. The prone position method saved several people's lives if you do some historical reading on influenza treatment back then when they had no equivalent to our modern ventilators. I have sitting next to me a printed out instruction sheet for doing exactly this kind of treatment in austere environments with no modern medical facility available.
So, the increased pressure of CPAP, Bi-Level or ASV might work well enough in conjunction with this positioning helping to eliminate fluid in the lungs and keep a higher level of airflow going into the lungs to inflate the alveoli.
What we're talking about here is helping someone who is on their death bed. They already have severe pneumonia; they are going to die without someone stepping up to the plate and thinking of ways to help. Perhaps methods that modern conventional doctors and hospitals would frown on as being "primitive and risky".
What we're talking about is essentially what war-time medics called "ditch medicine" where they would treat critically-wounded patients as best they could with what they had on hand. Such war-time medics would need to stop the bleeding in an artery with whatever they could, even if it was an old, dirty rag laying next to them in the fox hole. They would push the rag into the bullet wound in hopes of stopping the bleeding. No thought of "hey this rag isn't exactly the preferred method for packing a wound". No thought of "hey, this rag could give the patient an infection that could severely harm them". They simply worked with what they had to solve the more critical issue of massive blood loss. Modern medicine would say "OH NO! You should only use completely sterile gauze for that!". But the war-time medic had no such sterile thing anywhere near him and he literally had seconds to get the bleeding to stop. So he used what he had on-hand.
That's what this thread is all about. That is my challenge to you-- let's figure out a way that we can use these dirty old rags (CPAP machines) to help in a worst-case disaster scenario. If we wait to figure this out, people could die who might have been helped by us brain-storming ways in which to adjust our machines to address an off-script use for these machines during this pandemic.
Again, I don't want to argue or disagree. I simply want us to think how we can use the tools we currently have to do the work that hospitals will be increasingly incapable of doing as time goes on.
Apnea Board's whole purpose is so we can "help one another". We're not providing medical advice here, especially in this situation of a world-wide pandemic. The official "medical establishment" is NEVER going to provide insight as to how these machines might help us at home during this crisis. Or if they do, it will be too little and too late.
What I'm asking for is not what cannot be done, but what can be done with the limited tools that we have on hand.
We're more like the ill-trained, inexperienced and frightened army medic who's simply trying to save the lives of his buddies.
We already have a study posted that seems to indicate that CPAP indeed did provide some effective treatment for pneumonia (HERE) at least by "forestalling the need for intubation" (ventilation).
Quite frankly, in an emergency (which is exactly what we have now), and especially as this pandemic gets worse and worse, for the purposes of this thread discussion, I really don't care about what CPAPs, bilevels and non-invasive ventilators were originally intended for, nor do I care that under "normal" circumstances, some doctor believes them to be ineffective for treatment of pneumonia. We still have doctors today that believe that Auto-CPAPs should be set up at 4-20 on the pressure and they say "Let the machine do it's work!" We all know that's stupid advice in most every case. Using these machines for their intended purpose only is all well-and-good for NORMAL times, when there are enough hospital beds, when there are enough ventilators to go around, and when hospital staff is plentiful, rested and healthy. I agree with that assessment for normal times.
But, we have moved into ABNORMAL times now. Please re-read Post #6 (HERE). Conventional, careful, cautious thinking is not what this thread is all about. To think that we're talking about normal times like we have all the resources of a modern hospital, trying to find the optimal method for treating a pneumonia patient is to have a misunderstanding of the intention of this thread. What this thread is talking about is more like the "meatball surgery" experienced in a MASH unit, where you're forced to do the best you can with what you've got.
This thread is about thinking outside-the-box, and (like sheepless), if my family member has coronavirus and they move into the serious stage of pneumonia with no possibility of being hospitalized or being put on a ventilator, then I'm going to do my dead level best to give them a fighting chance as best I can, including using a CPAP machine to at least partially help with getting more air pushed into their lungs. At that point, does it really matter that they might be "uncomfortable"? Does it matter that they might have an elevated degree of central apnea events?
Quote:You can push all the pressure you want into an inflmmed, fluid filled lung, and not create air-exchange at the alveolar level. To imply otherwise is at best misleading, and potentially dangerous advise.
Is that not exactly what a ventilator is trying to do? (Push pressure into an inflamed, fluid-filled lung)? So if we can do some degree of that with CPAP, Bi-Level or ASV, you're saying that it will do no good whatsoever to someone who's dying?
Quote:but if infection and fluid impairs lung volume, you will not survive home treatment.
The patients we're talking about in this possible scenario are not going to survive anyway without hospital treatments, unless we come up with a radical method for dealing with the pneumonia with what we have on hand, at home. So why not at least explore the possibility for using these machines for a small degree of mitigation here for a future dangerous time when we have no alternatives?
Quote:There is no advantage to using higher pressure than you tolerate comfortably.
We're not talking about "comfort", we're talking about saving a loved one's life. If they have severe pneumonia, they're not going to be comfortable anyway.
Quote:There is an appropriate and comfortable level of pressure and pressure support that may provide more relief, and exceed ing that will do more harm than good.
Okay good. Now let's go from there. The question then becomes: how can we use our current machines to increase airflow into the lungs, but in a way that the negative effects will not outweigh the positive effects?
Quote:Most people are not prepared to use enough pressure support (8 to 12 cm) to overcome the central apnea, so your could do more harm than good.
Okay, you said "most people"... that seems to indicate that there are some people who could be prepared to use enough pressure support to overcome the centrals. So this is good, perhaps we can help some people, then.
Quote:AVAPS or iVAPS is the most appropriate ventilator to maintain alveolar volume, but the problem with pneumonia is that fluid in the lungs must be eliminated or there simply no volume to fill with air.
Again, in this thread, we're not talking about "the most appropriate ventilator". We're instead talking about a worse-case scenario - (working with what we have on-hand).
As far as the issue of eliminating or reducing fluid in the lungs, way back in 1918 they dealt with that very issue by putting the patient in the prone position (face down) with a pillow or some other soft object elevating their middle section (with their head lower than their stomach) so that the pillow pushed up against the bottom of the lungs, and gravity helped fluids flow out of the bottom of the lungs and into the upper respiratory tract, whereupon the patient would cough some of the fluids out of their system. In this case, a nasal mask or nasal pillows would be the preferred method so that the mouth was free to cough up fluid. The prone position method saved several people's lives if you do some historical reading on influenza treatment back then when they had no equivalent to our modern ventilators. I have sitting next to me a printed out instruction sheet for doing exactly this kind of treatment in austere environments with no modern medical facility available.
So, the increased pressure of CPAP, Bi-Level or ASV might work well enough in conjunction with this positioning helping to eliminate fluid in the lungs and keep a higher level of airflow going into the lungs to inflate the alveoli.
What we're talking about here is helping someone who is on their death bed. They already have severe pneumonia; they are going to die without someone stepping up to the plate and thinking of ways to help. Perhaps methods that modern conventional doctors and hospitals would frown on as being "primitive and risky".
What we're talking about is essentially what war-time medics called "ditch medicine" where they would treat critically-wounded patients as best they could with what they had on hand. Such war-time medics would need to stop the bleeding in an artery with whatever they could, even if it was an old, dirty rag laying next to them in the fox hole. They would push the rag into the bullet wound in hopes of stopping the bleeding. No thought of "hey this rag isn't exactly the preferred method for packing a wound". No thought of "hey, this rag could give the patient an infection that could severely harm them". They simply worked with what they had to solve the more critical issue of massive blood loss. Modern medicine would say "OH NO! You should only use completely sterile gauze for that!". But the war-time medic had no such sterile thing anywhere near him and he literally had seconds to get the bleeding to stop. So he used what he had on-hand.
That's what this thread is all about. That is my challenge to you-- let's figure out a way that we can use these dirty old rags (CPAP machines) to help in a worst-case disaster scenario. If we wait to figure this out, people could die who might have been helped by us brain-storming ways in which to adjust our machines to address an off-script use for these machines during this pandemic.
Again, I don't want to argue or disagree. I simply want us to think how we can use the tools we currently have to do the work that hospitals will be increasingly incapable of doing as time goes on.
Apnea Board's whole purpose is so we can "help one another". We're not providing medical advice here, especially in this situation of a world-wide pandemic. The official "medical establishment" is NEVER going to provide insight as to how these machines might help us at home during this crisis. Or if they do, it will be too little and too late.
What I'm asking for is not what cannot be done, but what can be done with the limited tools that we have on hand.
We're more like the ill-trained, inexperienced and frightened army medic who's simply trying to save the lives of his buddies.
SuperSleeper
Apnea Board Administrator
www.ApneaBoard.com
Apnea Board Administrator
www.ApneaBoard.com
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
DONATE to Apnea Board
Change your own pressure - Get the Clinician Setup Manual for your CPAP here
OSCAR - Open Source CPAP Analysis Reporter
Change your own pressure - Get the Clinician Setup Manual for your CPAP here
OSCAR - Open Source CPAP Analysis Reporter
