Improved treatment options could help save lives in the Covid-19 pandemic.
Something I get asked a lot is: Have we actually learned anything about how to fight Covid-19?
Given the continued debate over (proven) tactics like social distancing and mask-wearing, and the reticence of some political leaders to take preemptive action to curb the disease’s spread, it’s not an unreasonable question.
But when I hear that question, the first thing I think about isn’t Zoom calls or isolating in a cabin or strapping on my mask before I walk into the grocery store. I think about remdesivir, dexamethasone, and prone positioning.
Because, in fact, doctors and nurses have learned a ton about the best medicine for treating Covid-19. It’s too soon to say exactly how many lives have been saved by gains in our collective knowledge, but some effect seems certain.
Coronavirus deaths have been rising again in the wake of this summer’s record spike in cases, but they have not reached the same heights seen in the spring. There are likely a few explanations for that trend. First, the US wasn’t testing enough in March or April to identify all of the Covid-19 cases then and so a “record” number of cases in June and July may have been a bit of a mirage. Younger people also made up a bigger share of cases in the summer wave, and they are less at risk of dying from the disease.
But the doctors and hospitals I’ve spoken with recently feel confident that improvements in their standards of care are having a meaningful effect, even if they are reluctant to put an exact number on it.
“There is a lot that has changed. We’ve made amazing progress,” Dr. Daniel Kuritzkes, the chief of the infectious disease division at Brigham and Women’s Hospital and a professor at Harvard Medical School, told me in a phone interview last week. “Many of us do have the sense that we’ve gotten better at what we’re doing, and we are seeing less mortality, even among older hospitalized patients with Covid-19.”
Covid-19 deaths among Americans 65 and older peaked the week of April 15, when nearly 13,800 people in that age bracket died. In the first week of August, about 2,300 people over 65 died. At the same time, the number of confirmed cases was roughly twice as high as it was in the spring. (Again, these comparisons aren’t perfect, but the difference in death rates is stark.)
I talked with Kurtizkes about what we’ve learned about how to best treat Covid-19. There were at least four developments that seem to be improving patient outcomes and helping hospitals maintain sufficient capacity to treat their coronavirus patients.
1) Letting some patients ride Covid-19 out at home
Maybe the most important advance is one that doesn’t occur in the hospital at all.
Doctors have become more comfortable telling Covid-19 patients with a lower risk profile — younger, healthier, with less severe symptoms presenting — they can stay at home and monitor themselves, in consultation with their doctor, as their body fights off the disease, Kuritzkes told me.
By keeping those patients at home, hospitals can free up their beds and their staff to focus on the most at-risk patients.
Simple medical equipment makes it easier to have those less at-risk patients stay home. For example, patients can use a $50 at-home blood oxygen monitor to gauge how their lungs are working and whether their condition is deteriorating to the point that they should go to the hospital.
Doctors can rely more on home care now in part because many of the people getting infected are less at risk. The recent surges in Covid-19 cases have been concentrated, at least at first, among younger people. They are less vulnerable to developing serious symptoms (namely the difficulty with breathing) that require patients to be hospitalized. But it also reflects the growing confidence among doctors that they can manage these cases remotely.
2) Delaying ventilation as long as possible
Early on in the Covid-19 pandemic, some doctors were quick to put hospitalized patients who were struggling with their breathing on a mechanical ventilator. But they have done a 180-degree reversal in the months since, now striving to keep patients off ventilation if it’s at all possible.
“At the very beginning, there was some movement to intubate people quickly,” Kuritzkes said. “That turned out not to be the best move.”
There was a logic to putting patients on a ventilator early in the disease’s progression. Usually, doctors and nurses would prefer to do a controlled elective intubation rather than attempt to intubate a patient in the middle of a respiratory emergency. All kinds of things can go wrong when putting a patient on a ventilator; they can swallow the wrong way and end up with something damaging in their lungs. Doing it preemptively gave the staff more control over the situation. There were also early reports out of Wuhan, China, that indicated early intubation was a good idea, Kuritzkes said.
However, the initial conventional wisdom turned out to be wrong. Putting a person on a ventilator changes everything about their breathing and it can be very traumatizing to the body. Air is being pushed into the lungs and that puts pressure on the delicate air sacs that are responsible for processing oxygen and expelling carbon dioxide.
Considering Covid-19 is already damaging a person’s lung capacity, that was a dangerous combination. So now, hospitals are trying to delay ventilation as long as they can.
“We’re attempting to avoid that trauma as much as possible,” Kurtizkes said. “It would be better for patients than intubating them sooner if you could avoid it. For some people, we are able to get them through without needing to intubate them at all.”
3) Putting patients in the prone position
Hospitals have made another important change to their usual standard operating procedure for patients who are having trouble breathing: they should be put into a prone position, meaning they are lying on their stomachs, for a certain amount of time every day.
In many ways, caring for Covid-19 patients is the same as caring for any patients with significant respiratory distress. But prone positioning was a significant change from prior practices.
“That was something that was not done very commonly prior to this epidemic,” Kuritzkes said. “As soon as a few hospitals began reporting positive experiences, it was rapidly picked up.”
The University Health System in San Antonio, one of the first US hospital systems to have a major influx of Covid-19 patients because they took in evacuees from Wuhan and the Diamond Princess cruise ship, told me they quickly learned putting patients in the prone position led to better outcomes.
The science is pretty simple: Blood flow changes depending on how much pressure is being put on the lungs and where the pressure is coming from. Putting a patient on their stomach makes it easier for blood to reach different parts of the lungs and improves lung function. Research is still preliminary, but what’s available does indicate improvements in the blood oxygen levels of Covid-19 patients put in the prone position. (This is also helpful toward the goal of delaying intubation.)
“What you want to do is maximize the amount of blood going to the parts of the lung getting the best aeration,” Kuritzkes said.
It’s not easy to flip a hospitalized patient from their back to their stomach without dislodging all their tubes and drips. It requires a dedicated team. But at this point in the Covid-19 pandemic, hospital staff have much more experience with the process than they did at the beginning.
4) Using dexamethasone and remdesivir
The other piece of the treatment puzzle is the actual medicine. So far, the anti-inflammatory steroid dexamethasone and the antiviral medication remdesivir have proven the most promising and have been adopted by many hospitals across the US and around the world.
“Without question, the advent of remdesivir had a big effect,” Kurtizkes said.
Remdesivir has been shown in studies to help hospitalized Covid-19 patients improve more quickly, as STAT has reported. In one study with patients who had severe cases, they were shown to recover four days faster on remdesivir than patients who were given a placebo. In a different study, patients with mild Covid-19 symptoms were 65 percent more likely to see improvement after being given the drug.
Helping patients recover quickly is important to maintaining hospital capacity and preventing staff from being overwhelmed. It’s not yet clear whether remdesivir actually improves survival among Covid-19 patients, though a preliminary research paper presented at the AIDS 2020 Conference this summer did find lower mortality rates for patients who were given remdesivir.
Dexamethasone has been shown to reduce fatalities in Covid-19 patients with severe symptoms (those who require mechanical ventilation or oxygen support) and so it has also become part of the standard of care for those cases. However, it does not appear to make much of a difference for patients who do not need respiratory support, and doctors are still trying to figure out the best time to administer it.
Because dexamethasone is a steroid, it can have other deleterious effects on a patient’s body, making it more difficult to regulate blood sugar and sometimes leading to high blood pressure. Patients are also more vulnerable to opportunistic infections, Kuritzkes told me.
“You don’t want to give it where the benefits don’t outweigh the potential risks,” he said.
So there is still much to learn. And these are all imperfect measures. A vaccine or a cure would go even further toward reducing the coronavirus’s toll. Improvements in treatment are not a reason to be complacent about social distancing or wearing masks, either.
But heading into the fall, when many experts expect another uptick in Covid-19 cases, doctors are in a much better position to treat their patients than they were in the spring.
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Author: Dylan Scott
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