Not just an Intensive therapy!
At the beginning of the epidemic, we had reported that the main problem (reason for everyone to stay at home) was there were going to be many critically ill people all at the same time and that it wouldn’t be possible to treat them with the available resources.
The amount of critically ill patients and deaths would have determined different severity scenarios, depending on restrictive measures implemented by the authorities.
The combination of restrictive measures paralleled with the enormous effort to increase places in intensive care for critically ill patients has so far made possible to manage the emergency without having to resort to choose which patients to treat.
In the meantime, it seems that the contagions’ curve is flattening and this brings positive hopes.
For now, the massive arrival of patients in ICU seems to have held up. Thanks to the measures implemented: may not be everywhere in Lombardy, but at least in other Northern Italian regions.
Attention to “intermediate” patients
At the moment, the attention of the front line doctors is focused not only on critically ill but also on the so-called “intermediate” patients.
Let’s recap the three different categories or clinical pictures of Coronavirus-positive patients that we had identified.
- type A, asymptomatic;
- type B, mildly-ill patients who can stay at home and do not require hospitalization;
- type C, critically ill patients who require hospitalization because showing signs of respiratory failure.
- C1, with MILD shortness of breath, requiring only OXYGEN;
- C2, with MODERATE shortness of breath, requiring NON-INVASIVE VENTILATORY SUPPORT
- C3, VERY SERIOUS, requiring invasive ventilation and ICU.
Type C1 and C2 patients are those we call “intermediate” patients, who are ill enough to be hospitalized, but not yet that critical to be treated in intensive care.
These are the patients currently filling our hospitals. The REAL CHALLENGE now consists in better understanding the evolution of the disease in these subjects. Three strategies can be put in place to assess these categories of patients:
The first line of intervention on “intermediate” patients is trying to PREVENT worsening of their conditions, especially during the critical phase that could lead them to intensive care. This could better the individuals’ health conditions, reduce mortality and reduce the impact of the disease. The ongoing experimental therapies are aimed to “freeze” the disease at earlier development levels, reducing its impact.
2. Identifying early signs of exacerbation
Alternatively, efforts are being made to identify “EARLY SIGNS” of worsening, in order to anticipate the transfer of some patients to ICU and to know in advance any improvement of other patients. (1)
3. Change in the diagnostic procedures
It’s been on trial as to modify and streamline the diagnostic systems. The goal is to speed up the decision-making process and avoid transferring patients to other departments: such as radiology, with a greater risk for patients and staff infection.
Among the many open scenarios of this Coronavirus emergency, one of them is managing those “intermediate” patients who are not yet so critical to require intensive care but whose conditions can quickly worsen. This is the new challenge that doctors have to work on. The new approaches: diagnostic, therapeutic and prevention -will help reduce the impact of the disease on patients and on the health system.
(1) i.e. from this point of view it seems that running a Lung Ultrasound can help distinguish patients with “wet” interstitial syndrome -with only B lines versus a moderate sliding from “dry” patients -those with an interstitial syndrome composed of multiple subpleural consolidations and reduced sliding. In the first case, we can consider a non-invasive ventilation (C-PAP or NIV), while in the second, premature intubation is necessary.
Dr. Marco De Nardin, M.D., Anesthesiologist, Critical Care Doctor