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Article from LIVESCIENCE “Silent hypoxia’ may be killing COVID-19 patients. But there’s hope.”

As doctors see more and more COVID-19 patients, they are noticing an odd trend: Patients whose blood oxygen saturation levels are exceedingly low but who are hardly gasping for breath.

These patients are quite sick, but their disease does not present like typical acute respiratory distress syndrome (ARDS), a type of lung failure known from the 2003 outbreak of the SARS coronavirus and other respiratory diseases. Their lungs are clearly not effectively oxygenating the blood, but these patients are alert and feeling relatively well, even as doctors debate whether to intubate them by placing a breathing tube down the throat.

The concern with this presentation, called “silent hypoxia,” is that patients are showing up to the hospital in worse health than they realize. But there might be a way to prevent that, according to a New York Times Op-Ed by emergency department physician Richard Levitan. If sick patients were given oxygen-monitoring devices called pulse oximeters to monitor their symptoms at home, they might be able to seek medical treatment sooner, and ultimately avoid the most invasive treatments.

“This is not a new phenomenon,” said Dr. Marc Moss, the division head of Pulmonary Sciences and Critical Care Medicine at the University of Colorado Anschutz Medical Campus. There are other conditions in which patients are extremely low on oxygen but don’t feel any sense of suffocation or lack of air, Moss told Live Science. For example, some congenital heart defects cause circulation to bypass the lungs, meaning the blood is poorly oxygenated.

However, the increased understanding that people with COVID-19 may show up with these atypical coronavirus symptoms is changing the way doctors treat them.

Gasping for air

Normal blood-oxygen levels are around 97%, Moss said, and it becomes worrisome when the numbers drop below 90%. At levels below 90%, the brain may not get sufficient oxygen, and patients might start experiencing confusion, lethargy, or other mental disruptions. As levels drop into the low 80s or below, the danger of damage to vital organs rises.

However, patients may not feel as dire straits as they are. A lot of coronavirus patients show up at the hospital with oxygen saturations in the low 80s but look fairly comfortable and alert, said Dr. Astha Chichra, a critical care physician at Yale School of Medicine. They might be slightly short of breath, but not in proportion to the lack of oxygen they’re receiving.

A third phenomenon, particularly important in respiratory disease, is decreased lung compliance. Lung compliance refers to the ease with which the lungs move in and out with each breath. In pneumonia and in ARDS, fluids in the lungs fill microscopic air sacs called alveoli, where oxygen from the air diffuses into the blood. As the lungs fill with fluid, they become more taut and stiffer, and the person’s chest and abdominal muscles must work harder to expand and contract the lungs in order to breathe.

This happens in severe COVID-19, too. But in some patients, the fluid buildup is not enough to make the lungs particularly stiff. Their oxygen levels may be low for an unknown reason that doesn’t involve fluid buildup — and one that doesn’t trigger the body’s need to gasp for breath.

Working to breathe

Exactly what is going on is yet unknown.

Chichra said that some of these patients might simply have fairly healthy lungs, and thus have the lung compliance (or elasticity) — so not much resistance in the lungs when a person inhales and exhales — to feel like they are not short on-air even as their lungs become less effective at diffusing oxygen into the blood. Others, especially geriatric patients, might have comorbidities that mean they live with low oxygen levels regularly, so they’re used to feeling somewhat lethargic or easily winded, she said.

In the New York Times Op-Ed on the phenomenon, Levitan wrote that the lack of gasping might be due to a particular phase of the lung failure caused by COVID-19. When the lung failure first starts, he wrote, the virus may attack the lung cells that make surfactant, a fatty substance in the alveoli, which reduces surface tension in the lungs, increasing their compliance. Without surfactant, the increased surface tension causes the alveoli to deflate, but if they are not filled with fluid,, they won’t feel stiff, Levitan wrote. This could explain how the alveoli fail to oxygenate the blood without the patient noticing the need to gasp for more air.

The virus might also create hypoxia by damaging the blood vessels that lead to the lungs, Moss said. Normally, when a patient has pneumonia, the tiny blood vessels around the fluid-filled areas of the lungs constrict (called hypoxic vasoconstriction): Sensing a lack of oxygen in the damaged areas, the body shunts blood to other, healthier parts of the lungs. Because pneumonia fills the lungs with fluid, the person will feel starved for air and gasp for breath. But their vessels send the blood to the least-damaged parts of the lung, so their blood oxygenation stays relatively high, given the damage.

In the New York Times, Levitan suggests that patients who are not sick enough to be admitted to the hospital be given pulse oximeters, devices that clamp to the finger to measure blood oxygenation. If their oxygenation numbers start to fall, it could be an early warning sign to seek medical treatment. “It’s an intriguing possibility,” Moss said.

Even without widespread at-home oxygen monitoring, doctors are now starting to differentiate between patients who have low oxygen levels and who are working hard to breathe, and those who have low oxygen levels but are breathing without distress, Chichra said. Early in the pandemic, knowing that COVID-19 patients can start to fail quickly, physicians tended to put people with hypoxia on ventilators quickly. Now, Chichra said, it’s becoming clear that patients who aren’t struggling for breath often recover without being intubated. They may do well with oxygen delivered via nasal tube or a non-rebreather mask, which fits over the face to deliver high concentrations of oxygen.

Hypoxic patients who are breathing quickly and laboriously, with elevated heart rates, tend to be the ones who need mechanical ventilation or non-invasive positive-pressure ventilation, Chichra said. The latter is a method that uses a face mask instead of a tube down the throat but also uses pressure to push air into the lungs. “The key difference we’ve found between these folks is that the people who are working hard to breathe are the folks who usually need to be intubated,” Chichra said.

The Wild West of COVID19

In 20+ years of purchasing products for SOS Emergency Response Technologies, I have never encountered what feels like The Wild West of purchasing.

We have been able to resource, retool, and/or find manufacturers and have most PPE products locally made in BC and/or Canada. However, it has been almost impossible to find gloves (nitrile or latex) locally. The only alternative is to continue to try to work with our manufacturers and factories overseas. However, it has become very challenging to obtain products out of the country right now. The factories are auctioning off their production capacity to the highest bidder and orders are for cash upfront.  Even bought and paid for orders with factories have been stolen out from under us by people paying a higher price.

For the first time in 20 years, we are sourcing anything we can from any place we can, and what is coming in is from different suppliers, not necessarily in regular packaging because we have to just use whatever is available. We are not price gouging, we are doing our best to keep our profit margins the same as what they were prior to this pandemic. The struggling Canadian dollar and the Wild West mentality of bidding out the goods are resulting in higher costs to clients. It is our hope this situation will improve in the next couple of months and encourage our clients to not over-buy.

We thank our clients for the continued patronage and patience during this unprecedented time. Stay safe and wash your hands.

My Mom’s Journey with COVID-19. Please Stay Home. – Hopeful Learning: Kristi Blakeway

My Mom’s Journey with COVID-19. Please Stay Home.

A few days ago, I wrote a blog post entitled ‘This is Not My Story – This is OUR Story‘ and I encouraged people to see how we are in this together and need to respond by thinking of others first. The post was not about me, or my family – it was about us as a collective, and the difference we can make together.

This post is much more personal. With my mom’s permission, I am sharing her journey. I do so not for empathy (though your positive vibes are more than welcome), but so that the story of COVID-19 becomes more personal for you. It is my belief that stories are what connect us. Stories inspire us, lift us up, help us heal. Through story, we begin to make sense of these crazy times, and we begin to understand why our actions matter.

My mom is a healthy, happy, and social woman. For a stranger reading this, you probably think – ok -got it – your average woman. For those who know my mom, you are smiling knowing it’s much more than that. My mom has the energy of 100 people. Whenever people comment on my energy or drive, I tell them I am the ‘scaled-down’ version of my mom. To give you an example, my mom raised my brother and me as a single mom. On top of this, she worked full time as a teacher and then as a school principal. It doesn’t stop there. She also owned a catering business at the same time, sold Mary K and helped raise funds for many community events or charities.

My mom has two passions – cooking, and helping others. As you can imagine, those two gifts blend nicely. Now retired, it is not uncommon for my mom to cook for schools or churches, preparing meals for 100 or more out of the kindness of her heart. She also travels and spends lots of time with her husband, sisters, kids, and grandkids. She is ALWAYS on the go – and never misses a good sale. She can shop for hours. She usually has her Christmas shopping complete 11 months in advance. She is eternally positive, funny, sarcastic and full of grit. There truly is no one like her.

A month ago my mom and stepdad went on a cruise in the Caribbean. This is not an area heavily impacted by COVID-19, especially in February. Unfortunately, their cruise was stuck at sea as there was a Norwalk Virus outbreak so they floated through the Caribbean waters without getting to see their ports. While others were disappointed, this didn’t stop my mom. She was excited to enjoy the warm air, get a partial refund and a credit for another cruise. She saw the positive side of life when others could not.

After returning to Canada in February (and before we had learned much of COVID-19 in Canada), my mom developed a cough. She had not been to a country of concern so this was deemed a common cold. The cough worsened but other than that she was symptom-free with good energy. My mom went about her regular routine for two weeks, visiting Seattle and Bellingham as well as many shops and services in Greater Vancouver. She saw friends, spent time with family and continued to live life a million miles an hour. Around March 6th my mom started to develop flu-like symptoms. By the 11th, her cough had become persistent so we convinced her to get a swab for COVID-19 just in case. The doctor told her to self isolate while she awaited results but told her not to worry too much as she didn’t seem to have the typical symptoms.

On March 13th, my mom’s 74th birthday, she became incredibly weak after not eating for two days. Her cough was so significant she could not hold a conversation. She tried calling for her swab results but they were not yet available. At the time, the wait was 2-3 days. We learned that results are not given on Saturday or Sunday so she would need to wait until Monday. This seemed like a minor inconvenience as she could not get out and see others, but with her fatigue and cough, she was content to wait. That evening, she became weaker and my brother and I felt she might need hospitalization. We convinced her to call 911 around 8 PM. The ambulance took three hours. When it arrived, they told her they were worried she would contaminate the ambulance and it would take hours to disinfect it. She had two choices – they could arrange for my stepdad to drive her and have a quarantined space ready upon arrival or they could drive her but then it would take hours to disinfect the ambulance. They chose option one, and the paramedics followed behind the car to make sure she arrived safely.

On Friday night, around 11 PM, my mom began living in isolation in a small hospital room. Upon arrival, the hospital staff still couldn’t get lab results so they re-swabbed her. They put my mom on oxygen to help her breathe. She was given an IV with fluids and antibiotics. We were hopeful things would start to improve.

The weekend was rough. My mom was not eating and needed oxygen. She became extremely nauseous and couldn’t even read without feeling sick. Her physical health continued to struggle and her mental health started to decline. Her texts were infrequent and short. She could not talk on the phone. My mom, who has never experienced anxiety, could no longer cope. You see, isolation is not what you expect. It’s not a comfortable private room with working amenities. It’s more like a jail cell than a typical hospital experience. In isolation, you have very little human contact. Family and friends cannot visit. Flowers cannot be sent to the room because of the respiratory concerns. The door to the outside world stays closed. The nurse visits for a minute or two only a few times per day. There is no shower. There is little room to walk. The TV cannot be turned on because the TV guy would be at risk of a possible infection. If you press the buzzer for water it sometimes takes hours as staff cannot enter without dressing in full protection. The room does not get cleaned. The hospital staff does their best but these are different times.

For five days, my overly social mom paced back and forth in a tiny room the size of a bathroom. In her words, she became a caged animal. Confinement became unbearable. My mom requested to be put in a coma until the results were ready. She broke down mentally and needed anxiety medication and sleeping pills to help her cope. Her spirit was broken. Never in my 45 years have I seen my mom lose hope. Still – no results.

My mom describes her wait:

One of the glitches to the system is that test results are only available Monday – Friday, 8:30-4:30 which creates extreme stress while people wait. We have to assume we do have the virus so isolation is mandatory. Every day, the doctors told me, once I was off oxygen I could go home and self isolate. Every day I asked if they had results. Each day they replied – ‘maybe tomorrow’.

The days and nights were long. I asked for sleeping pills but the first two nights they wouldn’t give me any. By the second night, I was beginning to go crazy. I told them I needed a psychiatrist to help me through this. They gave me Ativan. By this time my family had brought photos I could look at (that the nurse delivered) so I managed ok with just a sleeping pill.

I remember thinking – Am I going to die? I thought back to the days I had smoked as a young adult and regretted every cigarette. It’s a mental game as no one has answers for you.

Luckily by Monday, my mom was able to breathe on her own and she was taken off the oxygen. She was told that if she could breathe on her own for 24 hours, she could go home and recover there. Friends and family sent messages and photos and we had the nurses deliver a care package. Her spirit lifted and she ate a chocolate chip cookie. She began to send photos of the horrible food being brought to her room and became a food critic for the hospital meals. She described the horrid salmon sandwich and chunky mulligatawny soup. A chef at heart, she was less than impressed, but with little appetite, she took a few bites purely for survival. We smiled knowing her sarcasm had returned. She awaited her diagnosis and packed her bag ready to escape as soon as she could. Still no results.

Tuesday came and my mom continued to improve. She reached the 24-hour mark and thought she was on standby to go home. She anxiously waited for the door to open so a doctor could set her free. The staff explained that with the provincial change to centralized testing, her results would come through the CDC, but the CDC closes at 4:30 PM and doesn’t give results in the evening. She would have to spend one more night. Frustration set in as my mom waited in the same pajamas, with greasy hair and no access to a shower. They explained they couldn’t risk bringing in a portable shower as she may infect it. With her cough subsiding a little, my mom was able to talk on the phone and my kids were able to help her learn how to download a solitaire app. Friends and family sent texts and she hung on to hope that she would be going home. Her health and her spirit began to improve.

On Tuesday evening, my mom was told she tested positive for COVID-19. It’s hard to say when she contracted it. The hospital suspects it is from her travels but it’s hard to determine. She is the first confirmed case at her local hospital. While the staff tried their best, it was obvious no one truly knew what to do.

When the results finally came in, they did not know what to do with me. They told me to pack my bags and wait for an evening ambulance to transfer me to another hospital. I had to wait 11 hours for the ambulance to arrive. Once it arrived, it had to be disinfected. I did not understand why I was going to a new hospital. After waiting up all night and pacing, I told the staff how scared I was. They gave me Ativan.

Finally, a nurse named Wendy who had just returned from her vacation challenged this process. She got in touch with a doctor who decided I could self isolate at home. Since I no longer required oxygen, I could self-quarantine. When I found out I could go home, it felt like I had won the lottery.

I write this post because I want you to know what COVID-19 can be like for seniors and those with compromised immunity. Up until two weeks ago, my mom was physically and mentally strong and healthy. COVID-19 can attack the human body while isolation can attack the soul. As this disease spreads, please use my mom’s story to remember to check in on others and find ways for human connection.

In many ways, my mom is one of the lucky ones. She is one of the first few hundred people to be diagnosed in BC and one of the first few dozen to be hospitalized. This means she was able to access all the services and equipment needed to help her survive. My mom will make it through this journey while others may not. As hospitals become more crowded, some may not be able to access the resources made available to my mom. This is why YOU have to act now. Isolation at home is much more convenient that isolation at a hospital.

If you are symptom-free and reading this, please think twice before going about your daily routine. The more we limit community engagement, the more we will protect ourselves and others. Ask yourself if you really need that latte or stop at the bookstore. Replace face to face errands with online purchases. Choose take-out over dining in. Put your to-do list on hold. Do not assume that travel to a low incidence area is safe.

This is the time to think of family, friends, neighbors, or strangers we have yet to meet. Send positive thoughts to my mom and every other human around the world simultaneously battling COVID-19. The coming days and weeks may just be the most significant days of our lives to make a positive contribution to our society.

Your precautionary measures will save lives. As much as you can, please stay home.

Love you mom.

CoronaVirus (COVID19) – To wear a mask or not?

  • If you are healthy DO NOT wear a mask.
  • If you are healthy and taking care of a person, or suspect that person has COVID 19 WEAR a mask.
  • If you are coughing and sneezing STAY HOME, if you must go out, WEAR a mask.
  • Wash your hands, frequently and PROPERLY
  • Use hand sanitizer (min. 60% alcohol) if no soap and water is available
  • At work regularly wipe down your desk, hard surfaces, phones & keyboards – we recommend accelerated hydrogen peroxide products ex. Accel TB Wipes or Spray

Please refer to the World Health Organization for the most reliable and up to date information. DO NOT rely on social media.

For more information:  https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/when-and-how-to-use-masks