“If we are to believe our colleagues in New York, 80% of the patients die on ventilator therapy. We have to change this therapy right now,” Groeneveld told Medscape.
He’s been testing passive ventilation without sedation in patients with respiratory failure for almost a decade and says he has achieved mortality rates as low as 2% to 8%. So when the pandemic hit Europe, he suspected his treatment approach could help. He left his job and home in Oberhausen, Germany, because the hospital there wouldn’t admit foreign COVID-19 patients. In Neustadt, he could treat patients coming in from overwhelmed hospitals in Italy, Spain, and France.
Patients who arrive at Neustadt for COVID-19 are “treated with oxygen, mask ventilation, and high tidal volumes to meet respiratory drive,” he said. Groeneveld and his team avoid intubation, regardless of saturated oxygen levels, until mental function is compromised. “We are sure that noninvasive ventilation is very effective and many people do not need intubation and sedatives,” he said.
Still, many physicians, such as Johns Hopkins’ Checkley, are resistant to forgo ARDS protocols.
“The importance of limiting tidal volumes in mechanically ventilated patients,” Checkley said, “is to avoid creating volume trauma ― same goes with pressure. The risk of liberalizing the amount of tidal volume delivered could be problematic in the sense that you could induce injury.” For patients with adequate respiratory system compliance, Checkley doesn’t think physicians should increase tidal volumes above 8 mL/kg of predicted body weight.
Todd Rice, MD, a pulmonologist and critical care specialist at Vanderbilt University, is more skeptical. “To me, in my hospital it doesn’t matter if you have ARDS. We do lung-protective ventilation on everybody because that’s what the research supports,” he said in an interview. In lung-protective studies, high tidal volume is often the control arm, Rice said. “High tidal volumes look better, their oxygen and CO2 levels are often better. But when the studies were done, we saw they died more often,” he said.
It’s true that studies from the ARDS Network show a higher mortality rate with tidal volume at 12 mL/kg of body weight, but Groeneveld argues that the high tidal volumes used in these studies are not a proxy for his strategy. In these studies, all patients were sedated and were receiving excessive fluids, and no one was extubated early. His approach uses highly individualized tidal volumes (usually >800 mL) determined on the basis of the disease, not body weight. The priority is to keep patients awake and passively ventilated so they aren’t breathing on their own and to extubate as soon as possible.