More efficient care of Covid patients in intensive care

The medical team in the intensive care unit of the Pellegrin hospital in Bordeaux on September 22, 2020. -

• How is an admission of a serious Covid-19 patient carried out?

  What treatments are administered?

  Is he systematically intubated?

  Two heads of intensive care units answered our questions.

• Because, despite the uncertainties about this new disease, protocols have evolved to take care of the most serious patients in intensive care.

• Less intubations, more corticosteroids and sooner, no more chloroquine… They give us details of the changes which lead us to hope that stays in intensive care are less heavy and long than during the first peak of the epidemic.

No treatment, for the moment, can cure Covid-19, even if many teams of researchers are working to find the miracle molecule.

But the most serious cases, those which end up in intensive care sometimes for weeks, are better taken care of today than at the start of the epidemic.

Because, even if the Covid-19 has not finished unveiling its mysteries, doctors know the pathology better.

How do patients arrive in intensive care?

According to the latest figures from Public Health France, the country has nearly 4,000 hospitalizations for Covid-19, including 815 in intensive care over the last seven days.

In the most severe cases, the patient suffers from pneumonia which can lead to acute respiratory distress syndrome (ARDS).

The inflammation can then destroy the lungs and the patient may die.

“Most often, there are two routes of arrival: via the emergency room because a patient has serious breathing difficulties which deserve to go directly to intensive care,” explains Jean-Damien Ricard, head of the intensive care unit at the Louis Mourier hospital (APHP) in Colombes (Hauts-de-Seine).

Or the patient was hospitalized in an infectious disease ward and their condition worsened.

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What exams are performed?

To assess the seriousness of the condition of these patients, doctors will rely on three examinations.

“Clinic first: we look at his respiratory rate, the higher it is, the more it reflects a significant impairment and we measure the oxygenation of the blood with a saturometer,” continues the professor of intensive medicine and resuscitation.

Then, x-rays will make it possible to see if both lungs are affected and if it is the whole lung or part of it.

Finally biological, we will do a dosage of D-dimers in the blood [the increase in this molecule reflects the presence of a blood clot or a thrombus] which will reflect both the inflammation and the intensity. coagulation.

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How are patients who can no longer breathe relieved?

To relieve the patient, and help him breathe when his lungs are no longer able, it is necessary to provide him with oxygen.

While serious patients were rapidly intubated during the first wave of the epidemic, today other methods are preferred.

“Either with glasses with two tubes in the nostrils which provide oxygen (between 2 and 6 liters per minute) or an oxygen mask (maximum 15 liters per minute), specifies Jean-Damien Ricard.

If that is not enough, we will put them under high flow oxygen therapy: flexible nasal cannulas in the nose can send 50 to 70 liters per minute a mixture of air and oxygen, warmed and humidified, so that it is well tolerated by the patient 24 hours a day. "

A second solution is also now proposed, it is non-invasive ventilation, which improves patient survival and reduces hospitalization time.

Instead of intubating, an invasive method, we use a mask connected to a respirator which will “push” the air up to the alveoli to reduce the effort provided by the lungs.

"When you have pneumonia, your alveoli, which contain air, tend to fill with pus and it is therefore less easy for the lung to admit oxygen and get rid of carbon dioxide, synthesizes Jean-Daniel. Chick,

intensive care professor and head of the intensive care unit at Lausanne University Hospital.

The range of solutions to help the patient breathe, depending on the severity of his condition, has therefore grown.

This development therefore allows the less severe patients to avoid the intubation box.

With all the consequences it entails.

"When you intubate, you do a general anesthesia except that instead of lasting 24 hours, it can go up to a month with the Covid-19, illustrates Jean-Damien Ricard.

People are still, they lose muscle after just a few days.

»And are exposed to many complications: infections with the catheter, bedsores (bed sore), difficulty in readjusting to swallowing, eating, walking ...

What changed between the first and second waves?

“Initially, some resuscitators were reluctant to use this high flow oxygen therapy because feedback from China and Italy showed that patients deteriorated very quickly and therefore had to be intubated very early, continues Jean-Damien. Ricard.

The other fear concerned viral dispersion: with a large flow of air that the patient will breathe out, the virus could spread more in the intensive care unit.

And contaminate caregivers and other patients in the service.

Same fear for non-invasive ventilation.

"However, studies have since shown that FFP2 masks and visors provide good protection", adds Jean-Daniel Chiche.

And a clinical study by Jean-Damien Ricard's team, familiar with high-flow oxygen therapy, has shown that this technique, offered from the first hours, prevents a third of patients from being intubated.

In addition, this publication defined

an index called ROX which can predict the use of intubation for a particular patient, an important decision support tool.

With these less cumbersome methods, some patients, who are not intubated, stay in intensive care for less time.

This is important data while some intensive care units are already under strain, especially in Marseille, which had 46 intensive care patients on Tuesday in the University Hospitals of Marseille.

But these two doctors are tempering: it does not always work and there are still very serious patients who must be intubated.

"Between 50 to 60% of patients who are treated by these two new strategies will be intubated", nuance Jean-Daniel Chiche.

Who is wary of a deceptive shortcut: mortality would have fallen thanks to these new strategies that avoid intubation.

For him, mortality has dropped slightly but not drastically, and it is a set of factors that explain it.

In particular, the less degraded condition of certain patients who arrive at the hospital.

The other parameter, which may change, is that the services are not overwhelmed and therefore the patients are taken care of by nursing staff specializing in resuscitation.

Finally, another important explanation: the therapeutic arsenal has improved.

What drug cocktail is given?

Six months after the first peak of hospitalizations in France, we know more about this new disease.

And publications have shown the interest of certain molecules in relieving symptoms.

"We dropped the chloroquine which has not shown its effectiveness", continues Professor Chiche, also president of the One-o-One foundation.

On the other hand, today we give corticosteroids much earlier and systematically, which will fight inflammation.

"During the first wave, we reserved corticosteroids for the most serious patients, but a British study showed an effect on mortality from the early use of corticosteroids, so we generalized this treatment to all patients," continues Jean- Damien Ricard.

Another new therapy: anticoagulants, intended to thin the blood.

“Today, anticoagulants are administered more systematically to prevent the occurrence of thrombosis,” adds the resuscitator.

This helped to improve the prognosis and limit complications.

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