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Comment by tcbawo | Hacker News Reader

If you read enough news and Twitter, you will find some really heartbreaking descriptions of the folks on ventilators. For most, this is a Hail Mary attempt with only 50% survival rate. Many will have significant lung damage if they survive. We need more ventilators to be sure. But we desperately need to find ways to halt the progression of runaway lung inflammation that leads to needing a ventilator.

Edit: this development looks very promising for 'sub-intensive' cases -- adapting decathlon masks to provide positive air pressure (to help reinflate lungs) without intubation or leaking contaminated exhaust: https://www.isinnova.it/easy-covid19-eng/. Some emerging theories of pathology suggest that lung function can be increased by reinflating collapsed alveoli with constant pressure: https://emcrit.org/pulmcrit/cpap-covid/

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> For most, this is a Hail Mary attempt with only 50% survival rate.

Non Hail-Mary Ventilators have only a 30% survival rate at 1 year mark:

https://www.ncbi.nlm.nih.gov/pubmed/8404197

Incidentally, that's exactly why medical systems to not stockpile ventilators. Under reasonable condition, the number of ventilators closely mirrors the expected number of Hail Mary procedures done at a given time and some spare units.

The links I added in my edit suggests that using non-invasive, constant positive air pressure (C-PAP) with a closed mask could help certain patients from needing intubation and ICU as early (or at all). If this turns out to be the case, this might reduce the overload on the hospital system. They might be attempting it in Italy. Hopefully, it works.

That paper makes me wonder what will be the long-term health consequences and outcomes for the survivors of COVID-19 who needed to stay at an ICU.

And the survival rate is only 3% to 20% for COVID-19 specifically, based on data from Wuhan, following patients for a month. Long-term mortality will be even less.

https://www.thelancet.com/journals/lancet/article/PIIS0140-6...

Plus you need nurses and doctors to intubate the patient and setup and monitor the actual ventilator. The machine itself is a small part of the equation.

I think the focus on ventilators is somewhat misleading. If you need mechanical ventilation, you're a goner anyway, and your bed and healthcare staff could be better used on someone else. The 'lack' of a machine is just a very visible component.

If this is true, the death toll of Covid-19 is going to be a lot worse than currently indicated, is that right?

The complications of ventilators and whatever lasting damage is caused by the disease itself; will be killing a significant portion of the recovered population, will it not?

Most mortality estimates and forecasts include only deaths directly attributable to the virus. There are many indirect deaths that will be caused by it. Long term lung damage is one of the ways this will happen, probably among the most delayed. Many more deaths will happen because hospitals that are operating at capacity won't have the resources to prevent other deaths that they normally stop, or will have to stop non-critical treatments in ways that will reduce patients' life expectancies. I live in Madrid and know a neurologist that has stopped any intervention that can't be delayed.

Actually Italy counts everyone who dies who has COVID19 as a COVID19 death. This does not include future death by long term after effects but it includes more then what e.g. was included in China, which is part of why the death rate is so much higher in Italy (the other part is in average people are much older in Italy then China).

Also put that in context with the fact that Italy reported that the majority of death is with people which have preexisting conditions/other illnesses.

Interesting, so a little improvement there may lead to less ICU beds and sorter overall time at the hospital. Wonder if that's possible.

My understanding is that's the hope for Chloroquine and the other drugs being rolled out en-masse this week. They have shown enough promise by various limited trials that we are rolling them out nation-wide to see if they actually do help reduce the severity of the virus.

If they do, then less hospitalization, and less ICU / ventilator needs.

If Chloroquine doesn't end up working, basically we need to find something that does, because that is the only feasible way to get us out of this mess. We have shuttered the economy because the healthcare system can't handle so many people needing hospitalization. The only scalable way around that is to find a treatment that significantly lowers the need for hospitalization.

At this stage it is totally unclear if Chloroquine will work. Unfortunately. Because, all the work published so far has not been produced through double-blind studies in randomized trials.

My god man, totally unclear?

I bet you could find five or more recent peer reviewed studies on it working quite well.

You realize most science isn’t double blind, right? I’ll grant you thats it a gold standard for long term drug use but saying “totally unclear it will work” is absurd.

And we still do useful work relying on simple correlations, r values, peer review. We have all that now supporting some of these drugs. In a crisis and last resort that seems like plenty.

"Peer reviewed" is a better assurance of the accuracy of the observation. It can't do anything about the fact that evidence for current treatment attempts is purely based on observations that could be the result of hope and the placebo effect.

Furthermore, there is a difference between observations of aggregate numbers, like the number of people on ventilators and their survival rate, and small numbers of uncontrolled drug interventions where there are obvious ways for the data to be deceiving. Not all observed data has the same reliability.

>You realize most science isn’t double blind, right?

That's nice, but most science isn't reproducible at scale. We need to do a drug trial for SARS-CoV-2 because we need to 1)establish efficacy and 2) establish safety for this drug in this disease. There are a significant amount of adverse drug effects in individual infectious diseases. Jarisch–Herxheimer reaction when treating syphilis, epstein-Barr mononucleosis and penicillin; Reye syndrome with Aspirin and influenza. The list is long here. We want the most vetted research possible because even if the chance of death is less than half a percent, half a percent of what seems like is going to be over a million is going to be in the tens of thousands here.

I'll take that bet.

Here's a recent review: https://www.sciencedirect.com/science/article/pii/S088394412...

They find hundreds of relevant-sounding papers, registered trials, and guidelines, but almost no data beyond one in vitro study to back it up. That one study is promising--and it'll be great to see what the trials show--but the road from "works in a dish" to "drugs for all" is a long, bumpy one at the best of times.

We need to do this right so that if it works, we know that it works, and if it doesn't, we can make informed decisions to do something else.

My understanding is that it's part of the official Chinese treatment regimen. That seems like good enough authority to me given they've been through the worst of it so far.

There are enough people with fatty liver, etc that chloroquine can’t be a magic bullet

Hydroxychloroquine is what's actually mentioned in at least some of the stories. It is supposed to be much less hepatotoxic. Though the point that neither may work stands.

" The only scalable way around that is to find a treatment that significantly lowers the need for hospitalization."

This isn't quite true.

Taiwan, Singapore and S. Korea have not 'shut-down' their economy, and they have tamed the problem.

Massive and widespread testing, assertive isolation and tracking of individuals who test positive can work on some level.

Combined with some other things like maybe keeping 'big gatherings' or 'social gatherings down', requiring people to wear masks on trains, busses, airplanes - we may be able to reasonably suppress Corona without a medical discovery.

Published literature suggests that surgical masks reduce the amount of escaped virus by 3x. If we can make enough masks, we need everyone to start wearing them. They should be handing them out at grocery stores!

I was going to say the same, there seems to be thread after thread about ventilators, but are they a golden ticket to good health ?

> are they a golden ticket to good health ?

I don't think anyone views them quite as starkly as that.

I think many people do as that is why there is so much focus on them.

People are hearing about Italy running out of ventilators and choosing which patients to save. Since we don't want that scenario we are looking to have enough ventilators.

may people think they're crucial to have. I doubt any of them think they're a "golden ticket to good health".

> but are they a golden ticket to good health

No, building a ventilator is like building an engine because you need to go to the store - you're missing so much of the solution to the problem. I've also posted before [1] on why they are a terrible idea to waste time on "designing".

That said, ventilators I believe are already a solved problem for COVID. We have tens of thousands in the strategic stockpile, and production capacity is being ramped up hopefully to meet demand. This is exactly how these stockpiles were intended to work.

1. https://news.ycombinator.com/item?id=22581652

I don't these stockpiles exist. At least the order by the German government seems only to be fulfilled by new production [2] and other governments might have to queue due to few manufacturers [3]. I don't know if in market forces and IP worked to our good here. I think current design challenges could at least channel random good ideas wrt ventilator designs. [1]

1.Montreal offers $200k prize for cheap and easy to build ventilator design - https://news.ycombinator.com/item?id=22637540

2. https://app.handelsblatt.com/unternehmen/industrie/medizinte...

3.https://www.srf.ch/news/schweiz/knappheit-wegen-coronavirus-...

It absolutely isnt a solved problems, most countries affected by the pandemic do not manufacture the ventilators and have like a 10x shortage compared to what's needed to incubate everyone who will be sick. (Obviously depending on how bad it gets).

The struggle to ramp up production is a desperate one, and this is one case where IP is killing people - there are several consortia in the UK that are ready to manufacture, but need a certified design they could build.

For the US, the potential needs is in the millions and the current ventilator count is 100,000 (plus or minus tens of thousands).

I think we probably agree that industrial production is the way forward, but the numbers are not particularly comfortable.

> potential needs is in the millions and the current ventilator count is 100,000

There are only 96,596 ICU hospital beds in the United States according to the AHA. As I said, ventilators are already solved to the point that something else is the bottleneck.

Are you referring to early testing for the virus, ie to take care of these patients well before they show up at hospitals with respiratory problems?

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