Never forget that the lab leak was a “conspiracy theory” that the New York Times’ head Covid reporter called “racist.” If you think I’ll tire of recalling this, my friends, you are wrong.

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[–]weavilsatemyface 1 insightful - 1 fun1 insightful - 0 fun2 insightful - 1 fun -  (8 children)

Back then the idea was still to avoid emergency intubation.

True, nobody can fault the hospitals for trying to avoid emergency intubation. To try to keep people well enough so that they don't suffer sudden and catastrophic respiratory collapse requiring emergency intubation is a good thing.

But as I said earlier, these are not the only two options:

  • wait until patients are crashing before calling Code Blue and performing an emergency intubation;
  • perform an early, preemptive intubation the moment a patient's Sp02 drops below some arbitrary cut-off without attempting any form of non-invasive ventilation first.

The other options include do what people did before Covid. As I have already documented repeatedly. No time travel required.

Google returns zero results for that quote. Where is it from?

Its a paraphrase of the consensus from the eight or ten or so sources I've already given. I thought it was clear from the context, apologies if it wasn't.

halfway down your own link

Now we're getting somewhere, thank you. You should read the whole article carefully. Quote:

  • Healthy subjects have a mean nadir SpO2 of ~90% during sleep
  • For Bleomycin or paraquat toxicity, TSANZ guidelines advise a target of SpO2 85%
  • In COPD oxygen should be administered if the SpO2 is less than 88%, and titrated to a target SpO2 range of 88% to 92%
  • Adults with sleep disordered breathing commonly tolerate SpO2 levels between 80 and 90% for prolonged periods
  • Adults with comorbidities tolerate SpO2 levels between 80 and 90% during long distance flights
  • ANZCOR guidelines recommend a default SpO2 target range of 94-98%, slightly higher than the TSANZ guideline recommendations.
  • avoid the harmful effects of hyperoxaemia

Would you like to rethink your earlier claim that "95% is low. 80% is dangerous"?

If there's no longer decreased oxygen to the brain, it's damage.

Thank you Doctor ActuallyNot for your diagnosis over the internet without ever meeting or seeing or testing the patient, or having any idea of her medical condition, or even any vague idea of the causes of brain fog 🙄

[–]ActuallyNot 1 insightful - 1 fun1 insightful - 0 fun2 insightful - 1 fun -  (7 children)

Healthy subjects have a mean nadir SpO2 of ~90% during sleep

That's the nadir, and it's during sleep. People who come into an emergency room will be awake and the SPO2 will current level.

For Bleomycin or paraquat toxicity, TSANZ guidelines advise a target of SpO2 85%

Good to know. Note that they are balancing the damage from low oxygen with the damage from lung injury by oxygen, in that case.

In COPD oxygen should be administered if the SpO2 is less than 88%, and titrated to a target SpO2 range of 88% to 92%

That low level of intervention is something specific to COPD. The next sentence reads: "In other acute medical conditions, oxygen should be administered if the SpO2 is less than 92%, and titrated to a target SpO2 range of 92% to 96%. [GRADE C]"

Adults with sleep disordered breathing commonly tolerate SpO2 levels between 80 and 90% for prolonged periods

Sleep disordered breathing commonly causes serious complications.

Sleep apnea is a serious medical condition. Complications of OSA can include:

Daytime fatigue. The repeated awakenings associated with sleep apnea make typical, restorative sleep impossible, in turn making severe daytime drowsiness, fatigue and irritability likely.

You might have trouble concentrating and find yourself falling asleep at work, while watching TV or even when driving. People with sleep apnea have an increased risk of motor vehicle and workplace accidents.

You might also feel quick-tempered, moody or depressed. Children and adolescents with sleep apnea might perform poorly in school or have behavior problems.

High blood pressure or heart problems. Sudden drops in blood oxygen levels that occur during OSA increase blood pressure and strain the cardiovascular system. Having OSA increases your risk of high blood pressure, also known as hypertension.

OSA might also increase your risk of recurrent heart attack, stroke and irregular heartbeats, such as atrial fibrillation. If you have heart disease, multiple episodes of low blood oxygen (hypoxia or hypoxemia) can lead to sudden death from an irregular heartbeat.

Type 2 diabetes. Having sleep apnea increases your risk of developing insulin resistance and type 2 diabetes. Metabolic syndrome. This disorder, which includes high blood pressure, abnormal cholesterol levels, high blood sugar and an increased waist circumference, is linked to a higher risk of heart disease.

Liver problems. People with sleep apnea are more likely to have irregular results on liver function tests, and their livers are more likely to show signs of scarring, known as nonalcoholic fatty liver disease.

-https://www.mayoclinic.org/diseases-conditions/sleep-apnea/symptoms-causes/syc-20377631

ANZCOR guidelines recommend a default SpO2 target range of 94-98%, slightly higher than the TSANZ guideline recommendations.

Consistent with the other information that we're seeing.

Would you like to rethink your earlier claim that "95% is low. 80% is dangerous"?

Not so much. Interventions seems to be well above 80%

Would you like to rethink your earlier claim that 70% is not dangerously low?

[–]weavilsatemyface 1 insightful - 1 fun1 insightful - 0 fun2 insightful - 1 fun -  (6 children)

Interventions seems to be well above 80%

Sure. As I've said many times, doctors like to see people have normal blood oxygen levels, and will intervene if they are below normal.

Would you like to rethink your earlier claim that 70% is not dangerously low?

You've given me no hard evidence that would change my mind, just a continue series of assertions without evidence at all, and links that indicate that doctors will put patients on oxygen if they present with an SpO2 below 90%. But I've never denied that.

I've seen evidence that doctors don't like to see an SpO2 as low as 70% because that is at the point of the blood oxygen curve that becomes strongly non-linear, which means that if your SpO2 drops as low as 70% or so, it could rapidly and catastrophically drop to critically dangerous levels (like 40%) with little warning. (Rapidly, in this case, typically means "over an hour or so", not "minutes or seconds".)

None of this goes against what I have been saying. And most importantly, none of your sources support the early intubation of patients with an SpO2 of 80% or even 70% without attempting prone positioning or non-invasive ventilation first.

An SpO2 of 80% is bad. For most people, without the special conditions that lead to happy hypoxia, it is probably terrifying as well as limiting what they can do, physically and mentally. None of this is in doubt. But it is not killing them, its doubtful that it is doing permanent, serious damage, and people do often tolerate a SpO2 of 80% for considerable periods of time. On its own it doesn't justify intubation.

I've given you a poor quality source that says that low SpO2 doesn't causing critical organ damage until it gets as low as 40%. As I have said previously, if you have a more credible, high-quality source that says differently, let's say that serious and permanent brain damage begins at (let's say) 60% -- not just mere "cognitive impairment"1 -- then show me the source and I'll welcome the better information. Until then, I see nothing in your sources that change my mind.

1 How much cognitive impairment? How was it measured?

[–]ActuallyNot 1 insightful - 1 fun1 insightful - 0 fun2 insightful - 1 fun -  (5 children)

Sure. As I've said many times, doctors like to see people have normal blood oxygen levels, and will intervene if they are below normal.

So you agree that intubation was primarily for the benefit of the patients?

You've given me no hard evidence that would change my mind

You've found quite a lot yourself, though haven't you?

PaO2 Levels in mmHg <60 means Critical low (supplemental oxygen is needed), according the second table on this page.

Figure 1 of this paper shows that this relates to slightly under 90% SPO2, perhaps about 88% or 89%.

[–]weavilsatemyface 1 insightful - 1 fun1 insightful - 0 fun2 insightful - 1 fun -  (4 children)

So you agree that intubation was primarily for the benefit of the patients?

Are you talking about intubation in general, or specifically for Covid?

In general, I expect that most doctors in most hospitals use intubation appropriately. I see no evidence that intubation is a discredited medical procedure that should never be used. There's a time and place for it and the pre-Covid protocols seem sensible.

In the case of Covid, its hard to say. I'll grant that, in some cases, patients may have needed intubation, if they were in distress and failed to respond to other treatments. But even there, by early in the Covid pandemic front-line doctors found that Covid hypoxia is often (always?) more like altitude sickness than ordinary hypoxia from pneumonia. Nobody treats altitude sickness with intubation. So possibly no Covid patient should have been intubated ever. Maybe.

But even if we accept that some intubations were necessary and for the good of the patient, even by the standards of the original SARS epidemic the early Covid protocols of early intubation and heavy sedation was bad and harmful to patients.

Hospitals were intubating patients who didn't need intubation in order to prevent infection of staff. The doctors say so, the nurses say so, respectable media like the Wall Street Journal says so, scientific journals say so.

If you go to the hospital with an infected cut on your leg, and instead of tying to clean the wound and treat it with antiseptics and antibiotics, the doctors knock you out and amputate your entire leg, that's not exactly "for the benefit of the patient". In this example we all agree that amputation would be medical malpractice. The hospital would have to explain why they failed to treat the wound, and nobody would be impressed if their answer was "we assumed that the leg would eventually go gangrenous, so we decided to save time rather than waiting for gangrene to set in and do an emergency amputation".

But when it comes to Covid, that's the answer you are prepared to accept: We intubated them early, before they needed it, rather than do an emergency intubation in the future.

Why didn't they try non-invasive ventilation first? Because we feared it would spread the disease to staff.

Not all hospitals. Not all doctors. But especially in the first few months, especially in New York and Italy, enough of them did it to send the fatality rate through the roof and cause mass panic over Covid throughout the world.

[–]ActuallyNot 1 insightful - 1 fun1 insightful - 0 fun2 insightful - 1 fun -  (3 children)

Are you talking about intubation in general, or specifically for Covid?

Covid.

Hospitals were intubating patients who didn't need intubation in order to prevent infection of staff.

No. Because they were suffering hypoxia that needed intervention.

You're very wrong about the oxygenation levels that require intervention.

Why didn't they try non-invasive ventilation first?

Because emergency ventilation has risks, and the SPO2 levels associated with happy hypoxia are fucking dangerous.

[–]weavilsatemyface 1 insightful - 1 fun1 insightful - 0 fun2 insightful - 1 fun -  (2 children)

they were suffering hypoxia that needed intervention.

Intervention, yes. Intubation, no.

The doctors and nurses on the front line agree with me.The medical journals agree with me. This is why the protocols have reverted back to the way they were before Covid: prone-positioning and non-invasive ventilation first, and only use intubation if you absolutely have to. And then, dial down the oxygen volume and pressure.

Even early on in the pandemic, it became clear that hypoxia as a symptom of Covid did not respond like doctors expected. It was more like altitude sickness. You don't treat altitude sickness by intubating the patient. But even by the standards of SARS, what hospitals did for Covid was unjustified and killed patients.

Not all hospitals. Not all doctors. But enough, especially early on in New York and Italy, to push the fatality rate way up and cause a global panic that was completely unnecessary. If they had even stayed with the 2003 SARS treatment protocols, there would have been no panic over running out of ventilators, and far few people would have died.

Why didn't they try non-invasive ventilation first?

Because emergency ventilation has risks

And here we go with the bait and switch. I'm asking why they didn't use non-invasive ventilation, and you switch to talking about emergency intubation.

There's a middle ground between "wait for the patient to go into cardiac arrest before calling for a crash cart and emergency intubation" and "intubate as soon as they experience a slightly lowered blood oxygen level". Why won't you acknowledge that according to pre-2020 protocols there was a whole range of options available to doctors to deal with hypoxia before intubation, but with Covid, hospitals threw that existing knowledge out and went straight for intubation? And then to make things even worse, they avoided giving prophylactic antibiotics, and had the oxygen pressure and volume turned way up.

Remember how in the early months people talked about how Covid was causing kidney failure? Kidney failure is a known side-effect of Remdesivir. When they stopped treating so many patients with Remdesivir, the number of kidney failures fell. Funny about that.

Remember in the early months when everyone was talking about Covid causing a cytokine storm and multi-organ damage? And now you never hear of it happening to anyone with Covid any more, vaccinated or unvaccinated? Go back and look at the link I gave you for the risks involved with intubation:

Mechanical injury to the lungs may prompt an adverse inflammatory response, which may exert damaging effects, known as "biotrauma". Activation of injurious cytokines and other inflammatory mediators cause biotrauma not only in pathological and normal lung regions but also in other organs, with resultant multi-organ dysfunction and increased mortality. The respiratory epithelium in the lungs has a high surface area. Additionally, a substantial volume of blood circulation passes through the lungs per minute. The implication is that relatively small-scale, local inflammatory responses may precipitate a large release of pro-inflammatory cytokines with high potential for hematogenous spread and multi-organ damage. Concomitant physiologic impairment, for example, from sepsis, trauma, surgery, or chronic illness, predisposes patients to VILI from a cascading immune response.

Makes you think, doesn't it? Well, not you, obviously, but anyone with a mind open to evidence.

[–]ActuallyNot 1 insightful - 1 fun1 insightful - 0 fun2 insightful - 1 fun -  (1 child)

Intervention, yes. Intubation, no.

Okay, we're making progress.

Before you were saying 70% oxygenation is fine, and there wasn't any obvious need to intervene in terms of benefit to the patient.

The doctors and nurses on the front line agree with me.The medical journals agree with me.

And when you say "agree with me" you think they agree that 70% SaO2 is not dangerous? Or that intubation of a patient with "happy hypoxia" was done primarily for the avoidance of risk to the staff, and very little to do with the fact that their oxygen levels needed to be brought up?

And here we go with the bait and switch. I'm asking why they didn't use non-invasive ventilation, and you switch to talking about emergency intubation.

No, that's the reason for intubation.

Here is you saying that:

"Early intubation should be considered to prevent the additional risk to staff of emergency intubation and to avoid prolonged use of high flow nasal oxygen or non‐invasive ventilation."

You're surprisingly incapable of following the conversation. Are you using a chat bot to respond to the last post?

[–]weavilsatemyface 1 insightful - 1 fun1 insightful - 0 fun2 insightful - 1 fun -  (0 children)

Before you were saying 70% oxygenation is fine

I never said that.

I said that 70% wasn't necessarily a medical emergency requiring immediate intubation, and unlike you who makes assertion after assertion but rarely provides any evidence for anything, I can back it up including with a peer-reviewed case study of a Covid patient who presented with SpO2 of 70% and was then put on an oxygen mask, at which point she quickly went up to 85% or so, where she remained for 30 days before making a full recovery. No intubation required.

Plus the various other sources I have provided that pretty much say the same thing: stop intubating Covid patients just because they have hypoxia. There may be good clinical reasons to intubate Covid patients under some circumstances, but 80% or 70% SpO2 alone is not a good reason.

People can and do frequently tolerate levels as low as 70 or 80% for significant periods of time, sometimes without any distress, and even as low as 50% for short periods of time without suffering serious organ failure. You seem to be fixated on this idea that any deviation from normal range of SpO2 is a medical emergency causing organ failure and requiring immediate intubation but you are unable to back it up and unwilling or incapable of reconsidering your position in the face of evidence.

and there wasn't any obvious need to intervene in terms of benefit to the patient.

And I absolutely never said that or anything like that.

As I have said over and over and over again, non-invasive ventilation can and should be used before dangerous invasive mechanical ventilation (intubation). I don't know how many more times I need to say it before you will comprehend.

I said that hospitals should have kept the pre-Covid protocols, which had been tried and tested over many years. This includes the protocols developed for dealing with SARS. Non-invasive ventilation and prone positioning first, only if they do not help should you consider intubation, in which case you need to keep the sedation mild, and the oxygen volume and pressure low. I've said this over and over again, yet somehow you are still arguing against the strawman "don't treat Covid patients at all if they present with hypoxia until they go into cardiac arrest from lack of oxygen".

Either your reading comprehension is terrible, or you are arguing in bad faith.

... Or that intubation of a patient with "happy hypoxia" was done primarily for the avoidance of risk to the staff

I quoted the Wall Street Journal, and Theodore Iwashyna, critical-care physician at University of Michigan and Department of Veterans Affairs hospitals in Ann Arbor, who explicitly said that. Quote:

“We were intubating sick patients very early. Not for the patients’ benefit, but in order to control the epidemic”. (Emphasis added.) The article also says "doctors often preemptively put patients on ventilators or gave powerful sedatives largely abandoned in recent years. The aim was to save the seriously ill and protect hospital staff from Covid-19." (Emphasis added.)

Of course they were trying to save the sick as well. As I have said before, we should put aside overly emotional claims of "murder" by some front-line staff. (Although the evidence of involuntary euthanasia in some cases is undeniable, and some very suspicious patterns of use of morphine and midazolam in nursing homes.) I have never suggested that preventing infection of the staff was the only motive. But the difference between the pre-Covid and early Covid medical response:

  • pre-Covid: use high-flow nasal oxygen (HFNO) or non-invasive ventilation (NIV), and only consider intubation if that fails to help;
  • early Covid response: use intubation preemptively, avoiding the use of HFNO and NIV;

was driven by fear that HFNO and NIV would spread Covid to staff. That fear was ill-founded, and driven by an exaggerated sense of Covid's fatality rate, and the very real shortages of PPE in New York hospitals (remember the nurses using garbage bags as make-shift PPE?). Nevertheless it was a real fear and in fairness we should recognise that in the very early months there was significant panic involving Covid.

I'm asking why they didn't use non-invasive ventilation, and you switch to talking about emergency intubation.

No, that's the reason for intubation.

There are other ways to avoid emergency intubation apart from preemptive early intubation. The question is, why not try those alternatives before going straight to intubation? I've given you multiple sources that agree that the reason they weren't used:

  • apparently many young, inexperienced doctors simply were not aware that prone positioning is a thing;
  • because of the fatalistic (and wrong!) opinion that intubation was inevitable, so you might as well do it early;
  • from a dubious theory that patients would damage their own lungs by breathing too hard;
  • and most importantly, to protect medical staff from infection.

Here is you saying that:

"Early intubation should be considered to prevent the additional risk to staff of emergency intubation and to avoid prolonged use of high flow nasal oxygen or non‐invasive ventilation."

Right, and I'll say it again. Early protocols for Covid patients were to incubate early, not because it was good for the patient but to reduce the presumed risk to staff from emergency intubation and non-invasive intubation.