Nicholas Caputo, MD, M.Sc., F.A.C.E.P., F.A.A.E.M., MAJ, Attending Physicianin the Department of Emergency Medicine at Lincoln Medical and Mental Health Center in the Bronx, New York and Richard Levitan, MD, an Emergency Physician and Airway Specialist, talk about how the use of prone positioning (PP) has kept some patients off ventilators during the COVID-19 pandemic.
I want to get your perspective on what you have been seeing come through the emergency room. Is it indeed starting to trickle off just a little bit in New York or what are you guys still facing?
Dr. Caputo: It is pretty few and far between in terms of COVID cases. The scary thing is that the people that were coming in prior to COVID, patients with chest pain or abdominal pain have not come back yet. So that is a major concern for a lot of my colleagues and me.
We have heard an awful lot about ventilators and that a lot of patients, by the time they get to the E.R. have needed them and there were not enough to go around. Is that still the case?
Dr. Caputo: Truth be told, the administration both locally and on the federal level did an amazing job of getting us the resources that we needed. There was no time where we had to make decisions in terms of who got a ventilator, who did not get a ventilator. There were times where things were tight but when the requests went in the system leadership at central office at New York Health Hospitals did a heroic job of obtaining ventilators for us, whether it be through the federal government, the local government, or just through procuring ventilators from within the system itself. They did a great job at load-leveling in terms of occupying empty space within the system, but also of resource sharing. That made a huge difference for us and allowed us to sort of take refuge in the fact that we had a leadership that was responsive and that was really working 24/7 to get us the resources we needed. We never hit that critical mass where it was, we do not have enough ventilators. We were close, but we did not get there.
Why is it so critical to avoid having to get to the point where a patient needs that ventilator?
Dr. Caputo: When you get to a point where a patient needs to be placed on mechanical ventilation, you are dedicating that patient to a massive amount of resources that are needed in terms of human power. The number of subspecialized physicians and nurses that are needed to – pumps of the medications – the need for all of these resources increases exponentially when a patient goes to a higher level of care, especially on mechanical ventilation within an intensive care unit. It’s always best to try to keep patients off of ventilators through less invasive techniques if you can because there as much of a benefit to patients who have mechanical ventilation in certain situations like patients who are going into respiratory failure or patients who have congestive heart failure that need to be placed on mechanical ventilation. There are also risks as well to be putting on mechanical ventilation. So, you kind of want to minimize the risks and you really want to use higher levels of care appropriately.
What are some of those risks?
Dr. Caputo: Risks to the patients on mechanical ventilation come in many forms. Patient Asynchrony, basically meaning that the patient is over-breathing or fighting the vent. That causes a lot of stress and agitation to the patient. Volutrauma – Barotrauma is something that needs to be considered in these patients. So, if you don’t have the right mechanical ventilation settings for these patients, you can cause a lung to burst, known as a pneumothorax, through giving them too much tidal volume or volume of air or just giving them too much pressure. So, these patients need to be watched and watched closely.
Talk to me about positioning. You and your other colleagues noticed that by putting a patient on their stomach and giving them oxygen, you are getting rather good outcomes?
Dr. Caputo: This is known as Proning. And Proning has been done in mechanically ventilated patients for years with decent outcomes. What you do is you turn the patients over, and what that does is it helps to open up some of the collapsed alveoli, which are the smallest parts of the lungs, and helps them to aerate and oxygenate so that you have more surface area to diffuse oxygen through and that improves oxygenation. One of the things that happens is when you lay down on your back, you get something called compression atelectasis. Just by the weight of your mediastinum – on your heart and your chest on the lungs, it collapses some of the spaces of lungs. You can get up to anywhere from 5 to 15% of your lung volume decreased by just compression atelectasis. So, by flipping the patient over, you can use some of that dead space and reoxygenate it or reaerate it so it can be used for diffusion and used to help oxygenate the patients.
What else is helpful for patients at that point?
Dr. Caputo: For patients who were hypoxic but were not in respiratory distress or dyspneic – having difficulty or trouble breathing – placing them on nasal cannula at certain levels, one, helps to decrease the deficit of oxygen that they need. This in combination with proning to open those areas allows aeration and oxygenation to occur in a more expedited manner. So, we found the best combination was to use supplemental oxygen concurrently with postural changes of proning. Whatever the patient really could tolerate. If they could turn over completely on their stomachs by themselves, that was great. After 20 minutes, they did not like that, we asked them to turn on their left or turn to the right. And just kind of keep rotating around to open up those areas of the lungs that could collapse again from compression.
What percentage of patients did this help?
Dr. Caputo: What we found was that, by the first 24 hours, 75% or three quarters of the patients we were able to keep from being intubated. And then, as time went on, some more patients were intubated – so by the third – second or third hospital day, two thirds of the patients were able to be kept off of ventilators through the postural changes or proning plus supplemental oxygen. So obviously there are going to be patients that it is not going to work on. You are never going to avoid that. But we found a rather good success rate in keeping patients off the ventilators using this technique.
What would you say to other E.R. departments that maybe have not tried the positioning or haven’t thought about the positioning?
Dr. Caputo: I would say some of the biggest lessons we learned during the surge of the pandemic was, number one, do not intubate early on. There is a significant number of patients that will have bad outcomes if you intubate them. We learned quickly to address the fact that they were hypoxic, but do not address it by intubating them right away. There are non-invasive ways that can be performed safely and used in conjunction with these simple maneuvers such as proning or postural changes that are low risk and are done by the patients themselves. So I would say the biggest lessons learned, at least clinically, in those patients who are known as silent hypoxemics – who are not declaring themselves in respiratory distress, struggling to breathe – who are kind of just sitting there pretty relaxed, though they look ill and are hypoxemic and the SPO2 monitor’s reading an O2 of 72% – put some oxygen on them and then have them prone. Have them postural change and see what happens. In a significant number of these patients, you are going to see that their heart rates are going to normalize, their oxygen saturations are going to increase and almost normalize. I say almost because, you know, having 90% oxygen saturation is still low relatively speaking, but it is better than 72%. And you are going to see their breathing improve. So you want to look at the patient as a whole and you want to see, all right, as I give these maneuvers and as I give this supplemental oxygen, if the patients work of breathing doesn’t improve, if their oxygen saturation starts to drop, if they become altered or if they have worsening of their breathing, those would be your triggers to intubate as opposed to just having a patient come through the door, see that their O2 stat is 72%, be like we need to intubate them now.
Dr. Rich Levitan and I talked about a proning pad. Is that something that you used at Lincoln Medical Center and if so what kind of a benefit did you find with that?
Dr. Caputo: It was interesting because we got the proning mattresses from Dr. Levitan. He was the one who thought of that and said, why don’t we use these maternity mattresses and I could get some for you. And his brothers started a charity called Prone 2 Help and, you know, Rich was true to his word. Literally within a few days of him saying, hey, why don’t we do this? We had a bunch of proning mattresses or maternity mattresses show up and we used them, and they absolutely helped patients who were on the heavier side or who just could not tolerate being on their stomachs to be more comfortable. And I think that helped us in those patients that were not able to tolerate it as well as other patients. So yes, having the proper equipment does help.
How do you and Dr. Levitan know each other?
Dr. Caputo: I know Rich through the emergency medicine community. We are both airway researchers. We both do a lot of teaching. Rich trained at Bellevue, but his first job as an attending was at Lincoln Medical Center in the South Bronx. So, there is that kind of connection as well. But I met Rich just through our common interest in airway and we became good friends in teaching, education, and research.
Richard Levitan, MD, Emergency Physician and Airway Specialist.
Dr. Levitan, if you could tell me a little bit about what brought you to New York. You’re not normally based there?
Dr. Levitan: I grew up in New York, many people I love, live in New York, and I have an addiction to Papaya King hotdogs.
So, you decided that you wanted to step back in for a little bit?
Dr. Levitan: So, I trained at Bellevue Hospital, the largest public hospital in New York City. I was watching them get crushed and I was up in New Hampshire watching the snow melt and I just felt like I had to go and help out.
When you got there, I mean, obviously, you had been seeing images on TV, but what did you see that surprised you that you weren’t expecting?
Dr. Levitan: Well, you know, it’s amazing to walk into an emergency department and have the entire emergency department filled with people with one disease. I worked the First World Trade Center bombing and we had 500 people covered in soot from head to toe who came from that one event. This was basically a slow-moving mass casualty where, every day, for weeks, the only thing that was showing up in New York City Public Hospital Emergency Departments were people with this one disease, specifically COVID pneumonia.
What about the COVID Surprised you in particular? I mean, you were expecting pneumonia and to be, you know, intubating people and treating people having a difficult time breathing, but along those lines, what was it again that surprised you?
Dr. Levitan: These patients presented in a way that I had never seen before. They had oxygen saturation is as low as 50 percent, normal is above 94 percent and they were talking to us. They were not in shock. They were not lethargic. They were not fundamentally altered. They were on their cell phones with oxygen saturations that we just couldn’t believe. But what I came to learn is that they had been sick for days and then they came in with a late sign of feeling shortness of breath, but they had been sick for a week and they slowly, I believe, got to these low oxygen levels. But to see such low oxygen levels was unlike anything I’d ever seen in somebody who was talking to you.
For our viewers who may not be familiar with the oxygen saturation and what it and can you explain what it is and what it does for the body?
Dr. Levitan: So, oxygen basically is supplied throughout our bodies. It goes to our brain. Our brain is among the most sensitive things to oxygen deprivation. We know in pilots who lose their oxygen mask that you pass out in seconds. We’ve all seen people who choke and pass out or if people drown or you have any other process where oxygen doesn’t get delivered to your brain, you go unconscious or you seize. These people had oxygen levels half of normal, but they were awake, alert. The thing that their body had done, which they didn’t even realize, was, in order to accommodate this low oxygen, they were silently breathing faster and they were doing that for days until, all of a sudden, they developed shortness of breath.
So, could this measure of oxygen be an early warning sign for people?
Dr. Levitan: So, to be clear, measuring oxygen the blood is not a test for COVID. It’s a test for COVID pneumonia that, as the pneumonia progresses in your lungs and your oxygen goes down, it can identify people who have this condition. I believe its greatest utility would be in regular monitoring in places like nursing facilities and long-term care facilities as well as in patients who we know have COVID, because roughly about one in 20 people who come down with COVID symptoms, and most people have no symptoms, but if you come down with COVID symptoms roughly about one in 20 will go on to get pneumonia.
A lot of people have been told, Dr. Levitan, to kind of ride this out at home, especially if you’re just having mild symptoms. Could this measurement also be helpful for them so that they know, when do I need help? When is my body working too hard and I need some additional medical assistance?
Dr. Levitan: Well, let me tell you recently about an email I got from northern Italy. An emergency doctor there told me about 250 patients who they identified had COVID. So, these were patients who had muscle aches and fevers and they didn’t feel well. They had many symptoms. They had a cough; they weren’t having any shortness of breath. Their oxygen was fine, but they sent them home with these tiny pulse oximeters, and one out of 20 of them developed low oxygen. They came back into the hospital. They diagnosed that they had COVID pneumonia. They treated them earlier, and they were able to keep them all off of ventilators and they all survived. So, my belief is that monitoring oxygen is important in the high-risk populations and in anybody who we know has COVID.
You showed your fingertip with the pulse oximeter. Most of us who’ve been to a doctor will be familiar with that, but can you just describe what it is and how it’s picking up what’s going on in your body?
Dr. Levitan: So, you just turn these on with one button, and basically they display your heart rate and they display your oxygen saturation. That information along with your temperature is of incredible value as you talk to your doctor or you talk to an emergency department or a telehealth line and you’re able to tell them, here’s what I’m feeling, and these are these numbers. That information, I think, is really important to make a good decision about when you need to get seen.
You had mentioned that having the measurement, the pulse oximeter may be helpful in keeping people off ventilators. It sounds like a simple question but, again, why is it so important to make sure that people don’t get to the point where they need ventilators?
Dr. Levitan: There are two aspects of this disease that are awful in terms of its impact on the health system. One aspect is that people are coming in all at once in the midst of the pandemic spike that happened to New York. But the other problem with this disease is everybody is coming in late in the course of illness, so they have terrible pneumonia, their oxygens are very low. Even though they came in with terrible pneumonia, New York has figured out that about two out of three of these patients can avoid ventilators doing simple maneuvers, putting them on oxygen, turning them on their stomachs. Well, what I’m saying is that if we could detect the pneumonia before it got severe, as they recently have started to do in Italy – if we could detect the pneumonia earlier, then many, many more patients can avoid ventilators.
You had mentioned that 94 and above 94 is a pretty healthy range. If someone has a high-risk member of the family and you have one of the pulse oximeters, at what level is it time to maybe start seeking help? When you dip under 94, or does it vary by individual?
Dr. Levitan: I can just tell you that in the hospital, we don’t send home patients who are below 92 percent and the federal government in the United States allows home oxygen if your oxygen is below 92. So, that is kind of the cutoff that we use from a treatment perspective. What I am saying is there is no easy off-ramp that I see for this infection over the next 12 to 24 months. If you add a pulse oximeter into your medicine cabinet and you can share that information with the hospital that you’re headed to or your doctor who you’re in consultation with, it’s really of great value and I believe as important as having a thermometer, and I don’t think that it is harder to use than either a thermometer or a blood pressure cuff.
And they’re commercially available, so easy enough for most people to be able to get?
Dr. Levitan: Correct. They are sold widely through pharmacies. There are some digital versions, however many of them have had problems with reliability.
I know you’d mentioned this earlier but again, for our viewers, who really should have one of these at home? High-risk individuals, or is it one of those things like a thermometer where it might just be a good idea to have it because we may see a resurgence in the fall as this may, as you said, be a year to 18 months of waves?
Dr. Levitan: Well, you know, it’s funny. Thinking about this, since we were little kids, we associate illness with fever. Since we were little kids, the determinant of whether or not you went to school was if your temperature was up. In this respiratory pandemic that silently attacks the lungs, it’s not a bad thing to be able to monitor that. Now, I think it’s best done with a physician you can speak to, but in this country where there’s a lot of difficulties necessarily unless you have a lot of money and you have a concierge doctor. If you can’t reach your physician, that information, heart rate, oxygen saturation, and temperature, you can share with a telehealth line at your local hospital and you can make a much better decision about whether or not you need to come and get evaluated. I just want to say patients need to know that they should not be afraid to come to the hospital. The CDC in this country has told people to stay home until basically, you get shortness of breath, you cannot be awoken, or you turn blue. Well, if you are turning blue and you cannot be awoken, that is a life and death late presentation. And, shortness of breath we are learning in this pneumonia is very late in the course. So, I would encourage patients not to be scared and they should come into the hospital if they’re having chest pains, signs of a stroke, they’re having abdominal pain. All this week, we are seeing patients who are coming in late because we’ve scared the public about seeking help in an emergency, and we shouldn’t do that. The earlier you get diagnosed as having COVID, the better in terms of knowing that you have it and also being closely followed.
Doctor, is there anything else from that time on the front lines that you would want to make sure that people know?
Dr. Levitan: You know, I went down to New York for 10 days. The heroes are those who were there fighting it for weeks before I arrived and who will be there for months. The lessons learned in New York City are going to help America and the world, frankly, do better with this disease.
And what was it you said about patients lying on their stomachs?
Dr. Levitan: So what happened was, and this hasn’t gotten out in the news much, but one of the amazing things about this pneumonia was that we learned that if we put oxygen on patients and we simply turn them onto their stomach, we can improve their oxygen saturation tremendously. What that did was it allowed people not to have to be put on a ventilator. And in fact, in a study out of Lincoln Hospital, we determined that two out of three patients would not need a ventilator throughout their course of hospitalization using this technique. And so, the first paper written about this came out of Lincoln Hospital, and I was one of the authors, but the primary author was Nick Caputo and there was another doctor named Rubin Strayer who’s from Brooklyn. But what we discovered was that patients sometimes were uncomfortable laying on their stomachs, and I came up with the idea to use a pregnancy massage cushion as a way to help patients lay on their stomach comfortably. Then we created a charity, my brothers and I, to get these cushions out, and we have shipped them to almost 125 hospitals, we have shipped cushions free so that they can allow their patients to comfortably prone and tolerate that, which appears to help tremendously in oxygenation and avoidance of the need for a ventilator.
And these pillows are like a wedge?
Dr. Levitan: So, I was, after one of my shifts at Bellevue, amazed at how remarkable it was that turning people onto their stomachs could boost their oxygenation. And seeing that some large people couldn’t do that, it occurred to me, if we used, you know, a massage mattress, basically, for pregnant people, that this would help. And I’m talking to my son on the way home from the hospital and he suggests to me this one version of this that he found on the web. I got it delivered the next day to the hospital and it was remarkable. We had two people, husband and wife, and they came in with oxygen saturations that were terrible. When we put oxygen on them and set them up, we made a big improvement. But when we laid them on their stomach, their oxygen improved dramatically, their heart rate came down, their work of breathing improved, and they were both able to avoid the ventilator.
And was this also what the paper with Nick Caputo was about?
Dr. Levitan: That is the first paper in the world’s literature on using this technique to improve oxygenation with COVID patients. Not only did it show that we could prevent the need for a ventilator in 75% of patients in the first 24 hours, but even throughout their whole hospitalization 2/3 of patients treated with this did not need a ventilator. And that, obviously, is extraordinarily good news.
Interview conducted by Ivanhoe Broadcast News in May 2020.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Nicholas Caputo
Attending Physician
Department of Emergency Medicine
Lincoln Medical and Mental Health Center
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