‘Oxygen therapy should have priority in Bangladesh’
Arjen M Dondorp is a physician of infectious diseases and intensive care and professor of tropical medicine at the University of Oxford. He is presently serving as visiting professor of clinical tropical medicine at Mahidol University, Mahidol University, Bangkok. Professor Arjen has an understanding of Bangladesh's existing health care system. In an e-mail interview with Prothom Alo, he speaks about various aspects of the COVID-19 crisis
What alternative and innovative ideas are there to treat critical COVID -19 patients?
Arjen M Dondorp : There is currently no proven antiviral treatment available for COVID-19. Based on the activity in the laboratory against SARS-CoV-2 (the cause of COVID-19), clinical trials evaluating hydroxychloroquine, chloroquine, remdesivir, lopinavir with ritonavir, and other drugs, are planned or currently underway. Before we know the results of these studies we don’t know for sure whether these drugs are beneficial, and therefore these drugs are not recommended, yet.
Routine use of corticosteroids or other drugs that affect the human immune system are also not recommended at this moment. Because of this, the treatment of COVID-19 at the moment is to provide supportive care to the patient as good as possible. Providing supplemental oxygen is the most important part of this. It is also very important that the doctors and nursing staff taking care of the patient are well protected by using adequate personal protective equipment (PPE), and strictly follow hygiene rules, such as frequent hand washing. It is also important that COVID-19 patients cannot infect other patients. They have to be isolated or grouped in a ward with other COVID-19 patients.
In a situation where ICU and ventilation supply are scarce or almost none, is heavy reliance on oxygenation possible?
Arjen M Dondorp : Supplemental oxygen can be provided from an oxygen cylinder or an oxygen concentrator. Some hospitals will have piped oxygen coming out of the wall close to the patient, fed by a large central liquid oxygen tank or other supply. The oxygen can be given with simple nose prongs or an oxygen mask. The oxygen concentration can be increased a lot by using a so called non-rebreathing mask, with an additional bag connected to the mask where the oxygen flows in. The oxygen in the blood in COVID-19 can often be increased by positioning the patient on his or her front (‘prone position’).
Some COVID-19 patients, around 10% to 15%, will need mechanical ventilation because their lungs are too much damaged by the virus and they get exhausted from the work of just breathing. These COVID-19 patients on mechanical ventilation will have a very high chance not to survive (>50%), also in very well-equipped intensive care units in rich countries. For a country like Bangladesh, where mechanical ventilation could be in short supply if the COVID-19 epidemic hits, an emphasis on the availability of supplemental oxygen therapy should have priority.
Mechanical ventilation can save lives in patients with severe COVID-19, but it can also cause damage to the lung if not applied carefully. This will need well-trained doctors to properly set the ventilator.
How do you look at the WHO initiative to increase country specific/global knowledge on clinical management and critical COVID-19 patients?
Arjen M Dondorp : The WHO is very active in providing countries with all sorts of good and useful information on COVID-19, including on the management of patients with severe or critical COVID-19. Specific recommendations for resource-limited settings, like many hospitals in Bangladesh, are important.
Why is the health care system of rich and developed nations so poor and inadequate in terms of ICU and ventilation?
Arjen M Dondorp : Many rich countries have been overwhelmed by the very large numbers of patients with severe COVID-19, and the availability of ICU beds was stretched to the limit. Time to prepare for this pandemic has been very short. As said, once a patient needs mechanical ventilation, the lung is severely damaged by the virus, and the chance to survive is at the moment less than 50%.
A report of 8 April stated that South Africa's National Ventilator Project plans to produce 1,500 ventilators by the end of May, and 10,000 by the end of June. Does it indicate that the production of more ventilators at the time of crises largely depends on the will of the policy makers of the respective governments?
Arjen M Dondorp : There are many initiatives now to produce affordable mechanical ventilators in a very short period of time.
These initiatives come from governments, research groups, as well as private companies. It is important to realise, however, that just having the mechanical ventilator is not sufficient to provide optimal care to the patient.
Mechanical ventilation can save lives in patients with severe COVID-19, but it can also cause damage to the lung if not applied carefully. This will need well-trained doctors to properly set the ventilator. Other issues can be for instance a shortage of consumables such as heat and moisture exchangers and suction catheters, spare ventilator parts like flow meters, unreliable oxygen supply and inconsistent electricity.
High-quality ICU care in a country like Bangladesh is a challenge, because it is an expensive form of healthcare. It will be important that ICU capacity is not only reserved for the private hospitals catering for patients who can afford this, but is also developed in government hospitals
Also, the procedures around mechanical ventilation, such as intubation of the patient, can produce small droplets that can infect the doctor or nursing staff, so that extra precautions for the health care workers need to be in place.
Bangladesh guidelines for clinicians say that 'patients with severe pneumonia or sepsis should be treated cautiously with intravenous fluids, because aggressive fluid resuscitation may worsen oxygenation, especially in settings where there is limited availability of mechanical ventilation.'' Can you comment on this in the light of COVID-19 patient management in the region?
Arjen M Dondorp : Being cautious with intravenous fluids is also important in patient with severe COVID-19, because too much fluid can cause edema (accumulation of fluid) in the damaged lung, compromising even more the oxygen exchange to the blood.
A 2019 Bangladesh study states, critical or intensive care has emerged as a distinct specialty in the world over the last 5-6 decades. The importance of mechanical ventilation was realised in the polio epidemic in Copenhagen in 1952. Mortality was reduced from 90% to 40% following its introduction. The survey highlights that Bangladesh’s hospitals have a mean percentage of ICU beds (6.22%) that is higher compared to that of Japan (3%), China (3%) and lower than Saudi Arabia (10%) according to an AISPO study . In a 2004 study from the US, adult ICU beds accounted for 9.0% of acute care hospital beds. Are you optimistic that this scenario will change drastically in near future?
Arjen M Dondorp : The number of ICU beds in Bangladesh is increasing, but my information is that the current number is around 0.5 beds per 100,000 population, which is lower than in rich countries. Developing basic but high-quality ICU care in a country like Bangladesh is a challenge, because it is an expensive form of healthcare. It will be important that ICU capacity is not only reserved for the private hospitals catering for patients who can afford this, but is also developed in government hospitals.