What your doctor is reading on Medscape.com:
APRIL 24, 2020 -- Clinicians have been fighting COVID-19 wrong, says an emergency medicine physician who has been on the front line of the COVID-19 surge in New York City. "Everybody's coming in too late."
Richard Levitan, MD, spent 10 days in early April working at Manhattan's Bellevue Hospital Center at the height of the COVID-19 surge.
"The x-rays I saw were all the same: multi-lobar pneumonia," he said. "If we could detect it earlier, we could initiate treatment earlier. We need to change messaging to the public, to physicians, to get earlier recognition of the disease."
Levitan says that use of home finger pulse oximeters by patients with COVID-19 could preempt the precipitous oxygen desaturation that leads to a crisis that needs intensive care.
This would greatly reduce the current strain on hospitals, he told Medscape Medical News.
Levitan argued in a recent New York Times opinion piece that everyone needs a pulse oximeter in their pandemic supply kit. The notion hit a nerve: more than 1500 comments flowed in to the NYT site, and Levitan's Twitter feed exploded.
"I believe earlier detection and treatment will make a big difference," he said.
But could such a simple, affordable device as a finger pulse oximeter be the ultimate weapon in this pandemic? Some experts are not convinced.
Levitan's article "is certainly a fascinating theory, but I am not sure that pulse oximetry will be the secret to decreasing COVID mortality," David Hill, MD, a pulmonary and critical care specialist in Waterbury, Connecticut, and a spokesperson for the American Lung Association (ALA), told Medscape Medical News.
"Levitan's supposition that patients who are hypoxemic are breathing more deeply and causing their own lung injury is a leap," he said in an email. "Ventilators can cause lung injury by delivering higher pressures to the lung, but I am not aware of any data suggesting increased respiration in non-intubated patients with hypoxemia causes lung injury."
Red Zone vs Blue Zone
Levitan, who is president of Airway Cam Technologies, a company that teaches courses in intubation and airway management in Littleton, New Hampshire, has spent 25 years in the field. He has produced a graphic illustrating how pulse oximetry could shift the battle lines to attack an earlier form of the disease with treatments like high-flow nasal cannula oxygen supplementation, continuous positive airway pressure (CPAP) devices, and patient positioning/proning.
"If we move the whole window of treatment from the red zone into the blue zone, there will be a logarithmic collapse of the resources needed to fight this disease. There is no win fighting in the red zone, you can't ramp it up enough. The mortality in the red zone is 70%.
"Clinicians need some way to win," he added in an interview. "Waiting for people to have pulse ox saturations in the 50s and 60s is asking for a tsunami of the walking dead."
But "the walking dead" phenomenon is indeed what ER doctors are currently reporting with many COVID-19 patients.
"These patients did not report any sensation of breathing problems, even though their chest x-rays showed diffuse pneumonia and their oxygen was below normal," Levitan points out.
"I am seeing patients with oxygen saturations of 50% ― roughly equivalent to what you'd see at the top of Everest," he told Medscape Medical News. "It is amazing ― shockingly amazing ― that these people are alive and talking on their cell phones."
Other physicians have also noted this and have suggested that some cases of COVID-19 pneumonia resemble high-altitude pulmonary edema (HAPE) rather than acute respiratory distress syndrome (ARDS), but experts in HAPE have pushed back on that suggestion.
Sooner Rather Than Later Always Better?
Erik R. Swenson, MD, a pulmonary specialist and professor of medicine at the University of Washington, Seattle, thinks using a pulse oximeter to detect advanced pneumonia earlier may be a good idea. He routinely advises his patients to check their oximetry anyway and agrees it should be advised for patients with COVID-19.
"There's something about this infection that has people dropping their oxygen levels without the usual distress," Swenson told Medscape Medical News. "It seems to cause you to lose that sensation, the normal alarms aren't going off, you're not getting breathless or tachycardic.
"This is probably a sign the virus is injuring the lung," he noted. "Without treatments, we don't know whether catching this earlier is going to make any huge difference, but I think general principles would say that catching anything sooner rather than later is always better, and we can always give oxygen."
The ALA's Hill is more dubious about its utility. "Pulse oximetry in the outpatient setting may identify patients who are deteriorating sooner," he commented. "Certainly in patients with comorbidities such as cardiac or cerebrovascular disease, it may be beneficial to have them come to medical attention sooner and receive supplemental oxygen."
However, Hill added, "I would suspect that the majority of patients who deteriorate with COVID-19 are deteriorating due to progression of their viral disease and systemic inflammatory response rather than silent hypoxemia causing them to increase their respiration and induce lung injury."
Much about COVID-19 is still unknown, he said, and "sudden deterioration in patients could be due to direct cardiac injury, increased clotting with cardiac, pulmonary, or CNS effects rather than progressive silent hypoxemia."
Nevertheless, Hill concedes that "pulse oximeters are relatively inexpensive (if available)," and providing them to patients with suspected COVID-19 for monitoring "would likely have little downside."
He noted, though, that detecting mild hypoxemia and tachycardia in patients who would otherwise do fine "could add to provider workload and potentially ER visits."
Patients would also need to be trained on proper use, ie, "no nail polish or artificial nails, making sure their hands are warm when checking oximetry," he added.
Another emergency physician, Jeremy Samuel Faust, MD, from Brigham and Women's Hospital in Boston, who describes Levitan as "a great doc and a friend," says he also has some concerns about the public's reaction.
"While I think some pulse oximetry for patients with a known diagnosis of SARS-CoV-2 makes sense, I don't support half the country buying these devices now on a 'just in case' basis," he told Medscape Medical News. "My concern is that people who don't have the virus are buying these in droves now. Like so many things, there will be shortages, and this will affect the people that actually have legitimate use for these devices."
Sales of pulse oximeters spiked very early in the COVID-19 crisis, according to a report in Quartz, with a more than 500% increase already in mid-January.
In addition, Faust added that "as with any home medical equipment, there's always the concern of over-triage. There is indeed such a thing as checking your numbers too often. Transient and spurious readings can lead to unnecessary fear, and this can send patients to clinics and emergency departments unnecessarily."