At the beginning of the pandemic, Dr. Lina Shihabuddin sent any patient struggling to breathe straight to intensive care. They would need to be hooked up to a ventilator and have oxygen delivered through a tube into their lungs.
“In traditional medicine, if your pulse [oximeter reading] drops below 80 and consistently stays below 80, that is an indication for intubation and putting the patients in the ICU,” she explained.
But nearly a year later, Dr. Shihabuddin, the Chief Medical Officer of RWJBarnabas Health in New Jersey, said the lessons of traditional medicine may no longer hold: “What we learned with COVID is intubation may not be the answer.”
As providers learn more about the disease and its treatment, they have become more discerning with how they deliver oxygen treatment.
New Protocols
“The decision to intubate and put [patients] on a machine is multifactorial. It’s not one thing. it’s not simply because your oxygen is low,” said Shihabuddin.
Now, if patients have low levels of oxygen saturation, Shihabuddin recommends they be monitored in the hospital’s ICU and delivered high-flow oxygen through their nose instead. The treatment is less invasive than intubation and doesn’t require patients to be sedated.
In California, a Los Angeles-based hospital has also revised its treatment protocols in light of new evidence.
“Very early in the pandemic we were intubating everyone — putting them on ventilators — because we thought that was the right thing to do,” said Dr. Larry Stock, Vice Chair of the hospital’s emergency department. “We learned that, even if they had a big oxygen need, they’d actually do better if we held off on doing that.”
Instead, the hospital began giving patients high-flow oxygen funneled through a network of pipes in the walls and delivered directly into patients’ rooms. Normally patients on high-flow oxygen receive up to 15 liters of oxygen a minute. But for those in critical condition, Dr. Stock and his colleagues were turning up the flow. “We were giving people oxygen at levels of 40 to 80 liters per minute. And sometimes even double that—up to 200 liters per minute of oxygen in some cases.”
Earlier this year, the need for this kind of treatment led to mass oxygen shortages across Southern California, shocking even the most seasoned physicians. “I don’t think anyone anticipated we were going to run out of oxygen,” said Stock.
The shortages led to rationing, which in some cases meant turning down the flow of oxygen patients were receiving. “Instead of setting the goal and trying to reach a pulse ox saturation of 95% or above, our goal became 90% or above, or sometimes lower than that,” said Stock. While it wasn’t ideal, it was enough to keep people breathing. “If we tried to provide optimal care for everyone, there wouldn’t be enough for some people,” he said. As shortages have subsided in some areas and flared up in others, oxygen remains a critical component of Covid-19 treatment.
Recovering at Home
It’s not just about inpatient care, either. During surges, when hospitals fill to capacity, oxygen acquires a new role: freeing up much-needed hospital beds.
Small, portable oxygen concentrators can be sent home with patients who are stable but still require oxygen support, allowing a more critical patient to take their spot.
Last spring, RWJ Barnabas Health began sending patients home with an oxygen concentrator, a pulse oximeter, and a virtual nurse to monitor their condition through telemedicine. The program helped offload hospital beds during their worst surge to date.
Dr. Shihabuddin says the portable concentrators have been particularly useful for certain patient populations.
“There’s a cohort of patients who are uninsured, and in the state of New Jersey, we have a lot of undocumented patients,” she explained. “Those concentrators, which we have, really saved the lives of those patients.”
Many of these patients are afraid to be checked into a hospital because of their immigration status. Others are weary of surprise medical bills.
“A lot of these patients did not want to be hospitalized,” said Dr. Shihabuddin.
While the CARES Act has provided funding to cover the cost of Covid-treatment for uninsured individuals, some patients are unaware of the new provisions. Others are doubtful.
“No matter how much you tell them, ‘No, you’re not going to get a bill. Everything will be the fine. The government is going to pay for it,’ they don’t really believe us because that’s not the historic experience,” said Shihabuddin.
At AltaMed Health Services in Los Angeles, a similar program is helping low-income patients, including uninsured individuals, get home sooner.
The health center is working with their local hospital to transition patients out of the intensive care unit into their homes, where supplemental oxygen and close monitoring are used in the final stretch of treatment. But the program is more involved than handing patients an oxygen concentrator.
“It’s not just the oxygen. It’s, ‘Who’s going to bring them medication? How are they going to drive to the clinic for a follow-up?’” explained Dr. Ilan Shapiro, the Medical Director of Health Education and Wellness at AltaMed.
For those without a caretaker at home, the health center is sending in a provider to routinely check their pulse oximeter and, if they have a chronic condition, make sure their medications are stocked.
The Long Term
While most patients will only need oxygen for a short period of time, others may require more long-term support.
That’s because Covid-19 can cause inflammation of the lungs and heart. If severe enough, this inflammation can lead to scarring.
“Once you get a scar, just like anywhere in the body, it doesn’t actually go away. You kind of work with the remaining tissue that’s healthy,” explained Dr. Larry Stock, the emergency medicine physician based in Los Angeles. This scarring can cause patients to develop chronic conditions, such as pulmonary fibrosis, that require long-term oxygen therapy.
For some of Dr. Shapiro’s patients, that presents more than just a health crisis. Without insurance, funding long-term oxygen care may be a financial impossibility. Out-of-pocket expenses can total thousands of dollars per year.
“That’s where things start melting down,” said Shapiro. “Covid doesn’t distinguish if you have insurance or not.”
Since the start of the Covid-19 pandemic, Direct Relief has delivered 3,942 oxygen concentrators to health facilities in the United States and abroad, including dozens to support patients receiving at-home oxygen treatment from RWJ Barnabas Health and Alta Med Health Services.
