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Wednesday, July 08, 2020

Ingenuity and knowledge-sharing in the time of Covid-19

Given the easy portability and greater affordability of other means of oxygen delivery, focusing only on ventilators during the Covid-19 outbreak would be like missing the forest for the trees.

Written by Nachiket Mor , Manuj Garg | Updated: April 17, 2020 1:13:03 pm
Covid-19, coronavirus, healthcare workers, nachiket mor, manuj garg, Glucocorticoids Covid-19: Thermal screening of visitors being conducted outside an emergency ward at a hospital during a nationwide lockdown in the wake of coronavirus pandemic, in Hyderabad. (PTI Photo)

Knowledge-building and knowledge-sharing will be our greatest assets, as India and the world take on the new coronavirus infection: Covid-19. Happily, this is happening on many fronts now.

On the one hand, vaccine scientists and medical researchers are working doubletime to find a cure for Covid-19. Doctors across the globe are also showing remarkable ingenuity in managing the symptoms of Covid-19 with therapies and drugs that exist already – albeit for a different purpose than treating Covid-19.

On the other hand, medical researchers, vaccine scientists and doctors are also sharing their findings and on-ground experiences quickly – through peer-reviewed journals, news articles, podcasts, among other channels – to build a large collective pool of information. The hope is that sharing knowledge will help save lives globally and may even help find a Covid-19 cure faster.

In the previous article in this series, we wrote about the role of community/family doctors in fighting Covid-19. Any attack we mount against this new disease must take into account what can be made available to these community doctors, and how. We also need to ensure seamless knowledge transfer to all doctors, for prompt – potentially life-saving – action.

So, in the spirit of sharing knowledge – and shifting the focus slightly away from vaccines and ventilators alone to include the therapies that can be deployed right now and at scale – here are some things that we can and should help community doctors build preparedness for:

Get ready to give oxygen therapy

One of the severe symptoms of Covid-19 is respiratory distress. Here’s how this happens: when the immune system mounts an attack on the virus, it can lead to inflammation in the tiny air sacs in our lungs (alveoli). Once inflamed, the alveoli start to fill up with fluid or pus. Fluid-filled alveoli are no longer able to pass adequate oxygen to the bloodstream. The shortness of breath associated with Covid-19 comes from this. In more severe cases, this presents as pneumonia.

A lot of attention – in the media and public discourse – has centred on ventilators for addressing this problem. Indeed, ventilators can be crucial for saving some Covid-19 patients. The government is acquiring more ventilators, and the importance of this cannot be overstated. That said, ventilators are – and should be seen as – a means to an end: giving supplemental oxygen to patients with hypoxia.

The health ministry and the Indian Council of Medical Research (ICMR) have also issued detailed guidelines on oxygen therapy for the management of Covid-19. Oxygen therapy with the help of nasal cannula (two tubes that go into the nostrils to supply high-flow oxygen from a tank or oxygen line), face mask, mask with reservoir bag or even oxygen concentrators (simple devices that increase the percentage of oxygen in the air patients breathe) can be effective in most cases – and for a fraction of the cost.

Nasal cannula, for example, costs between Rs 10 and Rs 30 per meter. An oxygen cylinder in India is priced under Rs 10,000, depending on the volume of oxygen. Compare this with a ventilator which can cost upwards of Rs 7 lakh and often requires infrastructure such as an oxygen pipeline to be in place.

Given the easy portability and greater affordability of other means of oxygen delivery, focusing only on ventilators during the Covid-19 outbreak would be like missing the forest for the trees. Doctors from the US, where Covid-19 has affected more than half a million people, have also found that keeping the patient mobile and giving them supplemental oxygen can be more useful than sedating them and placing them on mechanical ventilation.

Covid-19, coronavirus, healthcare workers, nachiket mor, manuj garg, Glucocorticoids A medic of the Elmhurst Hospital Center medical team reacts after stepping outside of the emergency room in the Queens borough of New York. (AP/PTI Photo)

Implementing oxygen therapy at scale

While the government-mandated Covid-19 centres will obviously make full use of oxygen therapy, it is important to build capability for it among as many doctors as possible: The Covid-19 pandemic may only be 15 weeks old, but it has taught us the value of being prepared.

To build preparedness for oxygen therapy at the local level, primary caregivers should review their current oxygen availability – where necessary, community health workers should step in to help doctors develop supply- and transport-capacity for oxygen.

Doctors should ensure they have at least five additional oxygen concentrators – this number may have to be increased, based on the number of patients serviced by the doctor or the clinic.

Endotracheal intubation – inserting a tube through the mouth into the windpipe – for ventilator use comes with its own risks. Research shows that early use of high-flow oxygen therapy can reduce or delay the need for intubation in patients. Doctors should be ready for this, and lose no time to administer this treatment when they think it could be useful.

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Rethink clinic design

The government has already given guidelines to create fever clinics and segregate patients in Covid Care Centres. Our community doctors could follow a similar model for segregating patients – to be sure, community doctors have for now been guided to send all suspected Covid-19 patients to designated Covid centres. That said, taking precautions to segregate patients could help to avoid accidental transmissions.

Some NGOs have also designed models to enable physical distancing in rural clinical settings. For example, Basic Healthcare Services – a non-profit organization in Rajasthan – has moved the waiting area in all its clinics outdoors, so patients can maintain adequate physical distance (previously called social distancing). In addition to this, they have also ensured enough distance between patient beds and placed oxygen cylinders in the wards of its AMRIT care centres in Udaipur for emergencies.

These steps need to be taken proactively. As we know, the health of five per cent of Covid-19 patients can deteriorate very quickly. Having these provisions in place before that happens is of critical importance.

From Opinion: What nation can learn from Kerala: Lockdown is not enough. Preparedness, decentralisation, are key

Stay up-to-date on therapies for Covid-19

The health ministry has issued very detailed guidelines for critical care for Covid-19 patients – including care protocols for the elderly, pregnant women and people with compromised immunity such as diabetes patients and people living with HIV/AIDS.

These include recommendations for existing drugs and therapies such as:

Fluid management: Sepsis is one of the causes of death in severely ill Covid-19 patients. Fluid management is an established therapy for sepsis: doctors administer IV fluids with electrolytes and medicines to manage the condition. For Covid-19 patients with no signs of septic shock, the ICMR and health ministry have recommended conservative fluid management to restore haemodynamic stability (stable blood flow) on the one hand and avoid worsening blood oxygen levels on the other.

Glucocorticoids: A class of corticosteroids, medicines such as methylprednisolone are only given for a short period, and only to patients whose condition is deteriorating rapidly. While these drugs can reduce inflammation, they can also prolong the illness by suppressing the immune system.

Empiric antimicrobials therapy: Many Covid-19 patients who die succumb because of sepsis, which may occur when the body fights any infection. Giving appropriate antibiotic treatment within one hour of detecting sepsis can save lives.

Of course, the therapies for Covid-19 treatment could change in the future, as we learn more about this disease and the results of ongoing clinical trials start coming in. In the meantime, the ability to offer these could improve a patient’s chances of recovery.

Community healthcare workers, NGOs, volunteers, private-sector companies in healthcare can all help with this through knowledge-sharing, donations of materials, and by developing supply chains to crucial therapeutic materials – for all doctors: only when we work together, as one unit, can we be ready for whatever might come next.

This is the fourth article in a five-part series, supported by myUpchar. Nachiket Mor, PhD, is Visiting Scientist, The Banyan Academy of Leadership in Mental Health. Manuj Garg, PhD is Cofounder of myUpchar. Also in this series: Four things India can do to break the chain of COVID-19 transmission faster, For India to reduce COVID-19 toll, its senior citizens must be under strict quarantine and Unsung heroes who can strengthen India’s response to COVID-19. In the fifth article, they will talk about using math to fight COVID-19.

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