Was it covid or pneumonia that killed intubated patients? Did technology play a role?

https://www.jci.org/articles/view/170682

In this study, they evaluated the incidence of mortality of ventilated patients. This is important information. This is a key statement: “We aimed to determine the contribution of unsuccessful treatment of VAP to mortality in patients with severe pneumonia.” Here is the problem. Ventilated patients are at a high risk for ventilator acquired pneumonia. The longer that a breathing tube remains in place, the higher the risk for VAP. It is why we encourage the placement of a trach if it appears a patient is not going to be successfully extubated within a week or so span of time.

So what killed “covid” intubated patients? Was it covid? Or was it ventilator acquired pneumonia? And in those with pneumonia, did we treat it?

“In a single-center prospective cohort study of 585 mechanically ventilated patients with severe pneumonia and respiratory failure, 190 of whom had COVID-19, who underwent at least one bronchoalveolar lavage. A panel of ICU physicians adjudicated pneumonia episodes and endpoints based on clinical and microbiologic data.” What data is missing here? What did they DO to treat the pneumonia?? The study does not say.

“CarpeDiem is a machine learning process that used historical chart data. It revealed that the long ICU length of stay among patients with COVID-19 is attributable to long stays in clinical states characterized primarily by respiratory failure. While VAP was not associated with mortality overall, mortality was higher in patients with one episode of unsuccessfully treated VAP compared with successfully treated VAP (76.4% versus 17.6%, P < 0.001). In all patients, including those with COVID-19, CarpeDiem demonstrated that unresolving VAP was associated with transitions to clinical states associated with higher mortality.

Unsuccessful treatment of VAP is associated with greater mortality. The relatively long length of stay among patients with COVID-19 is primarily due to prolonged respiratory failure, placing them at higher risk of VAP.

So taking these bits and pieces and putting something together? Patients with VAP due to NON covid reasons were treated for it. It says nothing about pre-emptive prophylaxis treatment of covid patients for possible VAP, while acknowledging that covid patients did indeed develop VAP, and that increased mortality outcomes. Covid patients were on ventilators for weeks at a time, especially in the early days. Why were they not trached to prevent VAP? Why do we have no data that supports early VAP treatment in intubated covid patients? Also interesting, during this retrospective chart data, notice that out of 585 ventilated patients, only 190 were due to covid? If we round that up, 1/3 had covid, 2/3 did not.

My hypothesis is they blamed all of the lung problems on covid, without looking deeper at VAP. It has been asked by several researchers why azithromycin was not given early and often to those with covid, intubated or not. Those are questions we deserve answers to. My hypothesis is also that the numbers coming out of the ICU were highly exaggerated regarding who had covid and who did not. This study clearly shows that those with covid were far lower than intubated patients without covid. I would also like to see the data on days from intubation to a trach in non-covid patients versus covid patients. I would also like to see how frequently we tested lung secretions in covid patients for VAP versus non-covid ventilated patients.

This article breaks down my above concerns pretty well. https://medicalxpress.com/news/2023-05-covid-patients-wasnt-cytokine-storm.html

They hypothesize the same thing. We were not looking for VAP, we were assuming cytokine storm as the cause of death, when in reality it was secondary bacterial ventilator acquired pneumonia. But they didn’t look deep enough to see that as the cause of death.