The Economist - USA (2020-03-28)

54 International The EconomistMarch 28th 2020

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their sessions to learn about covid-19. The

experience at hospitals in China, Italy and

Spain suggests that is prudent. As critical-

care wards in the affected countries were

inundated with coronavirus patients, they

rapidly had to train doctors and nurses

from unrelated specialisms in how to intu-

bate patients and perform other proce-

dures. Dr Caridi-Scheible, whose hospital

is already treating more than a dozen co-

vid-19 patients, warns the medics who are

standing by for their first cases to “call in

every friend and favour you are owed”.

To save the lives of gravely ill patients,

doctors are trying many drugs. They are

bombarded with suggestions from all

kinds of sources online. But as soon as any

particular medication is mentioned, every-

one rushes to buy or use it, even preven-

tively, despite the lack of evidence, says

John Hick from the Hennepin County Med-

ical Centre in Minneapolis. “Until we take

the time to figure out what works, throw-

ing the kitchen sink at every patient might

actually harm them,” he adds. Steroids

were used in the 2003 outbreak of sars, a

respiratory disease caused by another co-

ronavirus, but studies since then suggest

they may in fact have caused some harm.

Reliable answers can only come from

proper clinical trials. Hundreds are under

way. In early March Bruce Aylward, who led

the who’s fact-finding mission to China in

February, said 200 trials had been regis-

tered there. But with so many small trials, it

was difficult to enroll enough patients.

Small trials cannot distinguish a small ef-

fect from chance. Such a lack of data may

explain why a trial of Kaletra, an hivdrug

combination, in patients with severe co-

vid-19 was not conclusive, says Ana Maria

Henao Restrepo of the who. Trials from

China may yet bear fruit. The earliest, in se-

verely ill patients treated with remdesivir,

a drug developed to treat Ebola, is due to

finish collecting data on April 3rd.

What is really needed is a large, interna-

tional trial that collects data about lots of

drugs from many hospitals. The who

hopes that a trial it announced on March

20th will do so. It will test four different

possibilities: remdesivir, chloroquine, Ka-

letra, and Kaletra plus interferon beta, the

drugs which currently seem to hold most

promise. The hope is that medics, even

those working under great pressure, will

recruit patients. Patients are enrolled

through the who’s website, which will ran-

domly assign each of them to a trial drug

(which will be limited to those that are

available at the time).

The trial is “adaptive”, so it will change

asresultscomein.Datawillbemonitored

by an independent board. Ineffective treat-

ments will be dropped and replaced by

more promising ones. This will allow the

best treatments to be compared swiftly.

After patients are enrolled in the trial,

doctors need only record a few data points.

When did each patient leave hospital or

die? After how long? Did the patient need

oxygen or ventilation?

There will be no placebo and doctors

will know which treatment has been given

to which patient. Those are not features of

high-quality clinical trials in normal

times. But the design is the best way to find

out in the shortest time which of a number

of drugs works best. The whohas not said

how long it expects the trial to take. Coun-

tries including Argentina, Bahrain, Cana-

da, Iran, Norway, South Africa, Spain, Swit-

zerland and Thailand have already said

they will join. Some 3,200 European pa-

tients will participate under the co-ordina-

tion of a French biomedical research agen-

cy. Other international trials are being

planned—for example, to determine

whether the drugs being tested in patients

work to prevent illness when taken by

health-care workers. The pace of discovery

is unprecedented. But the stakes could

hardly be higher. 7

O

ne of themost worrying symptoms of

covid-19 is the way the coronavirus at-

tacks the lungs of those infected. This

means some patients need a ventilator to

help them breathe until their lungs recov-

er. But there is a dire shortage of these ma-

chines in hospitals, so intensive-care units

will be overwhelmed. Urged on by worried

governments, ventilator manufacturers

are working flat out and forming partner-

ships with carmakers, aerospace firms and

others to boost output as fast as possible.

But their efforts will still be not enough

to meet soaring demand. So hope is riding

on scores of new projects to develop

breathing devices that could be made rap-

idly by non-specialist companies and

small workshops. These are mostly sim-

pler devices; some could even be assem-

bled by diyenthusiasts. The response to

this call to arms is unprecedented.

Yet difficulties and dangers lie ahead. At

present ventilation is about the only way

doctors have to treat those who are serious-

ly ill from the novel coronavirus, and the

shortage of available machines is terrify-

ing. In America the Society of Critical Care

Medicine estimates that roughly 200,000

ventilators may be available, though many

are older machines that have been in stor-

age and may not be capable of supporting

patients with severe respiratory failure. By

some estimates, nearly 1m Americans may

need mechanical ventilation at the peak of

the country’s covid-19 epidemic. And the

number of potentially critically ill patients

who need ventilating could be much high-

er. At some point the people needing venti-

lators will probably far outnumber the ma-

chines available. Similar shortages exist in

other countries, and in some parts of the

world the number of ventilators in a hospi-

tal can be counted on one hand.

In their desperation some doctors are

trying to connect more than one patient to

a single ventilator, even though manufac-

turers do not recommend this because in-

dividual patients need different levels of

breathing support.

Ventilators work by pumping air, mixed

with additional oxygen as required by the

patient, into the lungs. Carbon dioxide is

expelled as the lungs contract. The air can

be supplied to a patient via a mask. If more

breathing support is needed, a tube is in-

serted down the patient’s trachea and into

his or her airways, a process known as intu-

bation. Alternatively, air can be delivered

Scientists and industry are rallying to make more urgently needed ventilators

Hospital ventilators

Wind rush

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