We are currently seeing historic levels of ventilator use and intubation in the United States due to the COVID-19 pandemic.
Why is COVID-19 killing so many of us, who are getting the best modern technology? We know a high number of patients have pre-existing medical conditions, where lung resiliency is diminished. But this new disease is encountering a powerful technology — one that is now being deployed, for the first time, on a mass scale.
Mechanical ventilation uses precise, controlled delivery to get more oxygen into the lungs, then into the blood, then into the cells to reverse hypoxemia, or low oxygen blood levels.
However, doctors are reporting that mechanical ventilators are being overused with COVID-19 patients. Perhaps unsurprisingly, alternative ventilator treatments are inching into the mainstream. As new data emerges that managing ventilators differently, or using nasal cannula alternatives, could significantly reduce the COVID-19 death rate, are we ready to openly discuss the limitations of traditional ventilator management — and consider viable alternatives?
Respiratory therapists have been propelled onto the front lines in the COVID-19 battle. In New York City, Fred Brown (RRT) confirms that less is more when it comes to ventilator management. His work in the Intensive Care Unit means caring for multiple ventilator patients each day, where he is applying a gentler approach.
One problem with ventilators, states Mr. Brown, is that by “forcing 02 the patient blows off too much C02”. Mr. Brown is also trained in the Buteyko Breathing Normalization Method for reduced breathing. By combining this method with over 20 years of training and experience in ventilator management, he has witnessed significantly improved patient outcomes.
But the greater danger of ventilators is hyperventilation of the lungs, which disrupts homeostasis, according to Dr. Andrey Novozhilov, a respiratory specialist and co-founder of the Buteyko Clinic in Moscow. Dr Novozhilov explains that, “Prolonged hyperventilation of the lungs [impairs] patency of the bronchi, [causes] an increase in uneven ventilation, changes in the pH of arterial blood and [leads to] fragmentary destruction of the lung tissue.” Dr. Novozhilov, who is also the Russian patent holder of the Buteyko Method, explains the sequence of how hyperventilation destroys lung tissue in his article, “COVID-19, Why Mechanical Ventilation Doesn’t Help.”
We may already hold the key to improving COVID-19 survival rates by using principles of the Buteyko Method , discovered in the 1950s by Russian physiologist and researcher Konstantin P. Buteyko, MD-Ph.D.
Once on a Ventilator, Eight out of Ten Patients Didn’t Make It
Early research from the Journal of American Medical Association (JAMA) suggested that 88% of COVID-19 patients placed on ventilators in New York did not survive.
The mortality (death) rate for all patients presenting with Acute Respiratory Distress Syndrome (ARDS) and placed on ventilators is typically 40–50%. The high COVID-19 fatality rate is both alarming and something of a mystery.
For severely ill COVID-19 patients, being on a ventilator for two weeks is not unusual. One thing is clear: the longer the patient is ventilated, the greater chance of serious lung damage and death.
Proning Is a Good Start
Mr. Brown treats COVID-19 patients by adopting two promising avenues: proning, and treating patients on ventilators with lower oxygen volume and lower pressure.
Before Coronavirus hit, Mr. Brown already knew about the benefits of proning. Dr. Buteyko consistently recommended turning patients onto their bellies as an effective therapy to reduce breathing.
Proning is now becoming widely adopted in US hospitals for ARDS patients. Updated guidelines recommend prone positioning based on promising recent data showing a 25% relative reduction in death rates.
Medical teams are integrating proning recommendations for COVID-19 patients both on and off ventilators. If a patient doesn’t respond well to even 100% oxygen therapy before intubation, proning is the new go-to.
Proning is also one of several examples of forward thinking by Dr. Buteyko, whose research long ago concluded sleeping in a prone position reduces breathing to ultimately improve oxygen levels. But his work on breathing goes far beyond technique to explain how, by breathing less, we gain more oxygen (02) at the cellular level.
O2: Less Is More
Higher volumes of oxygen (or any gas) from mechanical ventilation promote over breathing, so it is essential to get patients back to a normal, non-mechanized breathing pattern as gently and quickly as their condition allows. A ventilator supplying less volume helps the patient reduce carbon dioxide loss, and limits the dangers associated with hyperventilation of the lungs. This, in turn, can cut down the time the patient must be on a ventilator and on life support.
Lower oxygen pressure has several immediate and practical benefits: it is less harmful to the lungs, engages the patient’s respiratory muscles, and can decrease or minimize the need for sedation. Moving from high volume to low volume oxygen, sometimes by also transitioning to a CPAP of BiPAP machine, is a much more effective strategy, even with the sickest patients.
Mr. Brown has had excellent success with transitioning intubated patients to a CPAP machine after ventilation, which assists the patient to breathe on his own and provides a more protective lung strategy. When patients can maintain their own volume of 02 intake (and C02 loss), they are more likely to keep lung pressure lower.
In ARDS, permissive hypercapnia is a known treatment protocol, and this method should be considered for COVID-19 patients. Mr. Brown notes that, “When the goal is oxygenation, alternatives can include lowering pressure with ventilation, as well as minimizing PEEPs and Plateau Pressure towards 25 or less.”
As medical teams adapt to the uniqueness of this disease, employing low pressure and low volume on ventilators is still considered an aggressive respiratory therapy by many medical professionals. Yet, like proning, lower pressure (less oxygen) works in real-life settings because it aligns with Dr. Buteyko’s core discovery.
Cell Hypoxia and the Bohr Effect
Dr. Buteyko’s breakthrough relied on mainstream biochemistry. His research explored the far-reaching effects of chronic over breathing, following the pivotal scientific groundwork laid by Danish scientist and Nobel Prize recipient Christian Bohr. The “Bohr Effect” proved that hypocapnia (or a deficiency of C02) disrupts the pH of the blood by complicating the transfer of oxygen into cells.
Because the balance of oxygen (02) in the body is highly dependent on carbon dioxide (C02) levels, breathing is a dance between C02 and 02 in which the two partners’ moves are always intimately connected. The right balance of O2 and C02 also maintains the body’s correct pH level.
In patients with ARDS, a notable feature is over inflation of the lungs. This hyperinflation is associated with a lower partial pressure of carbon dioxide (CO2) in the lungs (termed pCO2A) and a reduction of arterial blood (pCO2a) in cells. Both of these states are examples of hypocapnia, and both contribute to changing the pH, thus mitigating transfer of oxygen into cells.
COVID-19 ARDS is atypical, without the usual fluid build-up of pneumonia. Researchers speculate that the lack of a substance called surfactant (which keeps alveoli from maintaining their usual robust, grape-like structures) is driving ARDS. Without surfactant, alveoli stick together and lose their shape — diminishing lung surface area.
CO2 Is Not a Waste Gas
Dr. Buteyko discovered that chronic hyperventilation, often accompanied by mouth breathing, is common in modern people and it results in a poor balance of CO2 and O2.
The proof that a lack of C02 could create cellular hypoxia (lack of oxygen getting to cells) is somewhat counterintuitive. While Bohr received accolades for his revolutionary discovery, Dr. Buteyko’s subsequent application and therapy have gotten little attention outside of Russia, and even there his innovations are known primarily as a holistic asthma therapy.
The Buteyko Method is beginning to receive the attention it deserves with grass-roots support as people around the world search for solutions to health problems, especially breathing difficulties. Since Jane Brody published an article in the New York Times about the remarkable results she observed in her asthmatic friend, the Buteyko Method has gained traction.
The reason Dr. Buteyko’s discovery is so profound is because this medical doctor and researcher recognized that a tiny deficiency of CO2 (over time) leads to an O2 deficit in lungs that affects oxygen at the cellular level. This deficit, in turn, affects all aspects of human health.
Dr. Novozhilov notes: “A functioning respiratory system supports two key metabolism constants, the so-called gas constants CO2 and O2, at three levels — in the cell, in the blood, in the lungs. The movement of these respiratory gases is the main regulator of pH.”
Eliminating Hyperventilation, On or Off a Ventilator
The Buteyko Method is used in hospitals throughout Russia and widely in the United Kingdom and Australia to train asthmatics who seek non-drug therapy for controlling their disease. Several controlled trials indicate the Buteyko Method is highly effective at reducing medication use.
When applying Bouteyko principles, Fred Brown discovered it is possible to improve oxygen uptake by, paradoxically, lowering pressure and permissive uptake. As more medical teams are willing to try a gentler approach to mechanical ventilation, Mr. Brown is noticing the 80% mortality falling. He has witnessed some intensive care units where death rates for patients on ventilators have dropped to an astounding 20% by implementing both proning and principles of lowering pressure and oxygen volume.
Hyperventilation and Homeostasis
As C02 deprivation impacts pH and metabolism, it also interferes with immune function. A pillar of Buteyko’s work is that the body creates defense mechanisms to protect itself and, using compensatory homeostasis, develops what we commonly categorize as disease states.
Although compensatory respiratory mechanisms stabilize bodily systems, they have both protective and undesirable effects. As Dr Novozhilov notes, “Compensatory reactions are formed where the constants are violated — at the cellular level, at the level of the cardiovascular system, at the level of the external respiration system.”
Compensatory respiratory homeostasis is not uncommon nor necessarily lethal. For example, it occurs with asthmatics who may experience an increase in blood pressure during the reversal of bronchial obstruction, following an asthma attack.
If a patient is hyperventilating as a result of COVID-19 and presents with ARDS signs, a strong immune reaction is often the culprit.
Diffuse pneumonia is another example in which an anti-inflammatory response causes serious problems, exuding substances that go on to damage capillaries and alveoli. The exudate of pneumonia — a mass of cells and fluid seeping out of blood vessels and/or organs — reaches into the alveolar air space, impacting lungs and degrading the normal, healthy gas exchange.
Since normalization of carbon dioxide in the lungs is also anti-inflammatory — and a much more conservative approach as a supportive treatment — Dr. Buteyko recommended small doses of corticosteroids (like inhalers used with asthmatics) that normalize the pressure of C02 in the lungs (pC02A) to calm down the immune response and prevent disturbance of normal gas exchange.
Compensatory Respiratory Homeostasis
At the turn of the 19th century a whirlwind of technological advancement produced, among other advancements, experiments demonstrating a surprising result: excessive ventilation of the lungs for several minutes led to the deaths of healthy lab animals. Likewise, lung ventilation significantly exceeding normal values can lead to the death of a healthy person within 10 minutes.*
The implications of such research are explained by Dr Novozhilov: “Lung hyperventilation violated gas constants for CO2 in the lungs, in arterial blood and for O2 in cells, at the metabolic level. That is, as a result of pulmonary hyperventilation within 10 minutes, the most severe form of hypoxia occurred — cell (metabolic) hypoxia.”
Ventilators are traditionally used to support what is essentially prolonged hyperventilation. The true danger of this state is the erosion of normal gas exchange. When acute hypercapnia develops, a chronic deficiency of alveolar CO2 leads directly to extensive bronchial obstruction, imbalanced ventilation, and a cascade of changes as the body compensates by trying to stabilize blood pH. The final result is a breakdown of oxyhemoglobin (the bright red result of oxygen combined with red blood cells). These intracellular events cause acute tissue hypoxia.
High Oxygen Is Obvious — and Wrong
Dr. Buteyko’s work demonstrated that arterial hypoxemia (lack of oxygen in blood cells) is not due to a lack of oxygen directly going into blood cells, which is what occurs when we “add oxygen” — but rather insufficient air intake to the zone of gas exchange, i.e. the lungs.
What is missing from the customary explanation of gas exchange is that in most cases it is the pH of the blood (not the degree of saturation of the blood with oxygen) that regulates the transition of oxygen from blood to cells.
The best way to correct pH is through normalized — or reduced — breathing. To both prevent and treat the respiratory symptoms of COVID-19, breathing normalization is essential. Proning and introducing lower oxygen volume keep pressures as low as possible, while reducing the time a patient is ventilated from weeks to days.
When heroic medicine is all over the front page, Respiratory Therapists and other medical professionals can radically change patient outcomes by turning down the air.
*From Dr. Novozhilov: “I heard about these experiments from KP Buteyko himself at his lectures; the experiments were carried out at the beginning of the 20th century, [possibly] the research of the father of Russian
physiology I.M.Sechenov, who studied the role of carbon dioxide, and
maybe these were the first studies in the middle 20th century on
mechanical ventilation in different modes, but I can not establish the
exact author and time of these studies.
The story is similar to that of the American professor Jacob da Costa,
who at the end of the 19th century first pointed to hyperventilation
of the lungs, examining veterans of the American Civil War.
Veterans named similar complaints about lack of air, impaired
functioning of the heart, poor sleep, fatigue and others, and yes,
Costa first drew attention to the extremely deep breathing of these
war veterans, coined the term “hyperventilation of the lungs”, but the
relationship between deep breathing and these complaints were not
established; only Buteyko did it after 100 years. Buteyko always said
in his lectures that he owns only the second part of the discovery of
the “deep breathing disease” — deciphering the mechanism of its
action, and the first part of the discovery of the “deep breathing
disease” belongs to the American professor Jacob da Costa.
This article has been completed with substantial information provided by Dr. Andrey Novozhilov. He recommends normalizing breathing to reduce (not exacerbate) hyperventilation.
Restore breathing through the nose in full, eliminate noisy and deep breathing through the mouth, put a patient with respiratory failure on his stomach to limit the excursion of the chest and abdomen, and to reduce pulmonary hyperventilation — these measures will have a greater positive effect than mechanical ventilation and oxygen therapy.
Breathe To Heal: Break Free from Asthma explains the Buteyko Method is more detail.
Special thanks to Fred Brown, RRT, who is currently assisting COVID-19 patients in New York City.
Lung Surface Area and Gas Exchange Illustrated
Basic biology texts note that normal adult lungs provide an area of 75 square meters for the exchange of 02 and C02 to occur (via 600 million aveoli).
Over breathing, whether habitually or due to illness, has the effect of significantly shrinking the lung surface area of gas exchange, which in turn reduces gas exchange effectiveness.
When lungs lack the normal surface area, the exchange of 02 and C02 diminishes. The effect is breathlessness. Hyperventilation reduces C02 gas, creating alveolar hypocapnia and decreasing in the airway’s ability to clear due to bronchospasm. This effect occurs on a spectrum, from habitual over breathing (chronic hyperventilation) to severe, acute respiratory distress.
The alveoli (thin-walled cells that look like bubbles or grapes) absorb oxygen over efficient over their 75 square meters, but C02 deficiency changes this picture radically.
When hypocapnia is combined with other bronchial obstruction (swelling of bronchi and/or over secretion of sputum) the overall result is imbalanced lung ventilation. The imbalance sets the stage for a reduced gas exchange area: the 75 square meters shrinks to much smaller patches, and hypoxemia becomes a real threat.
When acute or chronic hyperventilation is present, it is critical to normalize breathing. Dr Bouteyko’s practical application of his theory trainied patients in breathing normalization, which supports a healthy (large) gas exchange area in the lungs, optimal C02 and 02 balance, balanced blood pH, and regulated metabolism.