I was hoping I’d never have to write this piece, there’s been a nagging suspicion in the medical community for the last few weeks. But as more research emerges, the topic of ventilating COVID patients is now being more openly discussed and debated.

Let’s start from the beginning. When reports of a new deadly viral infection afflicting the lungs, first started to emerge from Wuhan, China, at the end of last year—the immediate worry for most physicians was: how would healthcare systems across the world cope if this became a pandemic? Would we have enough beds, particularly Intensive Care Unit (ICU) beds? And crucial to the survival of anybody with respiratory failure—would we have enough ventilators?

As the dramatic surge of cases then occurred country by country, the call from doctors and leaders became louder: Let’s get more ventilators…we need more ventilators…it’s all going to hinge on how many ventilators we can get.

This was of course understandable. After all—it’s how we treat failing lungs across the western world. However, as hospitals ventilated thousands and thousands of patients, the initial survival data paints a very bleak picture. Research from a number of countries shows that anything from 70 to 90 percent of patients placed on a ventilator—never come off (some of the worst results were actually from Italy). They die. This is far less than the statistics for many other respiratory ailments including bacterial pneumonia. While this may be because COVID patients are already very sick and overwhelmed by illness, it’s still left many doctors asking the question: could aggressively ventilating patients with COVID infection actually be harmful in some cases?

Let’s back up a bit. Why do we even ventilate patients? It’s a necessary intervention when inadequate oxygen is reaching your blood stream (hypoxemia). This can happen for any number of reasons, including devastating lung infection. Doctors measure your oxygen saturation via your finger, or can take a direct measurement from your bloodstream (arterial blood gas). In the case of COVID however, the processes occurring in the lungs appear different to those occurring in other conditions, like bacterial pneumonia and Acute Respiratory Distress Syndrome (ARDS). Because of the amount of inflammation and fluid leakage occurring, a school of thought is emerging that “forcing” oxygen into the lungs via a ventilator—may not be as beneficial. In fact, it’s possible that the initial rush to treat this illness like ARDS, may be part of where we went wrong—because it’s a very different pathological process. Other traditional treatment methods we use for ARDS, including diuretics, are also therefore in question.

Minimally invasive ways of delivering oxygen, including via simple nasal cannula oxygen, should be used for as long as possible (there’s concern with some other respiratory devices, even high flow nasal oxygen, that the virus becomes “aerosolized” thereby posing a hazard to healthcare workers). Additional conservative measures like placing the patient prone (on their belly) is also excellent for respiratory mechanics and improving lung expansion and hence oxygenation. Other reported techniques, such as ECMO (extracorporeal membrane oxygenation), need more research.

This is not to say that ventilators should never be used. There are lots of indications to use them when there’s no other choice, a patient simply cannot work hard enough to breathe, and complete respiratory failure is imminent. But for now, many physicians are heading towards a strategy of letting patients breathe on their own at lower oxygen levels than we’ve previously allowed.

The fact that there was this huge rush towards this medical intervention, with few physicians stopping to ask the immediate question—”Is ventilation even the right thing to do?”—also underscores a fallibility we have within the medical community. When there is a strong tailwind in a certain direction, doctors often too quickly follow that, and then find out later it was the wrong approach.

I am going to relate a story from my medical residency. When I was an intern, there was a big push in healthcare facilities to keep the blood sugar level of inpatients less than 110. It was written on posters on walls, and our attending physicians were constantly talking about achieving this on all diabetic patients. Nurses were going round checking frequent glucose finger sticks and administering insulin to meet the goal. This strategy was based on a single study published in the New England Journal of Medicine. For some reason, it just didn’t sit right with me—seemed way too aggressive and not in line with common sense. So I decided to conduct my own research study, into the outcomes of patients according to their blood sugars. It took me a couple of years to gather all the data and write up the paper, which in the end showed that a more conservative approach was much better for patients, and we could have needlessly been making patients hypoglycemic (which is very dangerous). I ended up winning a national prize for the research and it was published in the Journal of Endocrine Practice. Sure enough—other large studies soon came out—showing increased mortality with intensive blood sugar control. National guidelines were then changed to allow for blood sugars in the 140-180 range for all diabetic patients!

I tell this story not to blow my own trumpet. Simply to encourage physicians everywhere to always be asking questions about protocols that the whole medical community appears to be quickly jumping on board with. Especially when there’s inadequate data. Never get on that bandwagon too quickly (in fact: “Have we jumped on the blood sugar bandwagon too quickly?” was the title for my oral presentation, when I was one of the few people saying it). By nature, I’ve always been one who doesn’t mind standing apart from the crowd and frequently being a lone voice. I hope every doctor can do that, as long as what you are saying seems based on an iota common sense. Always ask questions about the evidence behind the things you are told to do. That doesn’t mean being obstructionist, difficult or needlessly always standing in the way. But it does mean challenging groupthink—and getting intelligent people to think more about what they are doing.

As for our push to ventilate so many patients early on with COVID, I hope I may be proved wrong on this. But my gut is telling me that physicians have been way too quick with this, and the initial drive and focus on ventilation and getting as many ventilators as possible, could have inadvertently produced some negative outcomes across the western world.

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