Fascinating article: https://www.nytimes.com/2020/04/20/opinion/coronavirus-testing-pneumonia.html
The comments section is also enlightening.
And the same doctor (who volunteered to work at Bellevue for ten days, coming down from NH) booted from his brother’s coop a couple of weeks ago: https://www.nytimes.com/2020/04/03/nyregion/co-op-board-coronavirus-nyc.html
I’m a member of an email group for physical therapists interested in cardiorespiratory issues, which often means PTs working in hospitals. They’ve bee talking about the prone positioning for a few weeks now, so the information is out there to some degree.
“ It requires detecting silent hypoxia early through a common medical device that can be purchased without a prescription at most pharmacies: a pulse oximeter.â€
Good luck getting one - they are sold out everywhere. - except EBay
I first heard about Pulse Ox about 6 weeks ago, and there was a run on these back then
“ It requires detecting silent hypoxia early through a common medical device that can be purchased without a prescription at most pharmacies: a pulse oximeter.â€
Good luck getting one - they are sold out everywhere. - except EBay
I first heard about Pulse Ox about 6 weeks ago, and there was a run on these back then
So what I’m hearing is if I can scrounge up the ones we have laying around here somewhere I can engage in a little profiteering 
Galaxy s8,s9 etc have a basic one built in with the Samsung Health app. Worth a look.
Galaxy s8,s9 etc have a basic one built in with the Samsung Health app. Worth a look.
https://www.ncbi.nlm.nih.gov/pubmed/31471076
CONCLUSIONS:
While iOx has modest concordance with control, Ox and POx showed almost none. The iOx device was best in correctly identifying hypoxia patients, but almost 1/4 of patients were incorrectly classified. The three apps provided inaccurate SpO2 measurements and had limited to no ability to accurately detect hypoxia. These apps should not be relied upon to provide accurate SpO2 measurements in emergent, even austere conditions.
Galaxy s8,s9 etc have a basic one built in with the Samsung Health app. Worth a look.
vivoactive 4?.. I think
Garmin Fenix (5/6) 945 also have it.
I can’t say I’ve seen this at my hospital, although hypoxemia is the predominant finding with COVID pneumonia, universally, for reasons explained in the article. CO2 retention is secondary to profound respiratory failure, but not an early finding. These patients typically require escalating levels of supplemental o2, going from room air to nasal cannula (2-6L/m) then oxygen mask (15L/m), then High Flow Nasal Cannula (50L/m often), then adding an oxygen mask over top of the HFNC. If they can’t maintain an spo2 greater than 90%, or if they’re in extremis from working to maintain that level (profound tachycardia, tachypnea, labored breathing, hypertensive, respiratory muscle fatigue, etc., I intubate them. Avoiding the vent until it’s clear that death from respiratory failure is a strong possibility, is the rule now.
My brother, also a Jersey boy, had COVID last week, and I recommended a pulse ox because of his concerning respiratory symptoms. He couldn’t find one in CVS or on Amazon at the time. I don’t know that I would have used that metric alone as a threshold by which to recommend hospitalization, but if he were to tell me he was feeling worse and his sats were dropping into the 80s or worse, despite how he felt at the time, I’d probably have told him to get his ass to the ER sooner than later.
Our ICU has overflowed to two of the above floors, where non-ICU nurses are the predominant attendants. I had two patients on HFNC+o2 mask last week and neither were on continuous pulse ox monitoring. Needless to say, we fixed that problem. Those are the patients at the highest risk of acute respiratory failure and death, even more so than those on vents, who have that time been stabilized and weaning becomes the challenge. We’re now keeping those non-intubated patients on our main ICU floor for that reason.
I’m curious about asymptomatic hypoxemia as the author described. I’ll talk to the ER docs and ask if they’ve seen this. We stay in fairly regular communication and it hasn’t been mentioned thus far, though.
This may be of interest (one of the comments to that Op-Ed piece was that most of this was common knowledge in Germany for months).
https://www.the-hospitalist.org/hospitalist/article/220301/coronavirus-updates/protocol-driven-covid-19-respiratory-therapy-doing
And more:
https://www.statnews.com/2020/04/08/doctors-say-ventilators-overused-for-covid-19/
To be “more nuanced about who we intubate,†as she suggests, starts with questioning the significance of oxygen saturation levels. Those levels often “look beyond awful,†said Scott Weingart, a critical care physician in New York and host of the “EMCrit†podcast. But many can speak in full sentences, don’t report shortness of breath, and have no signs of the heart or other organ abnormalities that hypoxia can cause.
“The patients in front of me are unlike any I’ve ever seen,†Kyle-Sidell told Medscape about those he cared for in a hard-hit Brooklyn hospital. “They looked a lot more like they had altitude sickness than pneumonia.â€
To my lay eyes, the non-protocol seems to be “if the patient seems okay, don’t use a ventilator, blood oxygen levels be damned.”
Thanks for posting this. I’ve been having my 82 year old father take his temp daily. I believe he already has a pulse ox monitor so I’ll have him pull that out and keep an eye on that too.
Yeah just tested my s9 out. Gave me 92% then 98% so doesn’t seem very accurate unfortunately.
Yeah just tested my s9 out. Gave me 92% then 98% so doesn’t seem very accurate unfortunately.
It should be 98% or up there every time unless you’ve got something going on.
To my lay eyes, the non-protocol seems to be “if the patient seems okay, don’t use a ventilator, blood oxygen levels be damned.”
That’s essentially our approach. We don’t get aggressive until patients’ start to fail the “eyeball test” and struggle to maintain acceptable oxygenation levels without compromising themselves in the global sense. I’m very hesitant to pull the trigger on intubation because we know the cascade of shit that can and does often follow. I would never electively intubate someone breathing comfortably on an o2 mask even if they’re hovering in the 80-90% range. It’s failing that passive oxygenation to the point of respiratory exhaustion and failure that intubation becomes necessary. That approach seems to be the commonality among treatment protocols; it’s the vent management that seems to vary from one practitioner, and from group to another. On nightly rounds I typically see a dozen or so patients proned, on oxygen masks, hovering around 90%, appearing relatively comfortable, and that’s perfectly fine.
You might try turning your finger sideways inside the device, if you haven’t. Sometimes you get more reliable readings in that position.
Also a fun experiment is to hold your breath and watch how long it takes for your saturation % to drop. Typically in the 30-40 second range, and then breathe normally to see how long it takes to normalize. I’ll do this on occasion if I question the readings on the finger clip pulse ox detector we use in the ICU.
Galaxy s8,s9 etc have a basic one built in with the Samsung Health app. Worth a look.
vivoactive 4?.. I think
Garmin Fenix (5/6) 945 also have it.
For anyone else looking the blood ox level is measured in the “stress” reading in the app.
I’m reading more and more references to HAPE. Interesting stuff. I live and play at altitude (6k, 10+k respectively) and it’s interesting how altitude effects are inconsistent. Some young, healthy, fit people have hell with the altitude, others no problem at all. Older, respiratory conditions, obesity are all going to dramatically increase the likelihood of having very poor adaptation to altitude… Seems sort of parallel to how Covid is playing out.
it’s interesting how altitude effects are inconsistent.
Even with the same person. I’ve done loads of 14K+ foot peaks with zero problem. The one time I came completely off the rails. Which was scary because I was solo - nearly passed out, which might have killed me. But managed to nearly crawl my way down. Then after that no problem since. It’s like a knife edge condition - you can just fall off the ledge.
Yeah just tested my s9 out. Gave me 92% then 98% so doesn’t seem very accurate unfortunately.
I’m just one random data point, but…I rarely get good readings from pulse oximeters, be it my own cheap CVS one at home or in the doctor’s office. About half the time, I can’t get a reading at all from one, and then half the time that I do get a reading, it’s 90% or lower, sometimes into the mid-80s. All this while I am otherwise totally fine. (I get it read once a month at the asthma doctor’s office when I go in for some injections, so I have a decent number of tries on record).
I have Raynauds and poor circulation in general, and I have always assumed that those conditions are why I get readings inconsistent with how I feel. I do wonder if perhaps there is something similar going on with COVID 19 patients who have low readings but are breathing normally - if perhaps the virus interferes with circulation in the extremities. (note: I have no professional medical training - just spitballing)