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Non-invasive oxygen therapy, steroids prevent Covid deaths, agree experts
Doctors of AIIMS and the University College of London Hospital also did not dismiss Remdesivir or plasma therapy completely, despite the WHO’s Solidarity trial showing no impact on mortality, duration of hospitalisation, or need for mechanical ventilation
Non-invasive oxygen therapy, antiviral drug Remdesivir and convalescent plasma therapy in the early stage of the disease, and steroids in the later stages help patients with coronavirus disease (Covid-19), said experts from the All India Institute of Medical Science (AIIMS) and the University College of London Hospital (UCLH) during the National Grand Round held on Wednesday to discuss the treatment protocols in both the countries.
The national grand round is a virtual platform for doctors across the country to get information about the trends and latest treatment protocols for Covid-19 in the country.
The doctors did not dismiss Remdesivir or plasma therapy completely, despite the World Health Organisation’s Solidarity trial showing no impact on mortality, duration of hospitalisation, or need for mechanical ventilation with the use of the former and Indian Council of Medical Research’s own PLACID trial showing no impact on mortality or severity of illness with the use of the latter.
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“Convalescent plasma, which was used in the previous pandemic of 1918, held a lot of promise. However, trials from the world over did not show the kind of benefits that were expected. It has been widely used in our country, but the effect has not materialised in the real life clinical practice. Most of the trials have an inherent problem – limited data from patients with mild disease, efficacy with early administration unknown, and no standardisation of antibody titres,” said Dr Neeraj Nishchal, assistant professor of medicine at AIIMS.
“There is a need to conduct a trial where the patients are given the therapy in early stages of the disease, we may have a group of patients who may benefit from this therapy. Further studies are needed before ruling out plasma therapy as an option,” he said.
As for Remdesivir, intensive care specialist Prof Mervyn Singer from University College of London said if he were a patient, he would want the drug. “I think it’s important to look at the evidence. Personally, I have a challenge with the platform trials as they are very vague about the randomisation of patients and the matching. For e.g; for Remdesivir, the randomised control trials with a placebo arm have shown a benefit in terms of time in hospital. The platform Solidarity did not show it,” he said.
A platform trial assigns patients to multiple groups that are administered different therapies for a disease, whereas, a randomised control trial assigns patients to two groups: One that receives the therapy and other that doesn’t (or gets a placebo) to test the efficacy of the therapy.
He went on to explain, “The opposite is true for steroids. The recovery trial showed this huge effect and none of the other randomised control trial showed anywhere near as big an effect.”
The doctors said that steroids – the only medicine to have shown mortality benefit in Covid-19 – were not used early on in the pandemic as Covid-19 was thought to be mainly a respiratory infection. “When the pandemic started, the WHO guidelines did not recommend giving corticosteroids in patients based on experiences with previous viral pneumonias like H1N1, SARS, and MERS. However, as we started seeing cytokine storm (an excessive immune response) in patients, we thought steroids might help. It was later included in the national guidelines in May,” said Dr Nishchal.
Initially, in the UK, doctors were also advised to intubate the patients early on to help them breathe. Dr David Brealey, consulting intensivist at UCLH discussed the case of a 41-year-old bar owner who had Covid-19 and was kept on CPAP (continuous positive airway pressure) for an extended period rather than being put on the ventilator.
The doctors started realising that the patients were better off with non-invasive ventilation and it did not lead to higher rates of infection among healthcare workers if proper precautions were taken.
With the realisation that they only had 12 of these life-saving CPAP machines, the doctors from the hospital also went on to design a non-electrical CPAP machine that was manufactured quickly by a Mercedes factory meant to produce engines for Formula 1 racing cars.
