LONDON — In normal circumstances, the patient’s congestive heart failure would have been straightforward to treat, in part with non-invasive ventilation. Not knowing whether the patient had COVID-19, however, created new risks, and, given the person’s age and frailty, all Tarek Loubani could do was to watch and wait. “We just waited until [the patient] deteriorated enough that we had the discussion about intubation,” the London Health Sciences emergency-room doctor says. “And we didn’t intubate, because [the patient] was too old and too sick to be intubated. And, of course, [the patient] died. [The patient] received no active treatment at all; we’d taken ourselves back 50 years.”
Experiences such as these are what motivated Loubani, also an associate scientist at the Lawson Health Research Institute, to work with others to develop a new type of mask to allow the use of non-invasive ventilation for patients with COVID-19. The institute is the medical-research arm of London’s two hospitals — London Health Sciences Centre and St. Joseph’s Health Care London. Loubani is one of several of the institute’s 1,500 principal investigators, researchers, technicians, support staff, and trainees searching for new ways to fight COVID-19 after the institute redeployed more than $200,000 in funds to create an internal COVID-19 rapid-response competition to kickstart research.
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Today, the institute has 25 COVID-19 studies underway; 40 more are going through the regulator-approval process. “That has happened in little over a month, which is outstanding,” says David Hill, the institute’s scientific director.
Researchers led by Robert Arntfield, the medical director of the critical-care trauma centre at London Health Sciences, Victoria campus, are combining artificial intelligence and ultrasound to determine whether someone has COVID-19-related pneumonia. The team has used the artificial intelligence to develop an algorithm that is used to scan the hospital’s extensive database of ultrasound images and data of lung conditions to find ways to distinguish between COVID-19-related pneumonia and pneumonia from other causes that go undetected by the human eye — or the traditional stethoscope.
Arntfield’s team recently used a similar approach to successfully distinguish between a life-threatening heart condition and a similar-looking, yet normal, finding. He uses ultrasound, he says, because its technology has evolved to the point that the equipment can be plugged into smartphones and computer equipment.
If it works, the approach would take less than one minute to confirm diagnosis of COVID-related pneumonia, he says. Currently, the most rapid test for diagnosis of the virus takes at least 24 hours to produce results.
Other work, such as the study Loubani is leading, uses existing equipment in innovative ways. Loubani and his fellow researchers are using a firefighter’s mask specially adapted with the assistance of engineers at General Dynamics (an armoured-vehicle manufacturer) to deliver non-invasive ventilation.
Loubani explains that non-invasive ventilation — machines that deliver continuous positive airway pressure to treat conditions such as sleep apnea — to treat a contagious condition is safer for patients than using mechanical ventilation, which can create other problems and can’t be used on some patients. The problem with non-invasive ventilation in terms of treating patients with COVID-19, he says, is that the therapy can increase infection rates among health-care providers. Yet, without a non-invasive option in the battle against COVID-19, doctors face tough decisions, he says — putting people on invasive ventilation much sooner than needed or leaving them untreated for a longer period of time.
So far, data shows that the mask reduces leaks, but they’re still determining whether patients can tolerate it — and, ultimately, whether it provides benefit.
Chris McIntyre is leading a project that’s employing dialysis to trick white-blood cells into dialling down their immune-system response to COVID-19. That response, which can follow virus-caused pneumonia, can cause “multi-organ failure and the risk of death,” he explains.
Using dialysis, McIntyre’s team removes blood and temporarily collects what he describes as “angry” white cells and calms them down with chemicals. The blood is filtered again to remove the chemicals before it’s returned to the patient and then, he says, “hopefully, those anti-inflammatory white cells are then capable of homing in to the different organs and modulating the inflammatory process within them.” He hopes to complete a clinical trial by fall; if it is successful, the treatment could show promise in treating sepsis, the bacterial infection that is the most common reason for all intensive-care admissions.
So far, McIntyre says, the treatment appears to reduce inflammation and improve blood pressure. It’s too soon to determine whether the procedure is saving lives, though, he says: “It would be nice to think like that. But no one’s going to pull any corks until it’s proven to be safe an efficacious and rolled out.”
Maxwell Smith, a Western University public-health ethics professor who is a member of the World Health Organization international working group on ethics and COVID-19, says a global effort is also underway to fast-track research. It’s based on a therapeutic protocol WHO developed in response to Ebola outbreaks from 2013 to 2016. Many, but not all, Canadian trials, he says, fall under the protocol. Smith says the urgent need to combat the virus creates an ethical question: “We also have an ethical imperative, on the other hand, to ensure that whatever products we do end up developing, that they’re safe, that they’re effective.”
The WHO protocol involves accelerating research by bringing scientists together from around the world to collaborate and coordinate projects to ensure that research will not be duplicated and that data is shared. Accelerating research isn’t about cutting corners, he explains, but rather “being creative and coordinating in a way that we don’t usually do in order to make up that time.” If anything, ethical norms and standards, he says, need to “apply with even more force once we’re faced with these emergencies because the public generally wants something as quick as possible that will benefit as many people as possible.”
Loubani, whose project does not fall under the scope of the protocol (the protocol is focused on drug therapy, he explains), describes experiencing pressure to release the adapted firefighter’s mask: currently, there are at least two jurisdictions that want to put it to work as soon as possible to spare intubation ventilators. But there’s simply still too much to sort out, he says: “The thing is, you can’t just hand a device like this to somebody and walk away.” The team will have to develop training protocols and methods for cleaning the equipment.
Loubani is considering widening the number of hospitals involved in the study. A rural trial is already happening in northern Ontario. Many rural and smaller communities can’t even consider using non-invasive ventilation, he notes, because they lack the negative-pressure rooms currently needed to reduce the risk of spreading the infection. If the mask is proven to be of benefit, it will eliminate that need — and, he says, “That’s huge.”
This is one in a series of stories about issues affecting southwestern Ontario. It's brought to you with the assistance of faculty and students from Western University’s Faculty of Information and Media Studies.
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