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Monday, May 4, 2020

What Is the Common Denominator for Serious COVID-19 Cases?

            Dr. Thomas Yadegar is my VIP for this week because he discovered the common denominator for treating serious COVID-19 cases. He has provided critical care for more than 20 years and is currently the director of the intensive care unit at Providence Cedars-Sinai Tarzana Medical Center in Tarzana, California. As anyone would expect, he has been on the front lines of the battle with COVID-19. Like many other intensive care specialists, he has searched for a way to treat patients with the coronavirus. It seems that there are many patients that seem to be improving, and then they suddenly start deteriorating.

            According to Kevin Pham, Dr. Yadegar was stumped when he first experienced a patient starting to deteriorate. Even though he had 20 years of critical care experience, he did not know what happened to his patient. One night an exhausted Dr. Yadegar searched through the records of his patients trying to find something that was common to all of them.

            Following suggestions from doctors throughout the world, Dr. Yadegar and his colleagues had avoided anti-inflammatory treatment but were aggressive in using ventilators to prevent further decline among patients. They knew that the guidelines were for treating patients with severe viral respiratory disease, but they also knew that they did not help patients whose other organs started to fail. After a long search, Dr. Yadegar recognized that the common feature of all his patients was inflammation. As Pham explained, ventilators were not the secret weapon.

In fact, using a ventilator is a highly invasive procedure, and the repeated and forced inspiration of air irritates the lungs, which feeds back into the inflammatory cycle….

The only way to explain the highly complex disease course that seems to change from one patient to the next is that the virus is causing an autoimmune response, in which the body’s natural defense mechanisms go haywire and begin destroying the body they’re trying to protect.

The disease course is so unpredictable because every person’s immune system is unique to that person.

            Once Dr. Yadegar understood that an autoimmune response was common in all the patients that deteriorated, he and the ICU staff adjusted their protocol.  After patient is tested for COVID-19 and their results come back positive, they are tested for inflammatory markers.

Those with elevated inflammatory markers are kept in the hospital with a close eye on their oxygen saturation levels. If the patient begins to desaturate, the medical team evaluates the patient before starting a course of steroids and an IL-6 inhibitor.

IL-6 (interleukin-6) is a powerful mediator for the inflammatory pathway, so an IL-6 inhibitor would prevent a significant amount of inflammation from happening. Steroids have strong anti-inflammatory effects and also suppress the immune system more broadly.

            As Pham explained, this treatment stops the autoimmune response before it becomes deadly but does not treat the coronavirus at all. Dr. Yadegar learned that each patient needed their own protocol because what worked with one patient did not work with another. Plus, the doctors had to watch closely for infections because the steroids shut down the immune system. An infection would most likely kill the patient.

            Because they were treating the autoimmune response rather than the virus, Dr. Yadegar and his staff stopped using ventilators and watched the mortality rate drop to single digits. It sounds to me like this information needs to be broadcast to other hospitals. Maybe this is the reason why the demand for ventilators suddenly dropped.

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