https://www.nytimes.com/2020/04/14/nyregion/new-york-coronavirus.html
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The biggest change: Instead of quickly sedating people who had shockingly low levels of oxygen and then putting them on mechanical ventilators, many doctors are now keeping patients conscious, having them roll over in bed, recline in chairs and continue to breathe on their own with additional oxygen for as long as possible.
The idea is to get them off their backs and thereby make more lung available. A number of doctors are even trying patients on a special massage mattress designed for pregnant women because it has cutouts that ease the load on the belly and chest.
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Yet many Covid-19 patients remain alert, even when their oxygen has sharply fallen, for reasons health care workers can only guess. (Another important signal about how sick the patients are from Covid-19 the presence of inflammatory markers in the blood is not available to physicians until laboratory work is done.)
Some patients, by taking oxygen and rolling onto their sides or on their bellies, have quickly returned to normal levels. The tactic is called proning.
Doctors at Montefiore Medical Center in the Bronx and Mount Sinai Medical Center in Manhattan have described it on Twitter; a flier is posted next to beds at Elmhurst Hospital Center in Queens as a guide for patients on how often to turn themselves.
At Lincoln Hospital in the Bronx, Dr. Nicholas Caputo followed 50 patients who arrived with low oxygen levels between 69 and 85 percent (95 is normal). After five minutes of proning, they had improved to a mean of 94 percent. Over the next 24 hours, nearly three-quarters were able to avoid intubation; 13 needed ventilators. Proning does not seem to work as well in older patients, a number of doctors said.
No one knows yet if this will be a lasting remedy, Dr. Caputo said, but if he could go back to early March, he would advise himself and others: "Don't jump to intubation."
The total number of people who are intubated is now increasing by 21 per day, down from about 300 at the end of March. The need for mechanical ventilators, while still urgent, has been less than the medical community anticipated a month ago.
One reason is that contrary to expectations, a number of doctors at New York hospitals believe intubation is helping fewer people with Covid-19 than other respiratory illnesses and that longer stays on the mechanical ventilators lead to other serious complications. The matter is far from settled.
"Intubated patients with Covid lung disease are doing very poorly, and while this may be the disease and not the mechanical ventilation, most of us believe that intubation is to be avoided until unequivocally required," Dr. Strayer said.
This shift has lightened the load on nursing staffs and the rest of the hospital. "You put a tube into somebody," Dr. Levitan said, "and the amount of work required not to kill that person goes up by a factor of 100," creating a cascade that slows down laboratory results, X-rays and other care.
By committing all the resources of the hospital to highly complex care, mass mechanical ventilation of patients forms a medical Maginot line.
For heavier patients, Dr. Levitan advocates combining breathing support from a CPAP machine or regular oxygen with comfortable positioning on a pregnancy massage mattress. He had one shipped to the hotel where he was staying in New York and brought it to Bellevue.
The first patient to rest on it arrived with oxygen saturation in the 40s, breathing rapidly and with an abnormally fast heartbeat, he said. After the patient was given oxygen through a nasal cannula clear plastic tubes that fit into the nostrils Dr. Levitan helped her to lie face down on the massage table. The oxygen level in her blood climbed to the mid-90s, he said, her pulse slowed to under 100 and she was breathing at a more normal pace. "She slept for two hours," he said.
His brothers are donating more mattresses.
"We have to see how it pans out, but it makes a lot of sense," Dr. Swaminathan said. "Obesity is clearly a critical risk factor."
Dr. Josh Farkas, who specializes in pulmonary and critical care medicine at the University of Vermont, said the risks of proning were low. "This is a simple technique which is safe and fairly easy to do," Dr. Farkas said. "I started doing this some years ago in occasional patients, but never imagined that it would become this widespread and useful."
This was rebuilding the engine on a car going 100 miles per hour.
"I wouldn't be surprised if in a couple of weeks someone around the country comes up with better way to do this," Dr. Swaminathan said.
