REBEL Cast Episode 80 –

A New War Plan for COVID-19

with Richard Levitan, MD

Thoughts on the “Happy Hypoxemic” Terminology: I prefer to

use silent hypoxemia, these patients are not happy, they are
dying from an incredibly slow onset of severe hypoxemia
associated with hypocapnia.
 Dr Sudjoko Kuswadji (MSc(OM) NUS , PKK IDI, SpOk IDI)

●
Swiss Cheese
 Upaya Penanganan Covid

• Tidak ada satu upaya apapun juga yang dipastikan bisa

menumpas virus corona ini.
• Setiap usaha merupakan satu lapis dari keju Swiss yang
berlubang-lubang.
• Dari banyak lubang itu kita tidak pernah tahu lubang mana
yang menyebabkan virus bisa lolos dan melakukan
penularan kepada manusia;
• Yang pasti makin sedikit lubang maka semakin kecil
kemungkinan virus itu akan lolos;
 Penyebaran virus Covid 19

• Droplets, ketika berbicara dan bernapas, lewat butir

droplets yang besar dan berat jatuh ke bawah pada jarak 50
cm;
• Yang kecil dan ringan (aerosol) terbang di udara lewat
batuk mencapai jarak 1-2 meter;
• Yang ringan (aerosol) bisa terbang dengan
menggumpal-gumpal (turbulence) mencapai jarak 8-9
meter;
Dilution is the best solution
against pollution

Pengenceran adalah penyelesaiaan terbaik untuk polusi

Bernapas, bicara, batuk dan bersin
https://www.youtube.com/watch?v=piCWFgwysu0&feature=youtu.be
 Kesan...
• Virus dalam tubuh manusia sukar dikendalikan: tanpa
gejala, diagnosis, patofisiologi, obat, vaksin dst;
• Virus di luar tubuh lebih mudah dikendalikan, bisa dihitung
viral loadnya, antiseptik dst.
• Konsentrasi penanganan lebih banyak menyangkut
manusia, dengan segala macam kesulitannya;
• Protokol kesehatan mestinya protokol kesehatan dan
lingkungan;
• Perlu disusun program pengendalian Covid 19 dalam
lingkungan;
Dr. Richard M. Levitan
Penemu Silent Hypoxia
• Dr. Richard M. Levitan is an emergency
medicine physician in Franklin, New
Hampshire and is affiliated with
multiple hospitals in the area. He has
been in practice for more than 20
years.
• Emergency medicine specialists
diagnose and treat patients with
life-threatening conditions like heart
attack, drug overdose, shock, or
massive bleeding.
• Littleton Regional Hospital, White River
Junction Veterans Affairs Medical
Center
 Pulse oximeters

• In April 2020, Levitan volunteered for 10 days to help treat patients with COVID-19
at the emergency room of Bellevue Hospital in New York City.
• He observed many patients with pneumonia and hypoxia (low oxygen levels in
blood) who did not have typical symptoms of breathing problems such as chest
discomfort or painful breathing.
• Levitan suggested in a New York Times op-ed that the widespread use of pulse
oximeters could lead to earlier detection of serious breathing complications, and to
better outcomes for patients with these complications.
• Although the op-ed was widely covered in the news, other doctors cautioned that
early detection might lead to overtreatment, and that the role of early detection of
hypoxia in treating COVID-19 still needed to be studied.
https://www.youtube.com/watch?v=wKHgDcbFTcM
Deadly Delay - Is Coronavirus a Silent Killer?
Clinical Phases of COVID Pneumonia:
 We are not calling this HAPE, but why is this important for
us to understand people at altitude in the context of
COVID-19 pathophysiology?
• COVID is caused by a respiratory virus, but what it does to
the lungs is something that we have not seen before
clinically.
• It causes a severe problem with oxygen absorption and we
think that is because of collapse of alveoli due to its attack
on the cells in the lungs that make surfactant (Alveolar type
II cells).
• Despite the impaired oxygen absorption, patient’s lungs
remain compliant. This is what Gattinoni refers to as the
“type L” phase of COVID pneumonia.1
 Endogenous physiologic response to hypoxia

• There is only one endogenous physiologic response to hypoxia and that is to

breathe faster.
• And we see this in people at high altitudes.
• The American Medical Research Expedition to Everest2 was an expedition where
researchers drew blood gases on the summit of Everest.
• What was interesting was you had blood gases with PCO2 measurements of 15
mmHg or lower and PO2 measurements were in the 30’s.
• Clearly in severe respiratory alkalosis due to breathing so fast.
• When thinking about this in terms of the alveolar gas equation, the only way to
improve oxygenation is to remove carbon dioxide by increase respiratory rate.
 https://www.youtube.com/watch?v=OsxEtog2OHA
7 Pasien Covid 19 di Banyumas Meninggal, 3 di Antaranya Alami
Gejala Baru yaitu Happy Hypoxia
 They don’t feel it
• We are seeing patients with respiratory rates of 40/min or higher and
SpO2 measurements of 50-60%.
• What I believe is happening in COVID is patients are slowly getting
hypoxic.
• They don’t feel it, because it’s not like a bacterial pneumonia that
causes pain with breathing.
• It’s not subjectively appreciated by the patient, but they modify their
respirations and increase their respiratory drive and minute
ventilation in response to the hypoxia.
• This effectively blows off carbon dioxide, keeping them from
subjectively feeling short of breath.
 “silent hypoxia”
• Patients come in with moderate to severe pneumonia with profound
hypoxia.
• “I’ve been sick for days, but I became short of breath suddenly.”
• This is consistent with the “silent hypoxia” we are seeing that is
corroborated with what I’m hearing from many patients and family
members.
• The human brain can’t tolerate sudden significant drops in O2 We
see this in aviation studies on “time of useful consciousness”.3
• Thoughts on the “Happy Hypoxemic” Terminology: I prefer to use
silent hypoxemia, these patients are not happy, they are dying from
an incredibly slow onset of severe hypoxemia associated with
hypocapnia.
“time of useful consciousness”
The remarkable
dissociation between
profound hypoxemic
respiratory failure
and a clinically
‘happy’ patient is
frequently seen and
should prompt
physicians and health
care workers not only
to rely on the
patient’s apparent
wellbeing but closely
monitor respiratory
rate, signs of
hyperventilation,
oxygen saturation
and invasive
measurements of
hypoxemia/
hypocapnia at regular
time intervals.
 Pulse oximetry
• Pulse oximetry should be interpreted with caution, because left-sided
shifting of the oxyhemoglobin dissociation curve. The arterial
hypoxemia is induced by intrapulmonary shunting, dysregulated
hypoxic pulmonary vasoconstriction, impaired lung diffusion, and
formation of intravascular microthrombi.
• As in the first days of the disease, the lung mechanics are
well-preserved and there is no increased airway resistance or dead
space ventilation. The respiratory center thus does not sense an
uncomfortable sensation of breathing. However, sudden and rapid
respiratory decompensation may occur, and tachypnea and
hyperpnea might be the most important clinical warning signs of
impending respiratory failure in COVID-19 patients.
 Hypoxia: general and local
• Hypoxia is a condition in which the body or a region of the
body is deprived of adequate oxygen supply at the tissue
level.
• Hypoxia may be classified as either
• generalized, affecting the whole body, or
• local, affecting a region of the body.
• Although hypoxia is often a pathological condition,
variations in arterial oxygen concentrations can be part of
the normal physiology, for example, during hypoventilation
training or strenuous physical exercise.
 Hypoxemia and anoxemia
• Hypoxia differs from hypoxemia and anoxemia in that
hypoxia refers to a state in which oxygen supply is
insufficient, whereas
• hypoxemia and anoxemia refer specifically to states that
have low or zero arterial oxygen supply.

• Hypoxia in which there is complete deprivation of oxygen

supply is referred to as anoxia.
 Hypoxemic hypoxia

• This refers specifically to hypoxic states where the arterial

content of oxygen is insufficient.
• This can be caused by alterations in respiratory drive, such
as in respiratory alkalosis, physiological or pathological
shunting of blood, diseases interfering in lung function
resulting in a ventilation-perfusion mismatch, such as a
pulmonary embolus, or alterations in the partial pressure of
oxygen in the environment or lung alveoli, such as may
occur at altitude or when diving.
 Generalized hypoxia
• Generalized hypoxia occurs in healthy people when they ascend to
high altitude, where it causes altitude sickness leading to potentially
fatal complications:
• high altitude pulmonary edema (HAPE) and
• high altitude cerebral edema (HACE).
• Hypoxia also occurs in healthy individuals when breathing mixtures
of gases with a low oxygen content, e.g. while diving underwater
especially when using closed-circuit rebreather systems that control
the amount of oxygen in the supplied air.
• Mild, non-damaging intermittent hypoxia is used intentionally during
altitude training to develop an athletic performance adaptation at
both the systemic and cellular level.
 Remarkably low oxygen saturations
• An acute or silent hypoxia, a person’s oxygen level in blood cells and
tissue can drop without any initial warning, even though the
individual’s chest x-ray shows diffuse pneumonia with an oxygen
level below normal.
• Doctors report cases of silent hypoxia with COVID-19 patients who
did not experience shortness of breath or coughing until their oxygen
levels had plummeted to such a degree that the patients risked acute
respiratory distress (ARDS) and organ failure.
• In a New York Times opinion piece (April 20th, 2020), emergency
room doctor Richard Levitan reports "a vast majority of Covid
pneumonia patients I met had remarkably low oxygen saturations at
triage — seemingly incompatible with life — but they were using their
cellphones as we put them on monitors."
Histotoxic hypoxia Cyanide poisoning

• Histotoxic hypoxia results when the quantity of oxygen

reaching the cells is normal, but the cells are unable to use
the oxygen effectively as a result of disabled oxidative
phosphorylation enzymes.
• This may occur in cyanide poisoning.
HYPOBARIC CHAMBER
 Continue reading the main story

• Even patients without respiratory complaints had Covid pneumonia. The patient
stabbed in the shoulder, whom we X-rayed because we worried he had a collapsed
lung, actually had Covid pneumonia. In patients on whom we did CT scans because
they were injured in falls, we coincidentally found Covid pneumonia. Elderly
patients who had passed out for unknown reasons and a number of diabetic
patients were found to have it.
• And here is what really surprised us: These patients did not report any sensation of
breathing problems, even though their chest X-rays showed diffuse pneumonia and
their oxygen was below normal. How could this be?
• We are just beginning to recognize that Covid pneumonia initially causes a form of
oxygen deprivation we call “silent hypoxia” — “silent” because of its insidious,
hard-to-detect nature.
 Patients don’t feel short of breath
• Pneumonia is an infection of the lungs in which the air sacs fill with
fluid or pus.
• Normally, patients develop chest discomfort, pain with breathing and
other breathing problems.
• But when Covid pneumonia first strikes, patients don’t feel short of
breath, even as their oxygen levels fall.
• And by the time they do, they have alarmingly low oxygen levels and
moderate-to-severe pneumonia (as seen on chest X-rays).
• Normal oxygen saturation for most persons at sea level is 94 to 100
percent; Covid pneumonia patients I saw had oxygen saturations as
low as 50 percent.
 Became short of breath the day

• To my amazement, most patients I saw said they had been

sick for a week or so with fever, cough, upset stomach and
fatigue, but they only became short of breath the day they
came to the hospital.
• Their pneumonia had clearly been going on for days, but by
the time they felt they had to go to the hospital, they were
often already in critical condition.
 Dangerously low oxygen levels
• A vast majority of Covid pneumonia patients I met had
remarkably low oxygen saturations at triage — seemingly
incompatible with life — but they were using their
cellphones as we put them on monitors.
• Although breathing fast, they had relatively minimal
apparent distress, despite dangerously low oxygen levels
and terrible pneumonia on chest X-rays.
 Still expel carbon dioxide
• We are only just beginning to understand why this is so.
• The coronavirus attacks lung cells that make surfactant.
• This substance helps the air sacs in the lungs stay open between
breaths and is critical to normal lung function.
• As the inflammation from Covid pneumonia starts, it causes the air
sacs to collapse, and oxygen levels fall.
• Yet the lungs initially remain “compliant,” not yet stiff or heavy with
fluid.
• This means patients can still expel carbon dioxide — and without a
buildup of carbon dioxide, patients do not feel short of breath.
 Patient’s physiological response

• Patients compensate for the low oxygen in their blood by breathing

faster and deeper — and this happens without their realizing it.
• This silent hypoxia, and the patient’s physiological response to it,
causes even more inflammation and more air sacs to collapse, and
the pneumonia worsens until oxygen levels plummet.
• In effect, patients are injuring their own lungs by breathing harder
and harder. Twenty percent of Covid pneumonia patients then go on
to a second and deadlier phase of lung injury. Fluid builds up and the
lungs become stiff, carbon dioxide rises, and patients develop acute
respiratory failure
Dr. Richard M. Levitan
• Dr. Richard M. Levitan is an emergency
medicine physician in Franklin, New
Hampshire and is affiliated with
multiple hospitals in the area. He has
been in practice for more than 20
years.
• Emergency medicine specialists
diagnose and treat patients with
life-threatening conditions like heart
attack, drug overdose, shock, or
massive bleeding.
• Littleton Regional Hospital, White River
Junction Veterans Affairs Medical
Center
 Littleton Regional Healthcare
• While he practices at Littleton Regional Healthcare in New
Hampshire, Levitan recently spent almost two weeks volunteering in
the emergency room of a New York City hospital near the epicenter of
the city's devastating outbreak.
• There he watched patients come into the emergency room with blood
oxygen levels as low as 50%, so low they should have been
incoherent, even unconscious.
• Normal blood oxygen saturation is between 95% and 100%, and
anything below 90% is considered abnormal.
• In addition, Levitan said, scans of these patients' lungs showed signs
of pneumonia so severe they should be in terrible pain as they gasp
for their next breath.
 KESIMPULAN
• Mekanisme terjadinya hypoxia pada pasien Covid 19
merupakan fenomena fisiologik, seperti ketika kita mendaki
gunung.
• Secara bertahap tubuh menyesuaikan diri dengan keadaan
kekurangan oksigen (kadarnya dan tekanannya).
• Mestinya pengujian kadar okigen dalam darah ini dapat
dipakai untuk menentukan tahapan penyakit Covid 19.
• Gejala sesak napas baru terjadi ketika sudah mencapai
tahapan kritis, di mana tubuh sudah tak bisa menyesuaikan
diri lagi.