Be afraid. Be very afraid.

This is the message the authorities keep sending and for good reason. South Africa is fully in the grip of the Covid-19 pandemic, with infections rising alarmingly every day and the death toll creeping up. And it isn’t going away anytime soon. Professor Shabir Madhi, the Wits vaccinology expert leading the first Covid-19 trial in Africa, recently told YOU that infections might come in many waves and could be around for another two to three years if a vaccine isn’t found.

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Scores are needing hospitalisation – and many have to be put on ventilators in a bid to save their lives. The machine is the last resort, required when patients struggle to breathe on their own. YOU asked medical experts to explain the ventilating process and the professionals have the same message: follow the precautions to avoid getting sick – you don’t want this.

A ventilator is a machine that breathes for you when you’re unable to do so yourself, says Dr Vidya Lalloo, emergency machine specialist at Steve Biko Academic Hospital in Pretoria. “It delivers breath to your lungs via a piping system called a ventilator circuit. This is attached to a tube called an endotracheal tube.

A ventilator is a machine that breathes for you when you’re unable to do so yourself, says Dr Vidya Lalloo, emergency machine specialist at Steve Biko Academic Hospital in Pretoria. “It delivers breath to your lungs via a piping system called a ventilator circuit. This is attached to a tube called an endotracheal tube.

This is the tube that must be inserted into your trachea (or windpipe) via your mouth,” she explains. Inserting the tube – otherwise known as intubating – requires special skills that doctors are trained to perform. It’s typically a 30- to 40-minute procedure performed by a team of three people – a doctor and two nurses to assist.

Before intubation, the team connect all the necessary monitors and administer oxygen via a mask to the patient to ensure oxygen levels are as high as possible, Lalloo explains. This ensures the patient remains as stable as possible during the process. The patient is then sedated and paralysed for the intubation procedure.

A special instrument called a laryngoscope, which has a handle and a flat blade with a light bulb at the end, is inserted via the patient’s mouth. “It displaces the tongue and allows visualisation of the vocal cords,” Lalloo says. “An endotracheal tube is then inserted between 21cm and 23cm deep into the patient’s trachea.”

The endotracheal tube comes in various sizes for infants, children and adults. In adults, a 7,5mm to 8mm tube in diameter is usually used for men and a 7mm to 7,5mm tube for women. “The endotracheal tube has a cuff, which is then inflated so it seals the airway,” Lalloo says. “This minimises leaking of air around the tube during mechanical ventilation. 

“The tube is then secured to the patient’s face using tape such as Elastoplast to prevent displacement. A tube – called a nasogastric or orogastric tube – is then placed into the stomach via the nose or mouth.” This tube is used to remove air and secretions from the stomach and is later used to feed the patient who won’t be able to eat once intubated.

Once a patient is attached to a ventilator, it takes over the function of breathing by forcing air into and out of the lungs. Heavy going Intubation is no walk in the park for a patient, which is why they need to be sedated and paralysed before the process takes place. Dr Bilal Abdool-Gafoor, a specialist physician and pulmonologist at Cape Town’s Melomed Gatesville Private Hospital, says the primary reason for this is to counteract the urge to gag or cough or try to breathe against the ventilator.

The point of ventilating a patient is to protect the lungs from further injury, he says. Fighting to breathe against a ventilator defeats the object of it. Patients are also sedated to give their bodies a break, Lalloo adds. “Remember that before intubation, the patient would’ve been struggling to breathe, their respiratory muscles would be working overtime and not coping.

We need sedatives to allow the body to relax and let the ventilator do its job. It can be uncomfortable for the patient if they try to breathe against the action of the ventilator,” she says.

The intubation process is a delicate one and things can go wrong, Lalloo and Abdool-Gafoor say, including:

Younger healthy people generally have “more forgiving” lungs and will usually recover faster, Abdool-Gafoor says. Their lungs also have more elasticity, which makes it easier for them to be ventilated.

Younger patients have more reserves and therefore bounce back more quickly, Lalloo adds. “They’re able to cope with the onslaught of the disease and the ventilator, and tend to recover much faster than older patients.

“Older patients often have comorbidities so their renal and cardiac function might be less resilient. Their lungs are ‘stiffer’ and have had more exposure to smoke, pollution, trauma and previous disease, causing scar tissue and fibrosis.”

Some Covid-19 patients reach a point in the disease where they become difficult to ventilate because their lungs develop an inflammatory response similar to pus in the lungs, Lalloo says. This means that no matter how much oxygen they get, it can’t get through the pus to reach the blood vessels where oxygen exchange takes place, and doctors have to increase the amount of pressure used to force the air in.

This can lead to pressure damage. Other long-term effects include confusion and dementia after long-term sedation, blood clots in the legs and lungs due to being immobile and stress ulcers in the stomach. “The lungs might suffer long-term damage, which is called fibrosis.

This might cause the person to struggle with shortness of breath after being discharged from hospital. Some people might need to be placed on home-oxygen treatment.”

Abdool-Gafoor says doctors try to mitigate the risk of complications, but sometimes they’re inevitable or unexpected.

“In medicine we perform procedures and prescribe medication with the intention that the benefit outweighs the risk of complications,” he says. “In ventilation it’s a matter of life versus death.”

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