Does President Trump Have COVID Pneumonia? How severe is his illness?

How severe is President Trump’s COVID illness?
Does he have COVID Pneumonia?
As a pulmonary & critical care doctor, I’m watching President Trump's medical team, including Dr. Sean Conley, give a press conference. His medical team includes 3 pulmonary & critical care doctors, 2 infectious disease doctors, & more. Unfortunately, Dr. Conley is choosing to withhold certain medical details.

So in this video, I will take what he is saying, with what information is being given, & do my best to read between the lines so that people can have a real understanding of what is going on here with President Trump.
We want to know, does he have COVID pneumonia?
And I will also try to classify the severity of his COVID illness. Then, at the end of this video, I will discuss what this means for President Trump’s health moving forward.

What constitutes mild illness, vs. moderate illness, vs. severe illness, vs. critical illness is still very much a grey area. Generally speaking, someone who has symptoms but is not short of breath, & does not have low oxygen levels, is mild COVID. Moderate illness is characterized by shortness of breath and/or lower oxygen levels. Evidence of viral pneumonia is seen on chest x-ray or CT scan of the lungs or even ultrasound of the lungs. Severe illness is characterized by someone who is having trouble breathing & consistently requires extra oxygen & or ventilatory support.

Then there is a critical illness when patients have either ARDS or hypotension & require either high-flow oxygen or mechanical ventilation. Defining the severity of illness is hard to do. And this also makes it tricky in terms of what medicine to give. For example, these studies show dexamethasone, a steroid type, reduces mortality in moderate and severe diseases but not mild diseases. But, what defines mild vs. moderate vs. severe disease? The rationale behind giving dexamethasone is that it can suppress inflammation within the body, so the hope is that it will suppress the inflammation within the lungs.

For COVID, we give dexamethasone in either IV or pill form, and it's 6 mg once a day, and we give it for a total duration of 10 days. One of the side effects of steroids is that patient’s blood sugar levels become higher, so hyperglycemia. And that is why we usually have to counteract that by giving patients insulin. And when you give insulin, sometimes the patient’s blood sugar, meaning blood glucose, drops too low, known as hypoglycemia. So when we give dexamethasone, we check blood sugar levels by fingerstick every 4 or 6 hours. At the press conference, they mentioned nothing about this. But if his blood sugars are out of whack, they would not be talking about discharge planning.

But stepping back and looking at this from a bird’s eye view, where does Trump lie on this spectrum of COVID illness. Right now, he is not requiring supplemental oxygen. What would the progression of his illness look like if he were to have clinical deterioration? Well, typically, this entails stepping up his oxygen therapy, so 2 L NC, maybe 3, 4, or 5 L NC. If that is still not enough oxygen, maybe an oxygen face mask or something called a high-flow nasal cannula. These devices provide a lot more oxygen than a nasal cannula.

If these are still not enough, that’s when you start talking about mechanical ventilation. Either non-invasive mechanical ventilation, meaning a Bipap mask, or a bi-level mask. Or the patient might need invasive mechanical ventilation, meaning a breathing tube connected to a breathing machine. Often, these patients require vasopressor support, meaning IV medications are given when the blood pressure is too low. So that would be the sickest of the sick. It’s the patients who are on mechanical ventilation, a breathing tube requiring 100% oxygen. Sometimes though, even that is not enough, so some patients get ECMO, which is extreme. And sometimes, despite us doing all of these things, patients still die. That is just the reality of this disease.

Currently, President Trump has to saturate 98% on room air, which is good. And this is to be believed because you see him in that the video of him; he is not in respiratory distress, not requiring supplemental oxygen, he is not cyanotic. But the important thing to keep in mind is that patients with COVID can look like they are doing fine. They can have an improvement in their symptoms. They can improve their oxygenation. But, within hours, they clinically deteriorate to the point of requiring mechanical ventilation, especially when the illness's inflammatory phase becomes very prominent, meaning the cytokine storm that develops. Typically around 7-10 days.

Doctor Mike Hansen, MD
Internal Medicine | Pulmonary Disease | Critical Care Medicine
Doctor Hansen's Courses: https://doctormikehansen.com/courses/
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