A Lungful of Life

IT TOOK SOME time for the medical profession to get to it but, when it did, the technique proved the easiest and cheapest to alleviate Covid symptoms—breathing could be improved by just turning the patient over to make him lie on his stomach. In a study published in JAMA Internal Medicine journal in June, 29 patients with severe respiratory distress were asked to lie as long as they could in the prone position. They measured the oxyhaemoglobin saturation (Spo2), which indicated the level of oxygenation in the blood, before and after. All patients had Spo2 less than 93 per cent when admitted. For the first hour, nothing happened. But after that, oxygenation improved markedly for a majority of them. And fewer of those whose oxygen increased in this manner had to be put on ventilators. More survived. The paper said: ‘Mean difference in the intubation rate among patients with Spo2 of 95% or greater vs Spo2 less than 95% 1 hour after initiation of the prone position was 46%.’

Indian doctors were also doing it by then. An article by New Indian Express listed a number of hospitals using this technique. AIIMS Jodhpur, it said, was doing a study on it and also quoted Tamil Nadu Health Secretary J Radhakrishnan saying that government hospitals in Chennai had been following this. People infected by Covid had also begun proning at home. An engineer, who saw his entire family of eight struck by the virus, got through the ordeal by taking an analytical approach that included the technique. After they all got cured, he recounted the experience in a note to his friends on social media which said this: ‘We followed the below treatment plan: Sleeping on stomach for 4 hrs/day. This is one of the most significant steps, needed to improve O2 levels. Whenever it goes < 90%, lying down for 30-min increases it almost by 10 points.’

Proning was not a discovery for Covid. Even earlier, it had been found to help patients with severe respiratory disorders. Its efficacy, even if yet to be confirmed in rigorous trials, points to a fundamental aspect about the novel coronavirus. Because it overwhelmingly targets the lungs, until a vaccine can kill the virus itself, a semblance of victory for humanity will depend on keeping the supply of what the lungs is designed to process and distribute—oxygen. As one of the country’s leading pulmonologist, Zarir Udwadia, in a co-written article in The Indian Express this month, while taking stock of the learnings so far when it came to Covid treatment, wrote: ‘Those with moderate symptoms will benefit from oxygen therapy, and “pronation,” which in plain English means lying on your belly, instead of your back. Doing so opens up the air chambers in the back of your lungs that are normally collapsed, thereby providing more oxygen to your blood. Early evidence shows that this helps avert the need for more aggressive intervention in some cases.’

There is a lot of oxygen on earth and in man. The atmosphere is made up of 21 per cent of the gas. A little under 50 per cent of the earth’s crust is oxygen. Water is made up of a molecule that has two parts hydrogen and one part oxygen. Oceans, seas, rivers, lakes of the earth are thus one-third oxygen by volume but, by mass, because oxygen is so much heavier than hydrogen, it is between 80 to 90 per cent. The human body is made mostly of four elements and, by mass, oxygen is 65 per cent of us. For an element that was not a major player initially in the gameplan of the universe, it did an impressive turnaround in one small planet to become the centre of life. Born from stars and passed on to the rest of the universe, we are the only known planet with such quantities of oxygen. What makes it more extraordinary is that when the earth began, oxygen was almost non-existent. It is the most successful entrepreneur among the elements of nature on earth.

When oxygen began to first flourish on earth, it arrived as a destroyer. The earth was formed roughly 4.5 billion years ago. Life had taken its first faltering steps around half-a-billion years later with single-celled microorganisms and bacterial forms. When oxygen entered the picture, it wiped out a large part of them. It is known as the Great Oxidation event. The irony is that the thing that got oxygen’s rise on earth was also a bacteria, a type called cyanobacteria that we can even now see in blue-green algae. Cyanobacteria evolved—the hows and whys are still debated—into a form that spewed oxygen as a waste product, a process very familiar to all schoolchildren now as photosynthesis. Every plant in the world does it; gathering energy from the sun while taking in carbon dioxide and giving out oxygen. But when the cyanobacteria started doing it those billions of years ago, it was the first time such a thing had ever happened and it slowly upped the levels of oxygen in the air. Human beings on earth are a product of just waste matter.

In A Short History of Nearly Everything, Bill Bryson writes:

‘At some point in the first billion years of life, cyanobacteria, or blue-green algae, learned to tap into a freely available resource—the hydrogen that exists in spectacular abundance in water. They absorbed water molecules, supped on the hydrogen, and released the oxygen as waste, and in so doing invented photosynthesis. As Margulis and Sagan note, photosynthesis is “undoubtedly the most important single metabolic innovation in the history of life on the planet”—and it was invented not by plants but by bacteria. As cyanobacteria proliferated the world began to fill with O2 to the consternation of those organisms that found it poisonous—which in those days was all of them. In an anaerobic (or a non-oxygen-using) world, oxygen is extremely poisonous. Our white cells actually use oxygen to kill invading bacteria. That oxygen is fundamentally toxic often comes as a surprise to those of us who find it so convivial to our well-being, but that is only because we have evolved to exploit it. To other things, it is a terror. It is what turns butter rancid and makes iron rust. Even we can tolerate it only up to a point. The oxygen level in our cells is only about a tenth the level found in the atmosphere. The new oxygen-using organisms had two advantages. Oxygen was a more efficient way to produce energy, and it vanquished competitor organisms. Some retreated into the oozy, anaerobic world of bogs and lake bottoms. Others did likewise but then later (much later) migrated to the digestive tracts of beings like you and me. Quite a number of these primeval entities are alive inside your body right now, helping to digest your food, but abhorring even the tiniest hint of O2. Untold numbers of others failed to adapt and died.’

Oxygen still remained too low in the atmosphere even after the Great Oxidation event for complex life to get moving. For about a billion years, called the Boring Billion, between 1,800 to 800 million years ago, the earth was in an uneventful state but then at the end of it, the equilibrium ended and as oxygen rose to present levels, complex cells became common and eventually evolved to animals and man.

Oxygen has multiple roles in the spectrum of earth. Add an atom and you have ozone, a form of oxygen in the stratosphere that protects life from the sun’s ultraviolet rays. Inside the human body, lungs take in air, separate oxygen from it and through the blood feed it to cells for energy. Meanwhile, carbon dioxide is exchanged as waste to release it out of the body, reverse of the process by which cyanobacteria first created oxygen on earth. What was a waste byproduct is the food of life for those at the latest ends of evolution.

In the US-based UCSB Science Line, where scientists answer questions by students and teachers, there is one in their archive about what would happen if a virus and bacteria were both introduced into an environment of pure oxygen. The answer was that both would die but for different reasons. The bacteria would die because ‘pure oxygen would poison any organism that depends on chemical reactions for life’. The virus would die because the bacteria dies. By itself, the answer said, the virus is the only organism that pure oxygen would not kill because it doesn’t ‘have all the chemical processes [metabolism] going on inside them that every other living organism does.’ Viruses, according to one body of scientific thought, are not even alive until they infect the cell of a host. Without a bacteria the virus has no chance at life but from the killing power of oxygen itself, it is immune. With Covid, the relationship takes a different turn. The virus attacks and thickens the linings in the lungs. The body tries to fight it and inflammation often worsens the condition. Damaged air sacs can become damp with pneumonia. In all such cases, the end result is tied to the disruption of the channel that gets oxygen to blood and from there to the rest of the body. The virus is not concerned about oxygen at all in its bid for life but, as its aftereffect, the body is shorn of it.

This connection also has a commercial fallout in the spike in demand for oxygen products and the sudden efflorescence of the industry around it in recent months. In the beginning of the pandemic, ventilators were thought to be key to keeping severely affected people alive, but there was soon growing recognition that by the time the stage for intubation is reached, chances of survival are dim. The focus has shifted to early provision of oxygen cylinders and concentrators that make the gas from air continuously. Late last month, the World Health Organization warned of a shortage of concentrators. Reuters reported: ‘The health agency has purchased 14,000 oxygen concentrators from manufacturers and plans to send them to 120 countries in coming weeks, Tedros [Adhanom Ghebreyesus, WHO director general] said. A further 170,000 concentrators— valued at some $100 million—will be potentially available over the next six months.’ It quoted Tedros saying at a news conference, ‘Many countries are now experiencing difficulties obtaining oxygen concentrators. Demand is currently outstripping supply.’

Ordinary folks are also hoarding oxygen. A Hindustan Times article reporting on this said: ‘…many families are stocking up portable oxygen bottles as a precautionary measure. According to the All Food and Drug Licence Holder Foundation [AFDLHF], the demand for oxygen cylinders and bottles in the past one month alone has gone up by 70%.’ Online shopping sites are offering a wide variety of oxygen products from portable canisters to concentrators. One small instrument that has seen a huge upsurge in demand is the oximeter, which measures Spo2 or oxygen levels in the blood. In his Indian Express article, Dr Zarir Udwadia has suggested that the Government could as a policy start distributing oximeters free to communities, so that Covid patients could remain at home and keep track of whether they need hospitalisation. Many are already buying these oximeters from a flurry of new vendors who have sprung up online. I, too, purchased one at a little under Rs 5,000, the price marked on the packet. While going through YouTube to understand its workings, I found one reviewer of pre-Covid times saying that he had bought it at Rs 1,500. The marked price even then had been the same but because of no demand, they were being sold at huge discounts. It was a little difficult to swallow that I had paid thrice what used to be the going rate but that was only till I remembered there is now a novel coronavirus occupying space along with oxygen in the air.

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