Ventilator is running out of supply under COVID-19, especially severely ill patients require non-invasive or even invasive ventilator support.
When there is outbreak of COVID-19 locally, physicians are facing the difficulties to choose between different patients for the allocation of limited medical resources.
Is there any simple way to turn something on hand to a usable ventilation machine? No matter household electronic gadgets, e.g. fan, vacuum cleaner, or existing medical equipment.
The whole world is currently trying to solve the conundrum you raise. However, the issue of how many ventilators may be needed during the Covid-19 pandemic is more complicated than just simply considering the number of machines available.
It is possible to treat several patients with a single ICU ventilator. The Society of Critical Care Medicine guidance on this is below.
https://www.gnyha.org/news/working-protocol-for-supporting-two-patients-with-a-single-ventilator/
However all the patients would have to be deeply sedated to prevent triggering. Patients with similar needs for oxygenation and ventilation would have to be cohorted.
Anaesthesia Machines can also be used as ICU Ventilators. The Society of Critical Care Medicine guidance on this is below.
https://www.asahq.org/in-the-spotlight/coronavirus-covid-19-information/purposing-anesthesia-machines-for-ventilators
As most elective surgery has been cancelled many anaesthesia machines are lying idle and available for use.
Another option would be to use portable ventilators that are normally used to transfer patients around the hospital. These are generally more similar to ICU ventilators than the ventilators used in the anaesthesia machines.
The availability of portable ventilators is also limited. Portable ventilators are usually reserved for intra- and inter-facility transfer of patients.
Once all of these options have been exhausted the last resort would be to train patient's relatives to manually ventilate (‘bag’) patients. This is not uncommon in the developing world where ventilators are a scarce commodity at the best of times.
Whilst the use of medical students to ventilate patients during the Polio epidemic in Copenhagen in 1952 resulted in the birth of modern intensive care units I sincerely hope that we do have to face that scenario again.
The next question is then which of these options should be used first.
If patients require invasive mechanical ventilation and only the portable ventilators are available I would have no choice but to use them. Before using portable ventilators or using ICU ventilators to ventilate several patients I would use the anaesthetic machine ventilators in operating theatres. This would also allow the use of anaesthetic vapours for sedation of these patients. This may be critical when supplies of propofol and opiates are limited. Anaesthetic machines are generally kept within operating theatres so the use of these theatres also facilitates infection control.
After the anaesthetic machine ventilators were all used I would then start cohort ventilating up to 4 patients with similar degrees of lung injury per ventilator.
In conclusion: in principle I would prefer to use the operating theatre ventilators before cohort ventilating patients with ICU ventilators or using the portable ventilators. This is so that I can still perform inter- and intra-hospital transfers of ventilated patients.
However this decision making is complex and will vary with the resources available at individual centres. Modern intensive care ventilators are much more sophisticated than those used in operating theatres. ICU ventilators have many more modes of ventilation than operating theatre ventilators.
Some portable transfer ventilators are much more sophisticated than those used in operating theatres (e.g. Hamilton T1) and have the full functionality of intensive care ventilators. Some portable ventilators are less sophisticated (e.g. Oxylog 2000) than even the operating theatre ventilators.
Anaesthetic ventilators can function continuously and even allow the use of anaesthetic vapours for sedation. This may be relevant if supplies of propofol and fentanyl etc are depleted.
So whether it is safer to use the portable ventilator or the operating theatre ventilator depends on which of each type of ventilators you have. Regardless, in my experience, the humidification of gases using a HME (as is standard in the operating theatre and with portable ventilators) is not as effective as the wet circuit commonly used with ICU ventilators. So the risk of mucus plugging is higher.
Article Checklist Proformas to Guide and Document the Assessment of ...
The anaesthetic and portable ventilators are not as effective as intensive therapy unit (ITU) ventilators. Rather than using the same settings as we would with ITU ventilators, I therefore recommend that we adjust the settings on these ventilators according to frequent measurements of oxygen saturation, end tidal carbon dioxide, arterial blood gases, lactate and haemodynamic parameters. This is labour intensive and will require the assistance of staff who regularly care for ventilated patients but do not routinely work in ITU (i.e. anaesthetists).
So, as the COVID 19 pandemic progresses we will need to upskill colleagues to facilitate the assessment and treatment of critically ill patients with and without COVID 19. This may be achieved by face-to-face education sessions. However this is very labour intensive and may result in spread of COVID 19 amongst healthcare professionals.
Article Checklist Proformas to Guide and Document the Assessment of ...
Article Checklist Proformas to Guide and Document the Assessment of ...The use of checklist proformas can facilitate the management of critically ill patients by staff who do not routinely work in intensive therapy units. This could improve outcomes in this high risk cohort of patients and improve the confidence of staff redeployed to ITU from other care areas.
Thanks Rajkumar for raising the pearls of the situation!
It is definitely a good summary of what we can do these days
As a member of the production team (Business Plan Writer), I say the world needs more ventilation - but increasing production is more complicated than it seems.
we can use more than one tube from one ventilator I mean the main tube then supply more than one tube 4 or more division so we can use for more than one patient
Will this extension increase the dead space of the breathing system, and weaken the ventilation?
What is the infection risk with this arrangement?
it may affect the dead space
you should use filter and then connect the tube to connector which have for e.g. 4 opening and the put the tube
There are many risks when ventilating more that one patient on a single ventilator. Patients must be sedated and not spontaneously breathing. Their lung mechanics have to be very similar. There are high risks of cross infection. This type of ventilation strategy should only be used as a stop gap measure and has only been used in cases of multiple trauma for a short period until a ventilator is available..
One ventilator for two patients: feasibility and considerations of a last resort solution in case of equipment shortage.
BMJ. 2020 Apr.
Article One ventilator for two patients: feasibility and considerati...
Asian Critical Care Clinical Trials Group.
Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations.
Lancet Respir Med. 2020 Apr 6.
https://doi.org/10.1016/S2213-2600(20)30161-2
https://www.cityu.edu.hk/media/press-release/2020/05/03/new-ventilation-system-helps-protect-healthcare-workers-covid-19-infection
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