The next two weeks are going to be very difficult, and the risk of ventilator shortages due to COVID-19 is high. Manufacturing will ultimately help, but it takes time.
I’m already aware of one hospital in New York that can no longer provision one “vent” per patient, and demand is likely to grow dramatically over the next 7–10 days as cases spike. Even with full lockdown and total compliance, one could expect admittance to grow for 10–12 days minimum, based on the data we have from other countries.
In emergency circumstances, the below modification can be completed in less than 10 minutes and enables one ventilator to intubate as many as four people (instead of one). I first learned of it from Victor Cheng earlier this week, and Dr. Charlene Babcock demonstrates it below:
This has been performed successfully in animals, such as on four human-sized (70kg) sheep (Increasing Ventilator Surge Capacity in Disasters: Ventilation of Four Adult-Human-Sized Sheep on a Single Ventilator With a Modified Circuit), and Dr. Charlene Babcock from the above video has also completed proof of concept studies with colleagues. The following text is from Victor Cheng’s blog post:
In 2006, Dr. Greg Neyman and Dr. Charlene Babcock, Emergency Medicine physicians in Detroit, Michigan, did a study on exactly this. They wondered if, during a disaster-related surge of patients, a ventilator could be reconfigured to support multiple patients. Would it work? Short answer: Yes. They used standard equipment found in an emergency room to create a two-way and four-way splitter. They then used the ventilator to ventilate four simulated-lung devices for 12 hours. These devices had several sensors to track the output of the ventilator for each “lung.” The data collected showed that the pilot project was successful.
ANOTHER POSSIBLE OPTION:
A separate friend in healthcare (Thanks, Franz!) linked me to the Philips Respironics bi-level ventilator BiPAP A40 and noted the following, which I’ve slightly edited for format:
[Hospitals] should consider using small CPAP devices with modes designed to deliver timed breaths. They look like small NIV or CPAP devices and are commonly used with a mask interface. But it may not be common knowledge that these devices are also approved for invasive ventilation and that they have pressure control modes with timed breaths.
In the above option, I realize that monitoring would be sub-optimal and that there are other complications to consider, but some oxygen may be better than no oxygen.
I am publishing this post with the full understanding that:
- Some hospitals are already considering these types of contingencies and preparing for worst-case scenarios. That said, many are not, hence this post.
- These solutions aren’t optimal, but they are likely better than choosing who lives and who dies, as we’ve seen happen in Italy. In the case of Dr. Babcock’s demonstrated modification, if doctors can match up size and lung compliance, and provided patients can all be on the same settings and you’re willing to accept cross-contamination on a single machine, this could very well save lives.
If you agree, thank you for sharing this piece.
And if you’re looking for some inspirational reading, I highly suggest “Not All Heroes Wear Capes: How One Las Vegas ED Saved Hundreds of Lives After the Worst Mass Shooting in U.S. History.”
Comment Rules: Remember what Fonzie was like? Cool. That's how we're gonna be — cool. Critical is fine, but if you're rude, we'll delete your stuff. Please do not put your URL in the comment text and please use your PERSONAL name or initials and not your business name, as the latter comes off like spam. Have fun and thanks for adding to the conversation! (Thanks to Brian Oberkirch for the inspiration.)
Sorry 50% survival rate was achieved with ventilators 30% was achieved understanding a background pressure needed to be kept for alveolus from collapsing, thus keeping co2 levels up (and patients trying to remove face mask) so let’s sedating them ( now extremely qualified nurses are required) was required 6% was achieved turning them around ( face down face up etc) all around the day. Quest: find enough skilled professionals
Thank God the government told us to that and has regulations to prevent us for doing so.
Fascinating options. Two comments: 1. Ventilator circuits need to be closed with this virus to prevent spread to healthcare workers. Not sure how the configuration would work with that. 2. Non invasive ventilation appears to be useless in people needing respiratory support and they need full intubation to manage their respiratory failure. Interesting ideas.
Very cool
You are welcome Tim! Also, we offer free mechanical ventilation online training to every hospital that’s taking care of COVID-19 patients. We have already trained thousands of clinicians and have activated accounts for hundreds of hospitals worldwide: https://www.medmastery.com/magazine/frontliners-fighting-against-covid-19
Hey Tim, This is great, I will make sure to share as much as possible. One thing I was thinking is if the problem of "match[ing] up size and lung compliance" could be solved using inexpensive PVC Ball Valves or something of the sort found in emergency rooms to limit the flow of air going into the tubing. Another option is that by extending the length of the tubing the airflow volume might be less given that it would be traveling a longer distance hence adapting to the size and lung compliance? I know this can't be known for sure without testing but this testing could be done using their same methodology to check the volume reaching each lung. If this works reliably it could save even more lives. I might try and get in contact with a friend in Health Care to try this test this idea to get a reliable amount of oxygen that could be measured to match the need of patients. Keep doing the awesome work. 🙂
Tim, one of my local doctors in Perth, Ontario has used this method to increase our low equipment capacity. He's received media attention for it if you Google Doctor Alain Gauthier!
Here is the thing I want to know more about. Covid19 patients are given ventilator support when they are in the advanced stages and at risk of developing pneumonia. But there are number of studies that show that ventilators (despite how well they are maintained) contain bacteria that increase the chances of contracting pneumonia. If more than one Covid19 patient is administered ventilation from the same machine, do they not run the risk of increasing the chances of contracting pneumonia even more?
Thanks for the info. I have been a respiratory therapist for almost thirty years and will likely be at the tip of the spear in the DC suburbs working in two hospitals part and full time. I only would add that the ventilation of multiple patients would be most effective under two conditions: If the patients are in advanced illness, and are given paralytics plus sedation to limit excess flow demand OR If patients are spontaneously breathing requiring only Continuous Positive Airway Pressure (CPAP). Just this morning I thought of a way to uilize common supplies to provide high FiO2 CPAP via mask without using any ventilators or CPAP/BiPAP devices. Also this device would filter exhaled gas to limit staff exposure. If utilized when oxygenation requires ANY O2, this system could prevent the collapse of surfactant deficient COX 2 cells in lungs, and maybe, just maybe, stop the viral spread with the lungs and halt the ARDS associated inflammatory cascade. This contradicts CDC recommendations to minimize CPAP, but I think we need to “keep the horses in the barn” early on in the process. Please contact me if interested.
This has been forwarded to a nurse practitioner at Mass General. Thanks.
The Portable BIPAPA40 is something I was myself checking out just yesterday.I am an ENT surgron in India and the lack of ventilators everywhere worried me too.But the co use of ventilator may be controversial. What I also need is hacks /inexpensive ways of making isolation rooms negative pressure.Thanks for this.
I have speaking with Spanish anaesthetists who are currently struggling to treat an overwhelming amount of patients in Madrid. They do not think this will work with patients with COVID-19 as each patient requires protective ventilation that is tuned to their individual needs. This just would not be possible with many patients on the same ventilator.
If only 3.5% of us are likely to have any serious complications from COVID-19, why don’t we quarantine those at risk instead of the 96.5% who won’t be serious in jeopardy? Wrecking the economy is unnecessary. Just apply the 80/20 principal. If we cannot stop the virus from spreading…then let those who can keep the economy alive do so and this will more than save and pay for the treatment of those in need.
Additional method: Italy is using decathlon scuba masks and printing valves using 3d printers successfully to create ventilators. https://www.mirror.co.uk/news/world-news/coronavirus-incredible-hack-turning-scuba-21746459
I'm not a medical professional of any kind – but one thing I've not seen anyone mentioning: Are there OLDER MODEL ventilators around somewhere? (Storage basements? Medical equipment "waste"/ recycling locations?) In an emergency, it seems like any ventilator, even if it's not the latest and greatest model, is better than none. Is there sources to check for finding and bringing old models back into functionality?
Thanks for the video. I would just ask that the owner of the video open it for community contributions so that a transcription and translations can be made. Many thanks
I am an on-site IT Analyst at a hospital in Westchester New York. I am on the floors fixing the computers that run the hospital no one ever even notices we exist. I have an elderly parent that lives with me many of my of my coworkers have gotten sick i am scared to death to bring something home and hurt my father i hope people also notice IT help the hospital run in this age of technology.
http://echo4.bluehornet.com/ct/98698434:7DarpHlrN:m:1:3168055951:3B2CB461EB29A88E1BB40E5BB07E1D39:r As an anesthesiologist and crit care MD I have used and considered many options for increasing ventilators throughout the world in short order. This is one of the best thoughts out there due to its simple, cheap design, using products available in every hospital, and most hardware stores. It isn’t fancy, or super adjustable. But, it is better than just skipping putting Grandma on a vent because she is over 65.
This has been done already here in Italy at S. Orsola Hospital in Bologna and other in Lumbardy.
Use a multi-tap manifold out to multiple patients, have an inline air regulator to each patient to control volume & pressure, install a check valve for each tube to prevent back-flow and cross contamination.
Hi Tim! Posting a question to flow from the Coronavirus pandemic episode. I’m a palliative care expert and have a question to pose based on a theory :I believe that we organize much of our lives avoiding thoughts of death, perhaps ‘running away’ from death. I’d appreciate your thoughts on 2 aspects of this premise. 1. If this is true, what do you believe is the greatest fear humans have about death and dying? Do you fear death, why or why not? 2. How can we live our most abundant experience to minimize regret at the end of our lives? Thanks for your consideration! PS I don’t believe you’ve had a podcast on death and dying? I’d love to join you! 🙏🏻🤗
Hospitals Will Need Helmets for COVID-19 but they don’t know it. In the USA two teams collaborate to get information to clinicians, connect hospitals with resources, improve current helmet design and increase production to meet a growing need. [Moderator: link removed.]
Sharing this cool video of how to obtain an emergency respiratory mask for assisted ventilation using a common snorkeling mask >> https://youtu.be/w4Csqdxkrfw
Could ventilators made for veterinary use (with smaller air volumes) be adapted for emergency use in a similar manner? How small a ventilator unit is potentially useful?
My brother is a neurosurgeon working on a potential disinfection solution for the mask/PPE that may lead to a technique for ongoing disinfection of masks/PPE that is not feasible with current methods, all of which have significant downsides. The ask is for funding or other support. He is working with WHO and CDC and the University of Washington at present to ramp this up. He can send you more details about this. Anyone you know of who is interested in this please have them contact him. Thank you for shining a light on what the medical community is grappling with at this time in addition to the actual corona virus disease.
Bespoke ventilator design by Doctor: https://www.bbc.com/news/uk-wales-52008745 This seems like something many small companies ( and large) Co’s could make quickly. Tim, maybe you could verify sources, and then help to get design published for others to manufacturer. I could not find design. Found via Huit Denim’s and David Hieatt’s awesome newsletter and work.
Hi, I just stumbled over the Emergency Ventilator project by MIT: https://e-vent.mit.edu/ It explores a low cost, easy to manufacture device based on the already available manual ambu-bags as a short-term solution for emergencies and developing world. Maybe you know someone who can contribute to development and/or can build upon that open-source design. Best, Max
CO2 levels up! Wasn't that the cure in the Andromeda Strain?!?!?
Patients should all be intubated. Keeping the circuit closed is essential and is easily done with this model. I was involved with the sheep study referenced. We did blood gases every 30 minutes for 12 hours and were able to effectively ventilate and oxygenate all 4 sheep for 12 hours.
Short answer we simply don't know yet. It's not that the ventilators themselves contain bacteria. This is easily preventable with good practice. However, ventilator circuits are great places for bacteria to grow. There may be ways to prevent cross contamination but it's definitely possible that this could occur. If this strategy is used it's important that the patients are both similar. They all should be confirmed covid positive and be in similar stages of disease. Lung compliance of one patient will affect the tidal volumes of the others.
If we are looking at alveolar COX 2 getting hit Very early and patients are presenting with diffuse pneumonia, and a bit later these folks are going straight to intubation with some success, I wonder if a group of minimally affected patients would benefit most from CPAP: presentIng symptoms slight SOB, fever, normal SpO2, ground glad CXR/CT ->> 21% CPAP!! Positive pressure is able to splint remaining alveoli open, reducing sheering forces. If effective, work on doing this even earlier! Oxygen should be minimized to diminish oxidative stress during inflammatory “micro-cascades” and less O2 minimizes absorption atelectasis; hopefully ldads to less viral exudate and nearby cells don’t collapse. Also the CPAP can be done via flow meter (to corrugated tubing to CPAP-mask at t-bar to HEPA filter to PEEP valve )(simple set up) will close off patient’s exhaled gas from room. Crank up the Flow add O2 as necessary crank up the pressure with zero tech! More Corrugated tubing will balloon a bit to allow for inspiratory flow demand. Sorry to dive so deep. I don’t share my brain often.
I believe Sweden is doing something similar to this. Only those those who are elderly & have underlying health issues are self-isolating. As regular citizens get the virus & become ill, they self isolate until they are not sick anymore, or they go to the hospital if necessary. Of course, Sweden is a much smaller country, with socialized medicine. Sorry for using the "S" word.
That's a great idea !
it is indeed
Lockdown, what lockdown? Sweden's unusual response to coronavirus – BBC https://www.bbc.com/news/world-europe-52076293