Hospitals must replace ventilators with simpler options to tackle shortage amid pandemic, say experts
The new coronavirus has the world scrambling for ventilators. As countries try to build more, some critical care specialists believe hospitals are overusing them.
They argue that hospitals can use simpler options that do the same job. "I think we may indeed be able to support a subset of these patients" with less invasive breathing support, Dr Sohan Japa, an internal medicine physician at Boston's Brigham and Women’s Hospital, told STAT news. "I think we have to be more nuanced about who we intubate," he added.
Ventilators are machines that help patients breathe. The lungs of COVID-19 patients are clogged with fluid. This compromises the lungs, leaving patients gasping for breath. To support breathing, doctors insert a 10-inch plastic tube from the machine to push oxygen through the mouth and into the lungs. This makes ventilators invasive. Further, doctors give sedatives to patients placed on the machine.
Other simpler machines exist, which are neither invasive nor do they need patients to be on sedatives. For example, breathing masks used in sleep apnea — a sleeping disorder where people struggle to breathe at night — also work. These night-time masks fit over the nose or mouth. Called a continuous positive airway pressure (CPAP) machine, it gently pushes air into the mouth and throat, keeping the airways open.
Generally, doctors begin helping patients suffering from low oxygen levels with this non-invasive breathing support. Only when they fail, doctors turn to invasive ventilators.
But because some COVID-19 patients' blood oxygen levels fall dramatically, doctors have been bypassing non-invasive support. This decision is based on data from China. "Data from China suggested that early intubation would keep COVID-19 patients’ heart, liver and kidneys from failing due to hypoxia," a veteran emergency medicine physician told STAT news. "This has been the whole thing driving decisions about breathing support: knock them out and put them on a ventilator," they added.
But not everyone is following this. According to Greg Martin, a critical care physician at Emory University School of Medicine, most hospitals, including his, are starting simple. "It doesn’t require sedation and the patient (remains conscious and) can participate in his care. But if the oxygen saturation gets too low you can achieve more oxygen delivery with a mechanical ventilator," he told STAT news.
But there is one problem with non-invasive options. They release virus droplets from patients into the air, potentially worsening the spread of the coronavirus.
Do ventilators work?
Patients with severe COVID-19 cases have a lot of fluid filling up their lungs and ventilators might not help. The thick fluid "limits oxygen transfer from the lungs to the blood, even when a machine pumps in oxygen," Dr Muriel Gillick, a geriatric and palliative care physician at Harvard Medical School, told Stat News. In this case, placing a patient on a ventilator could damage their lungs by introducing too much pressure into the organ, she said.
According to a Chinese study, of the 37 critically ill COVID-19 patients who were placed on mechanical ventilators, 30 died within a month. In a US study, only one of the seven patients older than 70 who were put on a ventilator survived.
"Contrary to the impression that if extremely ill patients with COVID-19 are treated with ventilators they will live and if they are not, they will die, the reality is far different," Gillick said.