Experts: HHS plan to optimize ventilators is ‘suboptimal’

The HHS assistant secretary for health and the U.S. surgeon general are asking health care providers to repurpose and share ventilators, cancel elective surgeries and transfer equipment and personnel to areas hardest hit by the COVID-19 pandemic.

However, David G. Hill, MD, clinical research director of Waterbury Pulmonary Associates in Connecticut, and others said the strategy does not solve the problem of ventilator shortages.

“Using non-ICU ventilators, whether anesthesia machines, transport ventilators or noninvasive ventilators for invasive ventilation will be able to gain us some ventilatory capacity, but such machines will be of limited use in the sickest patients,” Hill told Healio Primary Care.

“[Anesthesia] machines do not have the same monitoring capabilities or flexibility in modes of ventilation that the more sophisticated ICU ventilators have,” he said. “They are also not designed for prolonged use.”

 

Hill, who called the HHS plan “suboptimal,” noted that the use of anesthesia machines often require an anesthesiologist or an anesthetist to be present at the patient’s bedside because ICU nurses and respiratory therapists are not typically trained to use them.

HHS and the surgeon general also said that devices like the continuous positive airway pressure (CPAP), auto-CPAP and bilevel positive airway pressure (BPAP) machines — often used at home for the treatment of sleep apnea — can be used to support patients with respiratory insufficiency in the hospital setting.

Greg Martin

However, Greg Martin, MD, president-elect of the Society of Critical Care Medicine, told Healio Primary Care that these particular devices are “unapproved and less than ideal respiratory support devices,” which should only be used “if we are beyond the limits of conventional medical are and progressing towards crisis pandemic levels.”

To conserve valuable resources, health officials also encouraged providers to explore the option of co-ventilation, or the ventilation of two patients on a single machine for short-term use, when “all other alternatives are exhausted.”

However, there are significant limitations to co-venting.

“Splitting ventilators is a risky experimental procedure, particularly when expert staff may be overwhelmed,” Hill said.

According to Martin, who is also the executive associate division director of pulmonary, allergy, critical care and sleep medicine at Emory University School of Medicine, splitting ventilators presents operational challenges, such as finding two “sufficiently similar” patients to benefit from sharing the device.

“It will never happen that two patients with similar body habitus and lung size arrive to the hospital at the same time, both needing respiratory support and having similar extent of injuries to their lungs causing similar levels of impairment,” he said. “All these things together would make their lungs sufficiently similar to consider co-venting, but that scenario is less likely than an asteroid hitting earth before the end of the COVID-19 pandemic.”

The HHS and surgeon general guideline was released amid National Public Radio and other recent reports that members of the Trump administration said they felt that states should have been building their own ventilator stockpiles. At a press briefing on April 4, the president stated that some states were possibly overestimating their ventilator need. – by Janel Miller

Reference:

HHS. Optimizing Ventilator Use during the COVID-19 Pandemic. https://www.hhs.gov/sites/default/files/optimizing-ventilator-use-during-covid19-pandemic.pdf. Accessed April 9, 2020.

Disclosures: Hill reports previously serving as a spokesperson for the Pfizer smoking cessation product Chantix. Martin is president-elect of the Society for Critical Care Medicine.