Review: CPAP Machines Were Seen As Ventilator Alternatives COVID-19

The limited supply of ventilators is one of the chief concerns facing hospitals as they prepare for more COVID-19 cases. In Italy, where hospitals have been overwhelmed with patients in respiratory failure, doctors have had to make difficult life-or-death decisions about who gets a ventilator and who does not.
The mouthpiece of a CPAP (continuous positive airway pressure) device delivers enough pressurized air to keep the breathing passage of someone who has obstructive sleep apnea open throughout the night.

Within the U.S., emergency plans developed by states for a scarcity of ventilators embody utilizing optimistic airway strain machines — like these used to deal with sleep apnea — to assist hospitalized individuals with much less extreme respiratory points.

Whereas that measure might stretch the availability of ventilators and save lives, it has a serious disadvantage. Officers and scientists have recognized for years that when used with a face masks, such different units can probably enhance the unfold of infectious illness by aerosolizing the virus, whether or not used within the hospital or at house.

Certainly, that very state of affairs might have contributed to the unfold of COVID-19 inside a Washington state nursing house that grew to become floor zero in america. First responders referred to as to the Life Care Heart of Kirkland beginning Feb. 24 initially used optimistic airway strain machines, typically referred to as CPAPs, to deal with residents earlier than it was recognized the sufferers have been contaminated with COVID-19.

"It is best observe for us for folks with respiratory diseases," stated Jim Whitney, medical providers administrator for the Redmond Hearth Division, whose crews responded to the nursing residence's 911 calls. "We had no concept that we probably had COVID sufferers there."

It was solely later that King County public well being officers suggested Redmond Hearth and different first responders within the area to not use these machines for sufferers suspected of getting COVID-19 infections. Whitney stated responders have been utilizing the machines with specialised filters, which may cut back the quantity of virus launched. However county public well being authorities advocate first responders keep away from utilizing CPAP altogether. Redmond Hearth has now discontinued use of CPAPs for COVID sufferers.

"It is actually out of an abundance of warning for our folks and for the neighborhood that we put it on the again shelf, except we are able to verify it was the most effective use for our affected person," Whitney stated.

The misstep represents a basic instance of how the well being care system is enjoying catch-up in its effort to take care of the quickly escalating pandemic, and the way vital details about combating the novel coronavirus could be sluggish to achieve these on the entrance strains.

The American Society of Anesthesiologists issued steerage on Feb. 23 discouraging CPAP use in COVID-19 sufferers — recommendation largely knowledgeable by expertise with the SARS epidemic in 2003. Research relationship to 2003 recommend such units can pump viruses into the air, probably rising the unfold of a contagious illness.

In the course of the SARS outbreak in Toronto, half of all SARS instances, together with three deaths, occurred amongst well being care staff. A number of the best threat arose when docs and nurses have been uncovered to aerosolized virus by means of the usage of optimistic airway strain machines or different respiratory remedy units.

The experiences from the Life Care Middle of Kirkland now have docs rethinking their methods when confronted with ventilator shortages, and their recommendation to first responders about utilizing CPAP machines within the subject.

"Generally, we're simply telling them to not use it," stated Dr. Comilla Sasson, an affiliate medical professor of emergency medication on the College of Colorado College of Drugs. "As a result of we're involved about group unfold, and we have now to imagine that anyone with respiratory misery is a COVID affected person."

And docs even counsel those that use the gadgets at residence ought to take precautions to stop infecting others.

How CPAPs spread coronavirus

Ventilators are machines that push air out and in of the lungs via tubes inserted down sufferers' airways once they have hassle respiratory on their very own. The machines enable well being care suppliers to fine-tune the quantity of air equipped, the speed of respiratory, the quantity of oxygen and the stress as wanted.

Each hospital and residential variations of constructive airway stress machines are a lot easier gadgets that use excessive stress to push air into the airway, typically via a face masks. Steady constructive airway stress machines, often known as CPAPs, present a steady movement of air at a continuing stress. Extra superior bilevel variations, known as BiPAPs, which can be utilized at residence or in well being care services, push the air in, however then decrease the stress to permit the air to be exhaled.

"You possibly can really operate sure BiPAP machines to run like ventilators," mentioned Dr. James Finigan, a pulmonology and demanding care specialist at Nationwide Jewish Well being in Denver.

The important thing subject, Finigan mentioned, is how the gadget connects to the affected person. Ventilators require a respiratory tube and function as closed programs with a filter that traps any pathogens. Face masks typically used on CPAPs or BiPAPs enable air to flee, pumping the virus into the environment and doubtlessly infecting different sufferers, caregivers or anybody close by.

Constructive airway stress machines are sometimes step one in the usual algorithm for hospitals or emergency personnel when treating folks with sure respiratory issues. Finigan mentioned in sufferers with normal respiratory failure, medical doctors would possibly first see if sufferers can get by on high-flow nasal oxygen or on BiPAP machines to keep away from intubation and sedation.

"In case your hope is that possibly this may be a temporizing measure that may maintain them from hours to a few days, you will attempt to use the masks," Finigan mentioned. "There are some conditions the place anyone is respiratory OK, however is simply having hassle getting sufficient oxygen. Theoretically, a CPAP may be sufficient to get them sufficient oxygen. However, once more, doing it with a masks is extra prone to generate an aerosol and create an infectious drawback."

Dr. Jeff Sippel, a vital care specialist at UCHealth, primarily based in Aurora, Colo., mentioned BiPAPs may very well be used for COVID-19 in a closed system with out a masks, if sufferers are first fitted with a respiratory tube.

"The {hardware} really suits," he mentioned.

The jury-rigged gadgets may then be used for much less extreme COVID-19 sufferers, in addition to for different sufferers who may not be first in line for a ventilator. Extra extreme circumstances would nonetheless require full mechanical respiratory like that offered by a ventilator, and it is unlikely that BiPAP may absolutely make up for the undersupply of ventilators in a full-blown outbreak.

Some medical doctors have advised that governors ought to put out a name for folks with spare BiPAP machines of their houses to donate them to hospitals. However Sippel mentioned hospitals produce other steps they'd take first.

Medical doctors are investigating whether or not they can join a number of sufferers' respiration tubes to a single ventilator. At UCHealth, for instance, the hospitals have near 700 ventilators, Sippel stated, and will probably use roughly a fifth to ventilate two folks on the similar time.

This week, the Meals and Drug Administration supplied steering that enables hospitals to switch respiratory units, together with ventilators, CPAPs and BiPAPs, in the course of the public well being emergency, so long as they take steps to stop aerosolization of the virus.

What about CPAPs for home use?

Dr. Christopher Winter, a sleep medicine specialist in Charlottesville, Va., said people who rely on CPAP machines at home for sleep apnea can continue to use them as long as they have no symptoms of COVID-19. But they should speak to their physicians if they develop upper respiratory symptoms, to help determine if they should continue.

Winter is working on a guide with — and for — other clinicians to help them decide when patients infected with COVID-19 should keep using their CPAP machines.

"When does the steadiness of capturing all of it by means of your own home outweigh the negatives to the person by not utilizing it?" Winter requested.

Anyone who makes use of a CPAP machine at dwelling, he stated, could need to sleep in a separate room from family members to keep away from infecting them. That is true even when the individual with apnea does not have any COVID-19 signs. And if sufferers are suggested by their medical doctors to cease utilizing their machines, Winter says, they need to additionally keep away from driving, as a result of they might be sleep-deprived.

In most elements of the U.S., the necessity for further respiration units in well being care amenities isn't but important. However hospitals are bracing for a surge in sufferers who will want respiratory assist.

"That is getting actual now," stated Dr. Matthew Wynia, an internist and bioethicist who has been engaged on UCHealth's COVID-19 plans. "We're about to be slammed."

Kaiser Well being Information is a nonprofit, editorially unbiased program of the Kaiser Household Basis. KHN isn't affiliated with Kaiser Permanente.


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