From the Frontlines: Ventilators

I promised to write about ventilators. I have to say after 26 years in pulmonary medicine, it is almost nice for everyone to be paying attention to my specialty. For years, I would say I was a pulmonologist and people would be like, "oh, you're a heart doctor..." and I would say, "no, lungs... more complicated, less income." All in all, I wish it hadn't taken a pandemic for us to get some recognition. Speaking of lack of recognition – we need to recognize the critical care nurses who take care of sick patients 24 hours a day, 365 days a year. They are some of the most talented, dedicated, caring people I know. Another shout out to my respiratory therapy colleagues who are unrecognized, skilled practitioners on the front lines during this epidemic and every day as well. In critical care we are a team and I could not do my job at all without the brave people working alongside me.

Ventilators are devices that are designed to do the work of breathing for patients when illness, injury, neurological problems, or surgery make them unable to breathe on their own. There are two types of ventilators: non-invasive and invasive. 

• Non-invasive ventilators which can be used with a tight-fitting mask in patients who are not as severely ill. Their role in COVID-19 is limited because patients are severely ill and the non-invasive ventilators can lead to increased viral spread and risk of infection of healthcare workers. 
• Invasive ventilators require a tube to be put into the trachea (the windpipe). Patients usually requires some sedation and pain medications while they are on the machine. The ventilator works to deliver oxygen to the lung, to keep the lungs expanded, and assists in removing carbon dioxide from the body. The tube that is in the airway can also be used for suction to clear secretions and for delivery of medications directly to the lungs.

Modern intensive care unit (ICU) ventilators are complex machines with sensors to monitor airway pressures and the volume of air being delivered and exhaled. There are a variety of settings we can adjust to optimize their function. These settings vary based on the size of the patient and the nature and severity of their illness. In normal times less than half of our critically ill patients require ventilators and even during times of severe illness or disasters in the community we can rely on loaned equipment or sending patients to less affected areas to deal with a locally stressed system. We can also call upon local staff to increase their workload for short stretches or bring in medical teams from other areas. However, people can only work so many shifts and so many hours without risking their own health. The problem with a pandemic is that we can't shift the burden to another institution or obtain additional supplies that simply do not exist.

We are working to increase our ventilator resources. My own hospital has increased their supply of ventilators in the past few weeks, but even that supply is limited. There has been much discussion of novel ways to deal with the ventilator shortage. As with my discussion of medications in my previous blog post, this is not without risk and – in the case of mechanical ventilation – the risks may be more substantial. As I said, ventilators are complex machines. The staff with the expertise to monitor and adjust them appropriately is limited. Experimenting with new equipment or methods in a time where staff is stretched thin and under stress will increase risk. The ideal approach is to do all in our power to limit the spread of disease in our community, to obtain more widespread rapid testing to identify and quarantine patients, to protect healthcare workers so they remain healthy and don't spread the disease, and to avoid the need for more ventilators than we have.

Stay home. Stay healthy. Save lives.

Dr. Hill is a member of the Lung Association's National Board of Directors and is the immediate past chair of the Northeast Regional Board of the American Lung Association. He serves on the Leadership Board of the American Lung Association in Connecticut and is a former chair of that board. Read More.