Supporting more than one patient with a single mechanical ventilator: useful last resort or unjustifiable risk?

Laffey, John G.; Chikhani, Marc; Bates, Declan G.; Hardman, Jonathan G.

doi:10.1016/j.bja.2020.05.029

Cited by 17 publications

(17 citation statements)

References 8 publications

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“…Furthermore, this scheme is not intended as a permanent solution for ventilating multiple patients, and should be used only with hospital administration approval and acknowledgement of the unique ethical considerations during a crisis (such as the COVID-19 pandemic). 11,12 Although the COVID-19 pandemic inspired our designs, it may have utility in other mass casualty scenarios such as natural disasters, terrorist attacks, and battlefield medicine. Future versions should aim to extend to more than two patients per ventilator.…”

mentioning

confidence: 99%

Regulating inspiratory pressure to individualise tidal volumes in a simulated two-patient, one-ventilator system

Chen

Hellman

Irie

et al. 2020

British Journal of Anaesthesia

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mentioning

confidence: 99%

Regulating inspiratory pressure to individualise tidal volumes in a simulated two-patient, one-ventilator system

Chen

Hellman

Irie

et al. 2020

British Journal of Anaesthesia

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“…Testing outlined in this paper took place using the aforementioned sophisticated critical care ventilator, but the system has also been tested on a broad range of ventilators and can be utilised with any ventilatory source that is capable of Pressure Control Ventilation. As is common to many similar systems, the use of Volume Control Ventilation can result is unpredictable delivery of tidal volumes to each limb and therefore risks hyperinflation of areas of lung tissue [18] . This forms an obvious and important area for further research, as lung protective ventilation has been shown in both trials and reviews [19] to reduce mortality in ARDS.…”

Section: Discussionmentioning

confidence: 99%

“…There are many limitations to this approach, and it has even led some organisations to issue joint statements against its use [20] . Employing this solution demands a high level of sophisticated knowledge, staff training, and usually comes with significant restriction regarding the ability to alter respiratory parameters for each patient [18] . As such, the authors do not endorse or advocate ventilator sharing as a normal course of therapy.…”

Section: Discussionmentioning

confidence: 99%

Development and assessment of the performance of a shared ventilatory system that uses clinically available components to individualize tidal volumes

Hannon

Jones

Judge

et al. 2020

Preprint

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ObjectivesTo develop and assess the performance of a system for shared ventilation that uses clinically available components to individualize tidal volumes under a variety of clinically relevant conditions.DesignEvaluation and in vitro validation study.SettingVentilator shortage during the SARS-CoV-2 global pandemic.ParticipantsThe design and validation team consisted of intensive care physicians, bioengineers, computer programmers, and representatives from the medtech sector.MethodsUsing standard clinical components, a system of shared ventilation consisting of two ventilatory limbs was assembled and connected to a single ventilator. Individual monitors for each circuit were developed using widely available equipment and open source software. System performance was determined under 2 sets of conditions. First, the effect of altering ventilator settings (Inspiratory Pressure, Respiratory rate, I:E ratio) on the tidal volumes delivered to each lung circuit was determined. Second, the impact of altering the compliance and resistance in one simulated lung circuit on the tidal volumes delivered to that lung and the second lung circuit was determined. All measurements at each setting were repeated three times to determine the variability in the system.ResultsThe system permitted accurate and reproducible titration of tidal volumes to each ‘lung circuit’ over a wide range of ventilator settings and simulated lung conditions. Alteration of ventilator inspiratory pressures stepwise from 4-20cm H2O, of respiratory rates from 6-20 breaths/minute and I:E ratio from 1:1 to 1:4 resulted in near identical tidal volumes delivered under each set of conditions to each simulated ‘lung’. Stepwise alteration of compliance and resistance in one ‘test’ lung circuit resulted in reproducible alterations in tidal volume to the ‘test’ lung, with little change to tidal volumes in the ‘control’ lung (a change of only 6% is noted). All tidal volumes delivered were highly reproducible upon repetition.ConclusionsWe demonstrate the reliability of a simple shared ventilation system assembled using commonly available clinical components that allows individual titration of tidal volumes. This system may be useful as a temporary strategy of last resort where the numbers of patients requiring invasive mechanical ventilation exceeds supply of ventilators.Article SummaryStrengths and limitations of this studyThis solution provides the ability to safely and robustly ventilate two patients simultaneously while allowing differing tidal volumes in each limb.The designed solution uses equipment readily available in most hospitals.Accurate and reproducible titration of tidal volumes to each ‘lung’ was possible over a wide range of ventilator settings.Alteration of one simulated ‘lung’ conditions had minimal impact on the tidal volumes delivered to the unaffected lungThe system relies on patients being sedated and paralysed.We have not yet tested this solution in vivo, on COVID-19 patients.

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“…38 There was some support in the literature for what could be the very last resort for ventilator support: bifurcating or splitting an anesthesia machine between 2 patients. 39 , 40 As part of a system, as well as having the backup of New York State emergency supplies, neither of these last 2 options: anesthesia machines or bifurcation ever became a consideration.…”

Section: Planning For Surge: What Additional Equipment and Supplies Wmentioning

confidence: 99%

Planning for the Pandemic

Fiore-Lopez

2021

Nursing Administration Quarterly

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When the Covid 19 pandemic affected New York State, Federal and mostly State, mandates were given to hospitals to prepare for the expected influx of patients. This is a community hospital's planning journey that includes preparing for placing patients, educating caregivers, matching the abilities of the available caregivers with the needs of the patients, securing needed equipment and supplies, and caring for the caregivers. Planning for patient placement resulted in a phased-in guide, accommodating seriously and critically ill affected patients. Education and training were initial and ongoing, rapidly changing as new information became available. Effective care delivery models that focused on team were modified depending on the needs of patients and staff competence. Securing and maintaining equipment and supplies were challenging and caring for the caregivers was a priority. Working as a team, this community hospital developed a road map that was effective in planning for the surge and allowed the hospital to maintain a safe environment for staff and patients who received quality care in difficult time.

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Supporting more than one patient with a single mechanical ventilator: useful last resort or unjustifiable risk?

Cited by 17 publications

References 8 publications

Regulating inspiratory pressure to individualise tidal volumes in a simulated two-patient, one-ventilator system

Regulating inspiratory pressure to individualise tidal volumes in a simulated two-patient, one-ventilator system

Development and assessment of the performance of a shared ventilatory system that uses clinically available components to individualize tidal volumes

Planning for the Pandemic

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