In many hospitals ventilators have become a scarce or non-existent resource in the face of the COVID19 pandemic. We need a ethical structure to allocate ventilators and other scarce resources:
Exclusion Criteria before Entry into Ventilator Allocation Strategies
Reub's Adaptation of the NYC Vent Allocation Guideline
Original NYC Vent Allocation Guidelines
Publications
- NEJM Allocating Vent Discussion
- NEJM Fair Allocation of Scarce Medical Resources in the Time of Covid-19
- JAMA White & Lo
- Requests for Potentially Inappropriate Treatments in Intensive Care Units
Forming a Rationing Team
Additional New Information
More on EMCrit
EMCrit – Critical Care for Non-Intensivists during COVID19 Pandemic(Opens in a new browser tab)
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Instead of asking what happens when we run out of ventilators for patients that should be intubated, I think we should ask how we can keep these people alive with Mechanical ventilation.. It was done about 70 years ago during the 1952 Copenhagen polio outbreak. Hundreds of young people were dying from polio induced respiratory failure but with very limited technology,the mortality was decreased from 95% to 25%. There was no such thing as ICUs, ventilators or pulse ox but only one bedside nurse and one bagger per patient . We have much better equipment and understanding and we should… Read more »
Sorry above statement should have been how to keep people alive WITH OUT Mechanical ventilation.
Is it possible that things like this could fill in the gap between what we have and what is needed? https://carle.org/newsroom/staying-healthy/2020/03/carle-uofi-develop-emergency-ventilator-prototype
It sounds like it is relatively easy and cheap to make if engineers started working on assembling these in large quantities?
Rob
wasn’t polio a disease of resp muscle weakness where essentially any ventilations at all would completely solve the problem. Do you think that is a congruent situation to what we are dealing with now?
Yes. Polio was predominantly a respiratory muscle weakness but they also developed bulbar muscle weakness which probably made negative pressure ventilation less effective. Also, I am sure they eventually developed atelectasis but I strongly suspect that they did not have PEEP. So I think with the ability to use PEEP and higher oxygen delivery we should be able to bag pretty much anyone. I believe they used low oxygen concentration around 40%. Article: The physiological challenges of the 1952 Copenhagen poliomyelitis epidemic and a renaissance in clinical respiratory physiology. Website: nlm.nih.gov
These are excellent points. Why aren’t we hearing more about this option? Lay people would rise to the occasion for sure. Many lives could be saved.
Good evening from Namibia (Southern Africa). I can’t find the article again, been doing to much reading of late, but on the ventilator dilemma the write up talked about using the dual circuits to reduce or eliminate aerosol formation. Now most transport vents don’t have the dual circuit system and exhausts into the atmosphere with most only having a moisture filter to show when there is more in the system. All I can find and rationalise is the use of HEPA filter at the ETT connector, at the outlet then McGyver one into the exhaust. But I suspect that is… Read more »
hello, would you guys mind to talk a little about rational use of antibiotics in this scenario? is prescribing antibiotic for everyone really the answer line most of guidelines are suggesting? I understand the difficulty of differential diagnosis and high incidence of coinfection, but how you guys address this issue?
Amazing episode guys. Really appreciate it. Scott, what are your thoughts on deploying a disposable CPAP device, such as the Flow Safe II (I have no relationship with them) – in patients that say only require CPAP, are alert, can self prone etc? Does not require a machine or ventilator. Powered by wall gases. Can place in line viral filter and ETCO2. If we get into an extreme resource limited situation.? Similarly, is there any possible place for wall gas powered CPAP for selected intubated patient…, if we did end up without enough ventilators or had no means to transfer… Read more »
yes & yes
Hello, Thank you for talking about this difficult topic — our hospital in the process of developing these policies currently. One of the things I think might be neglected when discussing the ethics of this issue in your podcast is the bias associated with these choices. At one point in the discussion your guest mentioned the fact they we may choose to use a ventilator for a healthy 70 year old over a 60 year old with chronic medical problems. What this neglects is the fact that many chronic conditions disproportionately affect people of lower socioeconomic status, minority groups, and… Read more »
When Luciano Gattinoni starts talking about ” buying time” and “being patient”, you know you are really screwed – don’t you?
https://www.atsjournals.org/doi/10.1164/rccm.202003-0817LE
Hey guys, enjoy your work! I am a PulmCC doc and have my own blog, Caduceusblog.com. I applaud our profession for doing everything possible to keep people alive by allocating scarce resources as best we can. But I think one important thing to remember here is that this is not just a medical problem but a political one. There ARE enough ventilators to take care of our sick people right now — if we look at this from a national perspective and reallocate resources from areas which are not yet hit . We physicians need to advocate politically for our… Read more »
I am a layperson from London UK (M.Sc(Med) Cancer Sciences, B.Sc(Hons) Applied Biology, but I am trying to monitor and provide support should my family get COVID-19, and the Health Service (NHS in UK ) are overwhelmed. So we’ve put together a small number of N96 masks which we UV light lamp sterilize, have an O2 finger meter, BP cuff, IR thermometer and Obs chart for capturing readings should any begin to show symptoms. To support we’ve purchased, a nebulizer, O2 concentrator and CPAP, and sterilizer and have one bedroom set aside as a containment space. Personally I hope we… Read more »