Ventilators and oxygen: how does the BIS manage these problems?

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Leading doctor from Bradford says there is a “sense of dread” that decisions made in Italy – where doctors have not been able to provide intensive care to all patients due to lack material or personnel – could potentially be reproduced here.

As the estimated peak of the coronavirus crisis approaches, the Bradford Royal Infirmary (BRI) faces two problems: ventilators and oxygen.

Professor John Wright, doctor and epidemiologist, heads the Bradford Institute for Health Research at BRI and has shared his frontline knowledge as the hospital faces the challenges of the virus.

In the latest episode of his BBC newspaper, he explains how it is feared that the fans ordered by the hospital will not arrive in time to reach the peak.

But, he says, there is “growing evidence” that a machine used by patients with sleep apnea in their own rooms can be used as an alternative.

Oxygen is the other priority.

Professor Wright says hospitals are not built to provide the oxygen flow needed to keep so many patients on respirators.

“We find that our” red zone “infectious rooms can only receive a maximum of 10 ventilated patients before the oxygen flow decreases, triggering an alarm,” he said.

“When we ordered additional equipment to treat the coronavirus cases, we expected the surge to occur in May, but Covid-19 turned out to be more transmissible than expected and the peak came much earlier. So the extra fans aren’t going to be here on time. “

He says that continuous positive pressure (CPAP) is the form of non-invasive ventilation that seems to work best for patients with the virus.

Some of the hospital’s CPAP machines use 50 liters of oxygen per minute for a single patient – this is usually not a problem, as oxygen is generally not in short supply.

It has become a problem in Italy, due to the number of patients requiring ventilation.

“One of the problems is that although the beds have oxygen next to them, we have never needed such a high oxygen flow rate in service,” says Dr. Tom Lawton , intensive care consultant.

“We have something like 250 liters per minute available for each department, and around 3,000 available for the hospital – which, again, has never been an issue before. But if you use 50 liters per minute for each patient, then it’s suddenly only five in a ward and 60 in a hospital – and we need more than that.

“It’s not just us, it’s hospitals across the country – they weren’t designed for this level of oxygen use. “

Watford General Hospital said on Saturday a critical incident as it neared the point where it would not have been able to provide oxygen to patients who needed it.

Dr. Lawton has come up with ingenious ways to work around the problem, including working with the University of Leeds on a 3D printed valve that could be attached to ventilators to reduce the amount of oxygen they use.

He also studied the CPAP devices used to treat sleep apnea at home. These keep the air under continuous pressure, inside a mask, to keep the wearer’s airways open – they must be re-used to provide oxygen for hospital use, but they use much less than standard hospital ventilators.

Dr. Lawton called a local company to check for availability, which said it had 2,000.

The plan is to start with 100 to see if, if used early enough, doctors can prevent people from deteriorating and needing more complex ventilators and the intensive care unit.

“We tested them over the weekend, and there is evidence from China and the United States that they seem to work. They just help to inflate your lungs and that seems to be beneficial, “says Professor Wright.

“They’re also very simple, which means you don’t need a huge amount of training. “

Debbie Horner, the Covid-19 intensive care planning consultant, who has now returned to work after contracting the virus herself, explains the complexities of the oxygen supply.

She says, “One of the problems we didn’t originally realize was the diameter of the pipes entering the hospital.

“So it’s not just the total amount of oxygen that the hospital has, it’s also how much can you get at the bedside? Or how many bedside tables can you get oxygen at any one time?

“We had to think about how to distribute the patients in the hospital” according to the size of the pipes. “

The hospital wants to avoid the situation in Italy where doctors were unable to provide intensive care to all patients due to shortages of kit or staff.

Planning is underway to determine how the BIS will deal with this situation.

This means building a support network for clinicians.

There are also discussions on regional and national ethics committees, to support hospitals in the decision-making process, so everyone makes decisions using the same framework.

“This is unexplored territory for us. There is a sense of fear of potentially having to replicate some of the decisions that have been made in Italy, ”says Professor Wright.

“I hope it doesn’t get to this point. “



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