As the COVID-19 pandemic spreads worldwide, with the United States now experiencing the highest number of cases and an exponentially increasing number of cases and deaths every day, the shortage of supplies is becoming critical. Health care workers need personal protective equipment (PPE), which includes N95 masks, surgical masks, gowns, gloves and eye protection. The growing shortage of fans is also becoming a serious concern. What is less widely discussed is the worrisome shortage of professionals to manage ventilators, as an increasing number of healthcare workers are infected, hospitalized and die.
These machines are not only complicated to build and buy, but they are also quite complicated to use and maintain. There is no on / off switch and you are ready to go. Respirators, especially those used to manage and treat people with severe lung infections, require highly trained professionals, usually intensive care physicians, anesthesiologists, intensive care nurses and respiratory therapists. As those caring for an exponentially growing sick population become ill or worse, the level of care for critically ill patients will be exponentially compromised as their numbers increase.
Since most of you will not be called upon to manage a patient with a ventilator, it is always worthwhile to familiarize yourself with the operation and functioning of these machines, the meaning of the numbers and their limits. At least it will explain more clearly why the people who manage the fans are more critical than the machines. Yes, we already know that people are more valuable (let’s just say that they are priceless) than machines, but the focus must constantly be on preserving the human workforce behind them. ventilatory care.
It may be good to describe how a patient progresses from a cough and fever to a little trouble breathing, needing oxygen, needing a ventilator (hopefully here) detach from the fan and recover.
For the most part, people who develop symptoms compatible with COVID-19, including fever, body aches, loss of smell (and possibly taste) and cough, are advised to self-initiate quarantine at home, rest, stay hydrated, treat symptoms with over-the-counter medications like acetaminophen (Tylenol), and call your doctor to ask questions. Tests to confirm that the virus is evolving, much of which depends on access to test centers, and the risks of leaving home to get tested, putting all the people you would be in contact with while visiting a risk center to contract the disease.
But for those who have difficulty breathing, medical care outside the home is necessary. This can take the form of additional oxygen and / or breathing treatments. These can be administered in an emergency department or an emergency room, but as hospital beds become more and more scarce, more and more people are sent home with oxygen therapy. These home oxygen machines come in different sizes and shapes, and can deliver different concentrations of oxygen based on doctor’s advice.
In the days leading up to COVID-19, these were commonly used in patients with conditions such as chronic lung disease, severe asthma, chronic bronchitis, emphysema or pulmonary scars. After a brief training, a doctor is not necessary to manage oxygen at home, but the patient should be monitored, even from a distance, regarding oxygen concentration, frequency of use and ways to reduce the need for additional oxygen. Oxygen with home machines can be administered via plastic tubes via a face mask or nasal teeth. Respiratory treatments that can be used at home include inhaled medications that reduce inflammation in the small airways of the lungs, as well as those that open some of the blockage in small air passages. These are very commonly used safely at home and are used in people with asthma or other chronic lung problems.
When a patient develops labored breathing despite oxygen supplementation, care is usually left to hospital specialists. A mask without a recycler looks like an oxygen mask because it has a similar part on the face and is not connected to a ventilator. The difference is that the mask is attached to a plastic tank bag filled with high concentration oxygen. It has a one-way valve, preventing the patient from breathing in the exhaled air, which has a high percentage of carbon dioxide. They are generally used in emergency situations where patients are unable to maintain their oxygen levels in the blood. They are not used at home and are not long-term treatments. They are most commonly used to temporarily treat a patient who needs a mechanical ventilator.
As an acute lung problem progresses, despite prompt therapy with a non-recycler, many intensivists have experienced success with the lying position, which means that the patient will lie on their stomach in the bed and continue to receive a oxygen therapy. Although there has been a more common use of supine ventilation to treat ARDS or acute respiratory distress syndrome, seen in severe cases of COVID-19 as well as in other serious lung infections for patients already on respirators, lying down oxygenation can reduce the need for intubation and may avoid the need for a ventilator in patients with COVID-19.
When a patient needs to be placed on a ventilator, especially in the case of increasing respiratory failure due to COVID-19-related lung infections, there are several stages involved, followed by 24/7 care in the care of the patient once on this subject. coveted machine.
The first steps are usually performed when a patient develops increasing labored breathing, difficulty maintaining their oxygen saturation (a measure of the amount of oxygen in the bloodstream, which should be more than 90%) despite receiving supplemental oxygen, or increased fatigue from poor air. movement in the inflamed lungs. Patients should be sedated before switching to a ventilator, unless they are already at a loss of consciousness due to these limited amounts of oxygenated blood to the brain. But the majority of patients who need to be placed on ventilators and remain on ventilators require medication for sedation, muscle relaxation, and maintenance of vital bodily functions such as blood pressure and heart rate once the patient is mechanically ventilated. Although most states in the United States have not reached the maximum number of patients requiring respirators, there is already a shortage of essential drugs to put patients under safe levels of unconsciousness in order to continue to breathe safely security with fans.
If these drugs are administered, the first step before being placed on a ventilator is ventilation of the pocket mask. This is where the patient receives positive pressure ventilation by hand from the healthcare professional, while their airway structures are supported by the person who squeezes the bag. Oxygen is administered via tubes to this bag. This is a form of external ventilation because the patient is ventilated by an external force. It is not a machine, but a person. Emergency medical technicians (EMTs) and paramedics are trained in pocket mask ventilation, as are many hospital staff, including emergency physicians, specialists in intensive care units (intensive care), respiratory therapists , anesthesiologists, internal medicine specialists, pediatricians, otolaryngologists, pulmonologists, hospitalists, nurses, and all residents and fellows, to name a few. The ventilation of the bag mask can theoretically support a person’s airways indefinitely, but it is used as a time-out measure until a safer and more definitive step is taken.
The next step before being placed on mechanical ventilation is endotracheal intubation. This is where a qualified professional (many EMTs and paramedics, intensivists, hospitalists, emergency physicians, anesthesiologists, otolaryngologists and respiratory therapists, to name a few) uses a laryngoscope (shown below left) to be placed in the patient’s mouth. push the tongue down with the mouth open. At the tip of the laryngoscope, the vocal cords are visualized and a plastic tube (to your right, below) is placed through the vocal cords (in the voice box) down into the windpipe or windpipe. This plastic tube, or endotracheal tube, is fixed in place and acts to deliver oxygen from the ventilator to the patient’s lungs.
Once the endotracheal tube is attached, the patient can be connected to the ventilator via this tube. This plastic tube, roughly the diameter of his little finger, is literally the patient’s lifeline. If the tube comes out of the trachea (for example, if the patient becomes too awake and begins to cough), the whole process, starting with the ventilation of the pocket mask, must be repeated. Yet another reason why the shortage of drugs in the critical intensive care unit is dire.
Once the patient is placed on the mechanical ventilator, the machine does all the work to supply oxygen to the lungs. However, there is a lot to understand in fine-tuning a mechanical fan. Most ventilator settings depend on the patient’s lung function and the reason for intubation and ventilation. If a patient is placed on a ventilator due to a central nervous system problem such as a stroke or brain injury, with associated loss of respiratory control but with reasonable lung function, the parameters will be very different from those of a person with chronic lung disease, acute heart failure or, in the present situation, acute respiratory failure and severely inflamed lungs. The lungs of patients requiring mechanical ventilation due to COVID-19 are so inflamed that oxygen cannot reach the small air sacs (air sacs) when a patient breathes, and the mechanical ventilator acts to force oxygen under pressure towards these little air passages.
The fan settings are continuously changed. These parameters include the percentage of oxygen passing through the patient’s lungs (the air we breathe contains about 20% oxygen, but ventilators can supply up to 100% oxygen if necessary). It also includes the volume of air delivered, often depending on the size of the patient, at what pressure this oxygen is administered, at what rate and at what rate. In addition, variables such as the ventilation rate triggered by the patient versus the rate fully executed by the machine can vary, depending on the patient’s lung function and whether or not there is a residual capacity for the patient to generate breaths by itself. These parameters are continuously evaluated by highly qualified specialists, who modify the medication, ventilation parameters and patient positioning (on the back or on the stomach – supine or supine) depending on the clinical state minute by minute. patient. I cannot overemphasize the fact that, although these mechanical fans are essential, they are only machines which collect dust without the experts executing them. And in addition to all the ventilator settings and critical drug titrations that pass through the patient’s veins, these plastic endotracheal tubes require care. They must be reattached, repositioned and vacuumed regularly, sometimes as often as several times an hour. Again, they are trained professionals, not machines.
Even critically ill patients can detach themselves from the respirators and recover. The percentage of COVID-19 patients who have successfully done so has varied from single-digit percentages to over 50%. Being able to detach from a fan is also a decision made by professionals, not machines. Patients should show signs of improvement in lung function, which means that the ventilator will provide minimal breathing support, that it is strong enough and that it will be able to breathe enough oxygen, even with a face mask, to maintain sufficiently high oxygen levels in the blood.
The procedure for removing the ventilator is called extubation, whereby the endotracheal tube is removed. These moments are extremely well planned and the moments after extubation (again, with a trained professional, usually an intensivist or an anesthetist) are critical. The patient must be in a precise state of consciousness – not too awake where he would cough and spit, but not too sleepy where he would be unable to make the effort to breathe on his own. Again, detaching from the fan is not a simple on / off switch. Professionals and close supervision are required. Patients typically switch to high levels of supplemental oxygen through a mask after being out of the ventilator, and are closely monitored to ensure that they do not need to be re-intubated and replaced. fan.
Here’s a handy introductory video on how fans work. For beginners!
Not so simple, but the graphics are great.
Fans are desperately needed.
Hospital beds, both in intensive care and standard care are desperately needed.
Without the safety and protection of health care workers with adequate PPE, these ventilators become nothing more than display objects and beds become, finally, simple beds.