The limited supply of ventilators is one of the chief concerns facing hospitals as they prepare for more COVID-19 cases. In Italy, where hospitals have been overwhelmed with patients in respiratory failure, doctors have had to make difficult life-or-death decisions about who gets a ventilator and who does not.
In the U.S., emergency plans developed by states for a shortage of ventilators include using positive airway pressure machines — like those used to treat sleep apnea — to help hospitalized people with less severe breathing issues.
While that measure could stretch the supply of ventilators and save lives, it has a major drawback. Officials and scientists have known for years that when used with a face mask, such alternative devices can possibly increase the spread of infectious disease by aerosolizing the virus, whether used in the hospital or at home.
Indeed, that very scenario may have contributed to the spread of COVID-19 within a Washington state nursing home that became ground zero in the United States. First responders called to the Life Care Center of Kirkland starting Feb. 24 initially used positive airway pressure machines, often known as CPAPs, to treat residents before it was known the patients were infected with COVID-19.
“It’s best practice for us for people with respiratory illnesses,” said Jim Whitney, medical services administrator for the Redmond Fire Department, whose crews responded to the nursing home’s 911 calls. “We had no idea that we potentially had COVID patients there.”
It was only later that King County public health officials advised Redmond Fire and other first responders in the region not to use those machines for patients suspected of having COVID-19 infections. Whitney said responders were using the machines with specialized filters, which can reduce the amount of virus released. But county public health authorities recommend that first responders avoid using CPAP machines altogether. Redmond Fire has now discontinued use of CPAPs for COVID patients.
“It’s truly out of an abundance of caution for our people and for the community that we put it on the back shelf, unless we can confirm it was the best use for our patient,” Whitney said.
The misstep represents a classic example of how the health care system is playing catch-up in its effort to deal with the rapidly escalating pandemic, and how critical information about combating the novel coronavirus can be slow to reach those on the front lines.
The American Society of Anesthesiologists issued guidance on Feb. 23 discouraging CPAP use in COVID-19 patients — advice largely informed by experience with the SARS epidemic in 2003. Studies dating to 2003 suggest that such devices can pump viruses into the air, potentially increasing the spread of a contagious disease.
During the SARS outbreak in Toronto, half of all SARS cases, including three deaths, occurred among health care workers. Some of the greatest risk arose when doctors and nurses were exposed to aerosolized virus through the use of positive airway pressure machines or other respiratory therapy devices.
The experiences from the Life Care Center of Kirkland now have doctors rethinking their strategies when faced with ventilator shortages, and their advice to first responders about using CPAP machines in the field.
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