As COVID-19 spreads quickly across the country, hospitals are racing to respond — working on increasing bed capacity, staff and other key resources and equipment, namely ventilators, which are in short supply.
New York Gov. Andrew Cuomo said the state will look into using one ventilator for two patients at one time, as a potential solution to the ventilator shortage.
Here, seven healthcare experts discuss the feasibility and risks of this potential solution.
Jesse Roman, MD. CEO of the Jane & Leonard Korman Respiratory Institute-Jefferson Health (Philadelphia): The use of a single ventilator for two or more patients has been considered in the past for addressing needs during major disasters. At this point, it remains investigational as there are currently no good reports that indicate that this is easily implemented. Mechanical ventilation is instituted in patients with respiratory failure who need support for their breathing and oxygen needs. The amount of support required is dependent on the size of the patient, the extent of lung injury and other factors. These factors affect the 'stiffness' of the lung, among other variables, thereby leading to different requirements of volume, oxygen, and pressure requirements provided by the ventilator.
Since no two patients are identical, these differences represent the main challenge when attempting to support two or more patients with a single ventilator, as current technology does not allow for a single ventilator to deliver distinct supporting strategies. If this were to work, the patients would have to be matched for size and lung stiffness, heavily sedated or paralyzed, and should be hemodynamically stable. Additional, separate circuits would be preferable to avoid cross-contamination of gases.
Bruce Levy, MD. Chief of the Division of Pulmonary and Critical Care Medicine at Brigham and Women's Hospital (Boston): Theoretically, it's certainly possible. Complicated though. Definitely viewed as experimental. Physiologically, you could do it. I want to emphasize the fact that we just need more ventilators. That's a much more direct way to address the issue.
If you were to [use one ventilator for two patients] though, you'd have to be careful about matching the patients you'd partner — they would have to have a similar degree of illness, lung injury, similar course of illness.
There are two ways to deliver air to lungs via ventilator, and in this case, you'd have to use pressure mode, not volume mode.
Patients would have to be heavily sedated so they don't fight the ventilator. [They] might even have to be paralyzed, which would significantly increase risk for complications.
You could underventilate/overventilate if you based it on how one partner was doing — which overventilating can cause lung damage itself. When people are recovering, you wean off the ventilator, and that would be very difficult to do in a paired way. I think you'd have to separate them for that phase.
Also, [you] have to consider infection control issues if patients are not carefully separated, etc.
I wouldn't want to say this is straightforward. I'd say it's a distraction from the fact that we just need more ventilators.
Tisha Wang, MD. Associate Professor of Clinical Medicine at the David Geffen School of Medicine at University of California Los Angeles: This could work in theory, but it is far from simple, and many COVID-19 patients have very sick lungs that require frequent changes of their ventilator settings. This makes them poor candidates for "ventilator-sharing." To effectively share a ventilator, patients would have to be very similar in size/ideal body weight and ventilator needs, as both patients would have to be on essentially the same ventilator settings.
It would be extremely hard to coordinate and adjust settings that may be needed for one of the patients but not the other. So I think this is technically possible, but should probably only be utilized in a disaster setting. Many academic centers in preparation for this scenario are now doing simulations in their local simulation labs to better assess the feasibility of this.
Anthony Steve Lubinsky, MD. Medical Director of Respiratory Care at Tisch Hospital (New York City): Patients with respiratory failure don't necessarily require invasive treatment, but it seems like with [the COVID-19] illness, [lung protective] ventilators are required.
A ventilator delivers a breath and can deliver breath larger than the patients'. However, breath size depends on lungs.To use the [two patients on one ventilator] technique you'd have to have patients with similar lung breath size and similar lung damage. Body weight and body size of both patients would have to be similar, so breath could be similar. Currently, there's not a great way to know if two patients would have these similar components.
As people recover, we need patients to be able to breathe on their own. They interact with the ventilator, and we adjust settings depending on how they're recovering. Two patients are likely to have different recoveries. It's also not clear how a ventilator would respond to two different patients. We just don't know.
Will this solution work? Potentially, yes. If that's all [that's] available, you could use this configuration to use [one ventilator on] two patients at the same time, but then there are all the problems I just mentioned.
In the setting of a shortage, we need to consider techniques that are unconventional. This is one that may technically work, but how long it would work in practice, we don't know. It would be suboptimal.
Umur Hatipoglu, MD. Head of Chronic Obstructive Pulmonary Disease Services at Cleveland Clinic: It is possible to have two patients sharing a ventilator. It is something that's currently being studied, and some centers are preparing protocol for this. However, it's important to note that without appropriate circuit modifications, mechanical ventilation cannot be individualized, and care of each patient over time becomes very difficult.
Paul Currier, MD. Pulmonary and Critical Care physician at Massachusetts General Hospital (Boston): First of all, [ventilator-sharing] is definitely not ideal, just because different patients have different needs; their lungs are different. We should be focusing on getting enough ventilators to supply one for each patient to properly care for them. But this would require national leadership and coordination. There is competition between people and states and groups trying to get ventilators. We need a coordinated effort to get resources to people at the time that they need them, and that has not been happening.
It does seem like it is possible to do. There would have to be a lot of different requirements in place. For example, grouping patients of similar size and similar lung characteristics. [Ventilator-sharing] would require a lot of sedation or paralysis likely, so that you don't have patients trying to trigger the ventilator on their own. There would also need to be filters to ensure there is no transmission of viruses. Even if both have COVID-19, they could have other [viruses] that could get transmitted and bacterial infections even.
It is conceivable? Sure. Is it highly suboptimal? Yes.
Richard Castriotta, MD. Pulmonary Critical Care Physician at Keck Medicine of USC (Los Angeles): This could possibly work under certain well-defined circumstances, and the method would face specific difficulties during the COVID-19 pandemic. This was first done in 2006 using 'artificial lungs,' which were essentially modified rubber bags. This was done in real life only during the emergency response to a mass shooting in Las Vegas at the suggestion of the first author of that paper. Neither of those situations reflect the problems that would be encountered in attempting mechanical ventilation in COVID-19 patients with fulminant viral pneumonia, respiratory failure and acute respiratory distress syndrome.
The COVID-19 patients will have lungs full of fluid filling alveoli, severe inflammation and very stiff lungs with very low compliance, that is, the lungs will be stiff and hard to inflate. Any two patients attached to the same ventilator would have to have exactly the same lung compliance and airway resistance in order to share the ventilator with a 'Y-tube,' as done in the above cases. If the four lungs being inflated do not all have the same mechanical characteristics, there will be excess pressure and volume exerted to some parts with barotrauma, and the risk of rupturing the lung, called pneumothorax. While sharing the ventilator is possible, in practice this would be complicated and risky in [patients with] acute respiratory distress syndrome.
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