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Bellini C, Battaglini M, Pianta M, Houbadia Y, Calevo MG, Minghetti D, Ramenghi LA. The Transport of Respiratory Distress Syndrome Twin Newborns: The 27-Year-Long Experience of Gaslini Neonatal Emergency Transport Service Using Both Single and Double Ventilators. Air Med J 2023; 42:246-251. [PMID: 37356884 DOI: 10.1016/j.amj.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/03/2023] [Accepted: 03/08/2023] [Indexed: 06/27/2023]
Abstract
OBJECTIVE Twin pregnancy rates have increased in the past 30 years. We describe the experience of the Neonatal Emergency Transport Service of the Gaslini Hospital, Genoa, Italy, in the transport of twin newborns. METHODS This was a retrospective study (1996-2021); 7,852 medical charts from the Neonatal Emergency Transport Service were reviewed. We included all twin newborns who were transported with respiratory distress syndrome in the study. We split the included patients into 2 groups (group A and group B) based on if they were simultaneously ventilated by a single ventilator or by 2 different ventilators, and then each group was split by the different types of ventilation (nasal continuous positive airway pressure or intermittent positive pressure ventilation). The pH level, base excess, O2 saturation, Pco2, body temperature, plasma glucose, and Transport Risk Index of Physiologic Stability score were recorded at departure and arrival. RESULTS One hundred thirty-six patients were included (68 pairs of twins); group A consisted of 92 newborns and group B 44 newborns. Although some significant differences were observed (statistic), none of these had real clinical significance. CONCLUSION Transporting respiratory distress syndrome twin newborns is challenging. Our study provided a 27-year experience in the field. Transporting twins by a single ventilator is possible, but, in our opinion, using 2 ventilators mounted on the same transport module is the best possible choice in terms of clinical performance, logistics, and cost.
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Affiliation(s)
- Carlo Bellini
- Neonatal Emergency Transport Service, Neonatal Intensive Care Unit, Department Mother and Child, Istituto Giannina Gaslini, Genova, Italy.
| | - Marcella Battaglini
- Neonatal Emergency Transport Service, Neonatal Intensive Care Unit, Department Mother and Child, Istituto Giannina Gaslini, Genova, Italy
| | - Marianna Pianta
- Neonatal Emergency Transport Service, Neonatal Intensive Care Unit, Department Mother and Child, Istituto Giannina Gaslini, Genova, Italy
| | - Yasmine Houbadia
- Neonatal Emergency Transport Service, Neonatal Intensive Care Unit, Department Mother and Child, Istituto Giannina Gaslini, Genova, Italy
| | - Maria Grazia Calevo
- Epidemiology and Biostatistics Unit, Scientific Direction, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Diego Minghetti
- Neonatal Emergency Transport Service, Neonatal Intensive Care Unit, Department Mother and Child, Istituto Giannina Gaslini, Genova, Italy
| | - Luca Antonio Ramenghi
- Neonatal Emergency Transport Service, Neonatal Intensive Care Unit, Department Mother and Child, Istituto Giannina Gaslini, Genova, Italy
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Branson RD, Rodriquez D. COVID-19 Lessons Learned: Response to the Anticipated Ventilator Shortage. Respir Care 2023; 68:129-150. [PMID: 36566030 PMCID: PMC9993519 DOI: 10.4187/respcare.10676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Early in the COVID-19 pandemic predictions of a worldwide ventilator shortage prompted a worldwide search for solutions. The impetus for the scramble for ventilators was spurred on by inaccurate and often unrealistic predictions of ventilator requirements. Initial efforts looked simply at acquiring as many ventilators as possible from national and international sources. Ventilators from the Strategic National Stockpile were distributed to early hotspots in the Northeast and Northwest United States. In a triumph of emotion over logic, well-intended experts from other industries turned their time, talent, and treasure toward making a ventilator for the first time. Interest in shared ventilation (more than one patient per ventilator) was ignited by an ill-advised video on social media that ignored the principles of gas delivery in deference to social media notoriety. With shared ventilation, a number of groups mistook a physiologic problem for a plumbing problem. The United States government invoked the Defense Production Act to push automotive manufacturers to partner with existing ventilator manufacturers to speed production. The FDA granted emergency use authorization for "splitters" to allow shared ventilation as well as for ventilators and ancillary equipment. Rationing of ventilators was discussed in the lay press and medical literature but was never necessary in the US. Finally, planners realized that staff with expertise in providing mechanical ventilation were the most important shortage. Over 200,000 ventilators were purchased by the United States government, states, cities, health systems, and individuals. Most had little value in caring for patients with COVID-19 ARDS. This paper attempts to look at where miscalculations were made, with an eye toward what we can do better in the future.
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Affiliation(s)
- Richard D Branson
- Division of Trauma/Critical Care, Department of Surgery, University of Cincinnati, Cincinnati, Ohio.
| | - Dario Rodriquez
- Division of Trauma/Critical Care, Department of Surgery, University of Cincinnati, Cincinnati, Ohio; and Airman Biosciences Division, Airman Systems Directorate, Wright-Patterson Air Force Base, Dayton, Ohio
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Sorg ME, Branson RD, Hatipoğlu U, Chatburn RL. Multiplex Ventilation: Solutions for Four Main Safety Problems. Respir Care 2021; 66:1074-1086. [PMID: 33906955 DOI: 10.4187/respcare.08749] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The COVID-19 pandemic has led to an increased demand for mechanical ventilators and concerns of a ventilator shortage. Several groups have advocated for 1 ventilator to ventilate 2 or more patients in the event of such a shortage. However, differences in patient lung mechanics could make sharing a ventilator detrimental to both patients. Our previous study indicated failure to ventilate in 67% of simulations. The safety problems that must be solved include individual control of tidal volume (VT), individual measurement of VT, individualization of PEEP settings, and individual PEEP measurement. The purpose of this study was to evaluate potential solutions developed at our institution. METHODS Two separate lung simulators were ventilated with a modified multiplex circuit using pressure control ventilation. Parameters of the lung models used for simulations (resistance and compliance) were evidence-based from published studies. Individual circuit-modification devices were first evaluated for accuracy. Devices were an adjustable flow diverter valve, a prototype dual volume display, a PEEP valve, and a disposable PEEP display. Then the full modified multiplex circuit was assessed by ventilating 6 pairs of simulated patients with different lung models and attempting to equalize ventilation. Ventilation was considered equalized when VT and end-expiratory lung volume were within 10% for each simulation. RESULTS The adjustable flow diverter valve allowed volume adjustment to 1 patient without affecting the other. The average error of the dual volume display was -17%. The PEEP valves individualized PEEP, but the PEEP gauge error ranged from 17% to 41%. Using the multiplex circuit, ventilation was equalized regardless of differences in resistance or compliance, reversing the "failure modes" of our previous study. CONCLUSIONS The results of this simulation-based study indicate that devices for individual control and display of VT and PEEP are effective in extending the usability and potential patient safety of multiplex ventilation.
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Affiliation(s)
- Morgan E Sorg
- Cleveland Clinic, Cleveland, Ohio. Mr Branson is affiliated with the University of Cincinnati, Cincinnati, Ohio and is Editor-in-Chief of Respiratory Care.
| | - Richard D Branson
- Cleveland Clinic, Cleveland, Ohio. Mr Branson is affiliated with the University of Cincinnati, Cincinnati, Ohio and is Editor-in-Chief of Respiratory Care
| | - Umur Hatipoğlu
- Cleveland Clinic, Cleveland, Ohio. Mr Branson is affiliated with the University of Cincinnati, Cincinnati, Ohio and is Editor-in-Chief of Respiratory Care
| | - Robert L Chatburn
- Cleveland Clinic, Cleveland, Ohio. Mr Branson is affiliated with the University of Cincinnati, Cincinnati, Ohio and is Editor-in-Chief of Respiratory Care
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Dijkman WM, van Acht NMC, van Akkeren JP, Bhagwanbali RCD, van Pul C. Comparing Ventilation Parameters for COVID-19 Patients Using Both Long-Term ICU and Anesthetic Ventilators in Times of Shortage. J Intensive Care Med 2021; 36:963-971. [PMID: 34134571 PMCID: PMC8212026 DOI: 10.1177/08850666211024911] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
In the first months of the COVID-19 pandemic in Europe, many patients were treated in hospitals using mechanical ventilation. However, due to a shortage of ICU ventilators, hospitals worldwide needed to deploy anesthesia machines for ICU ventilation (which is off-label use). A joint guidance was written to apply anesthesia machines for long-term ventilation. The goal of this research is to retrospectively evaluate the differences in measurable ventilation parameters between the ICU ventilator and the anesthesia machine as used for COVID-19 patients. In this study, we included 32 patients treated in March and April 2020, who had more than 3 days of mechanical ventilation, either in the regular ICU with ICU ventilators (Hamilton S1), or in the temporary emergency ICU with anesthetic ventilators (Aisys, GE). The data acquired during regular clinical treatment was collected from the Patient Data Management Systems. Available ventilation parameters (pressures and volumes: PEEP, Ppeak, Pinsp, Vtidal), monitored parameters EtCO2, SpO2, derived compliance C, and resistance R were processed and analyzed. A sub-analysis was performed to compare closed-loop ventilation (INTELLiVENT-ASV) to other ventilation modes. The results showed no major differences in the compared parameters, except for Pinsp. PEEP was reduced over time in the with Hamilton treated patients. This is most likely attributed to changing clinical protocol as more clinical experience and literature became available. A comparison of compliance between the 2 ventilators could not be made due to variances in the measurement of compliance. Closed loop ventilation could be used in 79% of the time, resulting in more stable EtCO2. From the analysis it can be concluded that the off-label usage of the anesthetic ventilator in our hospital did not result in differences in ventilation parameters compared to the ICU treatment in the first 4 days of ventilation.
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Affiliation(s)
- Wouter M Dijkman
- Department of Intensive Care, 8185Máxima Medical Center (MMC), Veldhoven, the Netherlands
| | - Niels M C van Acht
- Department of Applied Physics, 3169Eindhoven University of Technology, Eindhoven, the Netherlands.,Department of Clinical Physics, 571115Máxima Medical Center (MMC), Veldhoven, the Netherlands
| | - Jesse P van Akkeren
- Department of Intensive Care, 8185Máxima Medical Center (MMC), Veldhoven, the Netherlands
| | - Rhasna C D Bhagwanbali
- Department of Anesthesiology, 8185Máxima Medical Center (MMC), Veldhoven, the Netherlands
| | - Carola van Pul
- Department of Applied Physics, 3169Eindhoven University of Technology, Eindhoven, the Netherlands.,Department of Clinical Physics, 571115Máxima Medical Center (MMC), Veldhoven, the Netherlands
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Serpa Neto A, Checkley W, Sivakorn C, Hashmi M, Papali A, Schultz MJ. Pragmatic Recommendations for the Management of Acute Respiratory Failure and Mechanical Ventilation in Patients with COVID-19 in Low- and Middle-Income Countries. Am J Trop Med Hyg 2021; 104:60-71. [PMID: 33534774 PMCID: PMC7957237 DOI: 10.4269/ajtmh.20-0796] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 01/04/2021] [Indexed: 12/16/2022] Open
Abstract
Management of patients with severe or critical COVID-19 is mainly modeled after care for patients with severe pneumonia or acute respiratory distress syndrome (ARDS) from other causes, and these recommendations are based on evidence that often originates from investigations in resource-rich intensive care units located in high-income countries. Often, it is impractical to apply these recommendations to resource-restricted settings, particularly in low- and middle-income countries (LMICs). We report on a set of pragmatic recommendations for acute respiratory failure and mechanical ventilation management in patients with severe/critical COVID-19 in LMICs. We suggest starting supplementary oxygen when SpO2 is persistently lower than 94%. We recommend supplemental oxygen to keep SpO2 at 88-95% and suggest higher targets in settings where continuous pulse oximetry is not available but intermittent pulse oximetry is. We suggest a trial of awake prone positioning in patients who remain hypoxemic; however, this requires close monitoring, and clear failure and escalation criteria. In places with an adequate number and trained staff, the strategy seems safe. We recommend to intubate based on signs of respiratory distress more than on refractory hypoxemia alone, and we recommend close monitoring for respiratory worsening and early intubation if worsening occurs. We recommend low-tidal volume ventilation combined with FiO2 and positive end-expiratory pressure (PEEP) management based on a high FiO2/low PEEP table. We recommend against using routine recruitment maneuvers, unless as a rescue therapy in refractory hypoxemia, and we recommend using prone positioning for 12-16 hours in case of refractory hypoxemia (PaO2/FiO2 < 150 mmHg, FiO2 ≥ 0.6 and PEEP ≥ 10 cmH2O) in intubated patients as standard in ARDS patients. We also recommend against sharing one ventilator for multiple patients. We recommend daily assessments for readiness for weaning by a low-level pressure support and recommend against using a T-piece trial because of aerosolization risk.
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Affiliation(s)
- Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘Academic Medical Center’, Amsterdam, The Netherlands
- Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, University of Melbourne, Melbourne, Australia
| | - William Checkley
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Chaisith Sivakorn
- Department of Clinical Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Madiha Hashmi
- Department of Anaesthesiology, Ziauddin University, Karachi, Pakistan
| | - Alfred Papali
- Division of Pulmonary and Critical Care Medicine, Atrium Health, Charlotte, North Carolina
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘Academic Medical Center’, Amsterdam, The Netherlands
- Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
| | - for the COVID-LMIC Task Force and the Mahidol-Oxford Research Unit (MORU)
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘Academic Medical Center’, Amsterdam, The Netherlands
- Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, University of Melbourne, Melbourne, Australia
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Department of Clinical Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Anaesthesiology, Ziauddin University, Karachi, Pakistan
- Division of Pulmonary and Critical Care Medicine, Atrium Health, Charlotte, North Carolina
- Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
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Kearns AJ. The principle of salvage in the context of COVID-19. Nurs Inq 2021; 28:e12389. [PMID: 33222346 PMCID: PMC7744901 DOI: 10.1111/nin.12389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 10/01/2020] [Accepted: 10/03/2020] [Indexed: 11/29/2022]
Abstract
The prioritisation of scarce resources has a particular urgency within the context of the COVID-19 pandemic crisis. This paper sets out a hypothetical case of Patient X (who is a nurse) and Patient Y (who is a non-health care worker). They are both in need of a ventilator due to COVID-19 with the same clinical situation and expected outcomes. However, there is only one ventilator available. In addressing the question of who should get priority, the proposal is made that the answer may lie in how the pandemic is metaphorically described using military terms. If nursing is understood to take place at the 'frontline' in the 'battle' against COVID-19, a principle of military medical ethics-namely the principle of salvage-can offer guidance on how to prioritise access to a life-saving resource in such a situation. This principle of salvage purports a moral direction to return wounded soldiers back to duty on the battlefield. Applying this principle to the hypothetical case, this paper proposes that Patient X (who is a nurse) should get priority of access to the ventilator so that he/she can return to the 'frontline' in the fight against COVID-19.
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Affiliation(s)
- Alan J. Kearns
- School of Theology, Philosophy, and MusicDublin City UniversityDublinIreland
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