So, what does a ventilator do?
With hospital ventilators so prevalent in the news lately, we asked Albert Fantasia, RRT, NPS, director of pulmonary services at Cape Cod Healthcare, to explain how they work and why they are so important.
“In the simplest terms, if a patient can’t breathe, whether it’s from the coronavirus, a pneumonia or even a traumatic injury, it’s basically a machine that breathes for you,” he said. “It pushes air in and out of the lungs. It’s also called a mechanical ventilator.”
Intubating is the act of placing an endotracheal tube or one that passes through the mouth and into the lungs. Once the tube is placed in the patient’s airway, it is connected to the ventilator. Patients are administered a combination of sedation and pain medication to maintain an adequate level of comfort and wakefulness, and decrease the chance they will pull their breathing tube out. The most difficult cases require medications that cause temporary paralysis if the patient is “fighting the ventilator,” he said.
“Ventilators are sometimes called life support. They are meant to rest the patient and allow the body to heal. In the case of a COVID-19 patient, we would support them until their lung function improved enough until they could breathe on their own,” he said. Patients would be unable to talk until the tube is removed.
Ventilators have been necessary for the sickest of COVID-19 patients, who experience a form of acute respiratory distress syndrome (ARDS). This causes the oxygen levels to plummet to the point that it is impossible to breathe without a ventilator.
Mechanical ventilation, in itself, does not come without risks, said Fantasia.
“There can be complications of therapy from mild to severe, but due to the implementation of evidence-based protocols, we’re able to avoid most of these risks,” he said.
Exacerbating the problem is the amount of time patients with COVID-19 must stay on the ventilator. Ever since Cape Cod Healthcare implemented a best practices protocol two years ago, the time people spend on a ventilator dropped from an average of six days to an average of two days. But COVID-19 patients who need ventilators are typically on the machines for around 10 days; four to five times longer than normal, he said.
“That’s where a medication shortage could possibly come into play. We need to keep them comfortable on the ventilator so it can do its job. Additionally, keeping them comfortable decreases the chance they will “self extubate” – pull the breathing tube out. This is not only unsafe for the patient but also for the caregiver. If they pull that tube out, there is high probability viral particles from the patient’s respiratory tract becomes airborne in the room and puts the caregiver(s) at risk,” he said.
For the most part, clinicians are able to give patients a good idea of their chances of survival, with “pretty accurate survivability scores,” Fantasia said.
“Patients generally present with some uniqueness to their illness, and we treat them as such. It is important for the physician to discuss options with the patient or their healthcare proxy, including the pain and suffering, likelihood for success and quality of life of each care plan option. Ï feel in these instances where there is high likelihood a patient may remain on ventilator support indefinitely, it is most important for a respiratory therapist to be part of the discussion.
“Respiratory therapist can best explain what daily quality of life is like for a chronically ventilated patient,” he said.
Elderly at Higher Risk
“Illness hits the elderly a little harder and they don’t bounce back like younger people do,” Fantasia said. “Age is a morbidity just like heart disease and pulmonary disease. The elderly are the ones with all the burden on this and that’s mostly what we’ve been seeing. We have seen a few middle-aged people and a couple in their 40s that needed to go on vents, but risks with the coronavirus and COVID-19 are directly proportional to age.”
The shortage of ventilators has been in the news a lot recently. Cape Cod Hospital currently has 70 ventilators and they have ordered 10 more. Falmouth Hospital has 28. Not all of them are conventional ICU ventilators; some of them are anesthesia machines normally used during surgery. Others are Bilevel Positive Airway Pressure (BiPAP) machines that are FDA approved to be used as ventilators.
“Here at CCHC, we have appropriate amounts of equipment and supplies to care for our community, now and going forward. This includes ventilators,” said Cape Cod Hospital Chief Medical Officer William Agel, MD.