Erwan L’Her MD PhD and Annie Roy RRT
Respir Care 2011;56(6) 751-760
Given the inevitability of virulent germs, encroachment of man into biologically active areas and worldwide population movement through Asian airports, a 10% pandemic flu outbreak requiring a 5% ICU admission rate is likely and would overwhelm the mechanical ventilation capabilities of hospitals. Low technology ventilators would be required to meet this challenge should society decide to incur the expense of also reserving a provision of drugs and equipment. Six ventilators varying in price, by a factor of as much as 18x were compared. The outcomes of the testing were proportionate to cost. The comparison findings were, that, given the certainty of ARDS, and concomitant changes in compliance, the cheapest units would be unable to provide a proper level of mechanical ventilation performance. The study liked the CAREVENT ALS, O-TWO MEDICAL TECHNOLOGIES, Mississauga, Ontario Canada (2300USD) and the MEDUMAT EASY, WEINMANNN GERLITE FUR MEDIZN, Hamburg, Germany (2600SD)
For those who know the LUNGLORD and have attended one of his lectures, you are aware of his vigorous and enthusiastic interest in this subject matter. Forgive his antics and think well of his ardent desire and cogent arguments. As for this article, the LUNGLORD compares his love of car magazines and technical journals. When they compare the Fiat 500 to the twin turbo Ferrari that costs 20x more, few comparisons can be made if the reader dwells in a world of reality with budgets and competing priorities. Like ergonomics. Please. This is to laugh. In the comparison, several very adequate machines are tested. But, at up to 3,000 dollars a ventilator, which hospitals would be inclined-with no immediate need– to accept an outlay of 600,000 USD to purchase a minimal defense umbrella of two hundred machines? One 750 USD ventilator seemed adequate, the ALLIED HEALTH CARE, EPV 100, St. Louis Missouri. Also tested were simpler machines, at 140 dollars apiece, the VORTRAN VAR-PLUS, VORTRAN MEDICAL TECHNOLOGY, Sacramento California.
A combination of these two ventilators is worthy of consideration in LUNGLORD’s flexible response plan herein described. 200 simple VORTRAN machines could deliver life saving ventilation for 2,800 USD until severity of the disease bloom is known. A modest number of EPV 100s @ 750 USD x 50 units = 37,500 USD–(the price of a single PB 840), could give a 3 tiered hierarchy of access to resources. As patients become sicker they would be evaluated and either triaged out of the system or taken to a more capable machine, up to the current generation ventilators in daily use. As for the basic ventilators, these are not designed to save the sickest patients. We will not know who is who when we intubate them. We are certain that the worst cases will not survive and will heavily drain resources in the meantime. So, for the patients whose course and prognosis includes hypoxia and very poor lung compliance, these would be extubated and allowed to succumb in the hope that the next person ventilated might have a mild enough case that they may benefit from the rare and rationed medications/care available.
People will be arriving hourly and this triage decision will have to be made.
Criticisms of the simplest machines include widely varying quality, compliance and potential malfunction issues. A Fiat 500 would likely get a non severe patient over the steep mountain of disease. It is preferrable to walking, which would be a bag/ETT or bag/mask combo, or not taking the risky trip at all.
LUNGLORD believes that Wright Respirometers will be necessary to check the level of patient ventilation hourly and that ancillary staff should be trained ahead of the curve (ie: now) to check tidal volumes/saturations/suction then reporting to the RCP any abnormal findings. A disposable PEEP valve cranked down to 30cm could be placed in the inspiratory limb to limit the potential for barotrauma, another on the expiratory side for adequate PEEP levels.