Risks and Benefits of Multi-Patient Use of Ventilators

The joint statement came about with a discussion when the COVID-19 took off, and we started to see more and more patients requiring ventilation, started to hear about the experiences in Europe. There was true concern that we would run into a ventilator shortage, and in certain areas we have. Even though there are stockpile beds, even though there's other opportunities, I think people were concerned that we may run out of ventilators and then have to have situations where more than one patient would have to be placed on a ventilator, and so as this was discussed, a lot of this was being seen. You could see it on social media, questions coming into professional organizations. It was felt that there had to be a unified statement on the part of the organizations to kind of give some guidance as to whether this was something that was okay to do.

And I think the way it was outlined is it really gave a background on what the lung disease looked like COVID-19 severe pneumonia MDS, requiring ventilation very quickly in most circumstances, and then because of that, what were going to be the resources needed and a concern that we may run short, and what the statement did is walked through what some of the limitations might be, looking at this as a safety concern and thinking in the course of let's do no harm first, and how do we ventilate a patient? What are the shortcomings of using one ventilator for two patients? And so that was outlined over several bullet points, and from a technical standpoint, there are a number of limitations in doing that because the ventilator was always designed to be one patient to one ventilator, and the alarm systems, the controls, the monitoring parts are all designed around that.

So for us to then go down a pathway and say we're going to ventilate more than one patient with really limited data and only a few studies, and most of those are bench data and animal studies, it seemed important to come out and say in dire circumstances, you may try this, but the overall position would be it's not a good idea because of the limitations of our equipment and safety concerns. Studies that we quote within the physician statement and also that have been even quoted among the procedures that have been developed for multi-patient ventilations speak to only bench research, looking at ventilating test lungs as well as a sheet model, but nothing really that speaks well to how this would work out in humans and what those outcomes would be, including the safety features of this. No less than I've seen ... since this has started, no less than three techniques described, and some of the more recent ones have been very well thought out in modifying the monitoring and such, but all of them are a bit different and not really tested, and in theory, do work on test lungs and have worked in animal models, but in COVID-19, with the differences in lung pathophysiology among patients, in between patients, yet it's really unproven, and so for that way and except in really dire circumstances where you had no other options, it's probably something where we need more data.

What would those circumstances be? They would have to be something where you had no other options, where you would not be able to use any type of ventilator. That would just not be available to you, because even with normal lungs, there are still some risks associated with that, and again, I see the main risks are you're modifying a device designed for one patient, to interface with one patient, and when you do it with more than one, you're going to have some compromise in the capabilities of the machine around alarms and monitoring and triggering and such, and in those circumstances, one of the things that's recommended is that if you're going to put more than one patient on the ventilator is that you're going to paralyze the patients so that they're not triggering the ventilator differently, and that may not be appropriate for patients that have relatively normal lungs.

It might not be something that we want to do, but again, in dire circumstances where you had ... in an austere environment where you had no other option, a unified approach, a well thought out approach that everybody uses, that maybe has some data behind it and tests would be something we'd want to think about. At this time, we're just not there. So I think that these protocols are well-meaning. I think that they are something that may need to be done and something that should be studied, but not the default for these circumstances unless you had no other option. When you're trying to make that decision as a team, I think that what has to happen is there has to be, as you would with any clinical decisions, is there has to be a discussion as to the risk benefits, nursing respiratory care, the physician whole critical care team included, and then a plan generated as to how you're going to do it and then who's going to monitor that patient and who's going to make changes on that patient being the best qualified.

The other thing to consider is that when you set up a system like this that is not well known, probably the most qualified person who would be able to set this up and monitor it is the respiratory therapist, and I often think of in these circumstances, they can be spread thin. So the most qualified person to monitor them as a therapist, will they have the ability to do that, or will they be spread thin? Because I could see others being responsible for making changes on ventilators, for monitoring ventilators. That may be difficult enough in a one to one situation where you have one ventilator per patient with full monitoring capability and alarms, but when you then split it out like this, and there are all these nuances, this requires an expert level of somebody who can troubleshoot that and keep an eye on it.

So if you were to go down that path and say, "I have two patients, I need to ventilate them. I'm going to use this mode of ventilation," it should be done with everybody on board, everybody understands it, and that the most qualified people are at the bedside all the time because it's going to require an extra level of monitoring, not less. Should you be forced to do that because you truly had no other options, then it would be important that a well-designed protocol that everybody's following and familiar with it and understand the risk and benefits of this, because they are insignificant and they've been outlined, not only in the physician statement, but even in some of the protocols that have been designed, they've been thought out and what the limitations are and using the strategy has been laid out, and so as the bedside nurse, I think it's important that they be familiar, as everyone else is, with the decisions that are made.

What are the goals of therapy for this patient? And at what point do we maybe need to change that? And how can we get that patient back to conventional ventilation, one ventilator per patient as soon as possible? Especially because you're not going to be able to ... if you're keeping them paralyzed over a period of time, that will sustain you, but at some point, you're going to have to get back to a single ventilator patient ratio in order for them to be liberated. I'd encourage people to, as they view this statement, view it for what it was designed to do, and that brings awareness to the risks of this strategy, that it is something that can be done, and I think the way that the statement was aligned out, it actually speaks to those risks. Some of them, again, can be mitigated depending on the design, but I think it was really there to provoke thought and kind of give caution to using a mode or strategy for which the machine was not designed, and so that if you choose to do that, you're proceeding with caution, you're proceeding informed, and in the mind of that team, they are doing what they feel is best for the patient at a given time.