Among the many fears people have expressed during the COVID-19 epidemic in our country, one question appears uppermost on American’s mind: “What if I need a ventilator?”
In this blog, I hope to clarify what assisted ventilation from a ventilator (or respirator) entails and give tips for you and your family or patient advocate should that unlikely but daunting prospect arise.
Much has been said in the press, on the street and among our government leaders about the potential shortage of ventilators during the present COVID-19 outbreak. Many people misunderstand what it means to be ventilated or “on” a ventilator. As an anesthesiologist for nearly three and a half decades who has managed artificially ventilated patients in operating rooms, ICUs and other clinical settings, I feel it is important to understand the concept and mechanical details of artificial ventilation.
When a patient is rendered anesthesia-induced unconscious for surgery or is in the ICU and intubated for treatment of respiratory failure, the need for artificial ventilation arises. Since 1870 when Dr. Trendelenburg performed the first intubation in Germany, I and specially trained doctors, nurses and assistants like me have intubated people so that they may be mechanically ventilated.
Intubation is the act of placing a breathing tube into a patient’s trachea (windpipe) so that mechanical ventilation can be achieved. The breathing tube is generally placed either through the patient’s mouth or nostril. More rarely, it is done surgically via a tracheostomy through the patient’s anterior (front) neck. This is achieved with a tool called a laryngoscope or with the use of a fiberoptic scope.
This “breathing for” the patient is, by definition, the forced inspiration of oxygen-enriched gas and the exhalation of carbon dioxide rich gas. Sometimes we anesthesiologists or critical care doctors “paralyze” patients with neuromuscular blocking drugs (paralytics) to ease our ability to ventilate for them. Other times, patients are not paralyzed and allowed some degree of auto-respiration, usually with support from the ventilatory apparatus. In almost all cases, patients are sedated, especially in the ICU setting, in order to permit tolerating the physical, mental and emotional trauma of intubation and ventilation.
A lot has been written recently about the potential shortage of ventilators needed to deal with the present crisis. I will not debate here whether that concern is legitimate or not. But we certainly have come a long way in that during the polio epidemic of the 1950s, the shortfall of “iron lung” ventilation systems was made up by other means, namely the squeezing of a bag (like a bellows) by a team of medical students pressed into service to offer temporary round-the-clock ventilatory support.
Already in this nation, elective surgeries are being cancelled to divert anesthesia machine ventilators for possible use in the novel coronavirus outbreak. Also, automobile manufacturers are being asked, as other industries are, to quickly retool their plants to churn out more ventilators. Whether that will be sufficient to meet the potential need for intubated patients in respiratory failure is not yet clear.
But what is clear is this: being intubated is physically, emotionally and mentally taxing. People have a right to be concerned. But do realize that only the sickest minority of COVID-19 patients will require intubation and ventilation. The odds are in your favor, depending on your age and pre-existing medical state, that this will never come to pass for you.
Should the situation arise, it is important to ask the providers if there are sufficient sedatives (like benzodiazepines and propofol), painkillers (like morphine) and paralytics (like pancuronium and vecuronium) available to keep you comfortable and immobile to achieve effective ventilation. I know these are difficult questions but they are, in these times of drug shortages, legitimate.
I truly hope you never need to ask them.