key: cord-267942-ykl2xy7y
authors: Stiers, Michiel; Bleeser, Tom; Mergeay, Matthias; Pinson, Hannah; Janssen, Luc; Schepens, Tom
title: Successful ventilation of two animals with a single ventilator: individualized shared ventilator setup in an in vivo model
date: 2020-08-27
journal: Crit Care
DOI: 10.1186/s13054-020-03248-z
sha: 
doc_id: 267942
cord_uid: ykl2xy7y

nan

Dear Editor, As the ongoing COVID-19 crisis is spreading from developed into developing nations, a shortage of ventilators in ICUs can be expected during peak prevalence. Sharing a ventilator among patients has been put forward as a rescue solution [1, 2] ; in this setting, the so-called pairing of patients with similar characteristics is needed [3] [4] [5] . We have developed a modified shared ventilator design that allows for individualization of tidal volumes and driving pressures, positive end-expiratory pressure (PEEP), and inspired oxygen fraction (FiO 2 ) [6] , which can thus substantially individualize the delivered breaths, removing the need of pairing (see Fig. 1 ).

We have now successfully used this ventilator setup in an in vivo model in a pair of ventilated sheep with different lung compliance, further supporting the potential of this shared ventilator setup as a lifesaving intervention in a crisis setting.

After ethical approval, two healthy Swifter sheep (62 kg and 60 kg, 1 year old) received general anesthesia (buprenorphine-sevoflurane), intubation, arterial catheter, and a C-section. After baseline blood gas and respiratory mechanics measurements, both sheep were connected to a single ventilator. Animal 1 had a lung compliance of 38 ml cmH 2 O − 1 , while animal 2 had a lung compliance of 28 ml cmH 2 O − 1 , differences in compliance could be explained by their position. Ventilator settings and measurements are shown in Table 1 . The targeted tidal volume of the shared ventilator was set by adding together the individual tidal volumes of animal 1 (600 ml) and 2 (800 ml), creating a combined tidal of 1400 ml. We measured individual airway pressures, with a fluid-air interfaced pressure transducer (Edwards Lifesciences, Irvine, USA), and individual end-tidal CO 2 (etCO 2 ) levels (see Fig. 1 ). We then partially closed the inspiratory flow for animal 1 until the measured etCO 2 levels for each animal were similar to those measured at baseline. This titration was successfully achieved within a few breaths, and the total set tidal volume could be distributed accurately among the two animals. With the added in-line individual PEEP valve, animal 2 received a PEEP of 7 cmH 2 O, whereas the other received 3 cmH 2 O of PEEP. The individually measured airway pressures demonstrated that the set PEEP levels were successfully achieved for each animal. FiO 2 could be adjusted as expected, with one animal receiving an FiO 2 of~0.3 and the other~0.8 with added O 2 to its breathing circuit during a short test period. Adequacy of ventilation and oxygenation in this setup was demonstrated with repeated blood gas measurements. Both PaCO 2 , PaO 2 , and pH values remained within normal range, thus we can assume that the individual tidal volumes before and after sharing the ventilator were similar. Hemodynamic parameters remained unchanged from baseline during the shared ventilator period. The animals were sacrificed after 3 h of mechanical ventilation.

We demonstrated the potential to modulate delivered tidal volumes and pressures, PEEP and FiO 2 in a shared ventilator setup in this in vivo model. The added ventilator circuit modifications are inexpensive and readily available or can be 3D-printed. This setup has allowed to safely ventilate a pair of animals with different lung compliance with a single ventilator, while monitoring and adjusting individual airway pressures and tidal volumes. However, I/E ratios and respiratory remain identical, and supplemental monitoring is required for safety reasons. We must stress that this setup is only to be used temporarily in a crisis setting while arranging for safer and more structural alternatives. The lung compliances were similar to what is frequently seen in ARDS. We think that this is a relevant step in the progressive development Abbreviations PEEP: Positive end-expiratory pressure; FiO 2 : Inspiratory fraction of oxygen; I/ E: Inspiratory/expiratory time ratio; Ppeak: Peak pressure; vent: As measured by ventilator; Indiv: Individually measured on circuit; etCO 2 : End-tidal carbon dioxide; PaO 2 : Partial pressure of oxygen, arterial; PaCO 2 : Partial pressure of CO 2 , arterial Table 1 shows the settings of the ventilator per animal and for the shared ventilator in a volume-controlled ventilation. In animal 2, inline PEEP was applied; in animal 1, the flow restriction with our valve was applied to distribute the pressures as desired among the two animals.

A single ventilator for multiple simulated patients to meet disaster surge

Increasing ventilator surge capacity in disasters: ventilation of four adult-human-sized sheep on a single ventilator with a modified circuit

Two for one with split-or co-ventilation at the peak of the Covid-19 tsunami: is there any role for communal care when the resources for personalised medicine are exhausted?

One ventilator for two patients: feasibility and considerations of a last resort solution in case of equipment shortage

Ventilator sharing during an acute shortage caused by the COVID-19 pandemic

Individualized mechanical ventilation in a shared ventilator setting: limits, safety and technical details

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We would like to thank Prof. Dr. Jan Deprest and his lab personnel in facilitating this experiment.

Authorship was based on the ICMJE guidelines. All authors contributed to the study conception and design. Material preparation were performed by MS, TB, MM, LJ, and TS. The data collection and analysis were performed by MS, MM, HP, LJ, and TS. The figure and tables were designed and edited by HP, MS, and TS. The first draft of the manuscript was written by TS and MS. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

The authors received no specific funding for this work. Hannah Pinson acknowledges a fellowship from the Research Foundation Flanders (FWO), under grant no. 11A6819N.