key: cord-0894904-kg6pzu7k
authors: Dar, Mohammad; Swamy, Lakshmana; Gavin, Daniel; Theodore, Arthur
title: Reply: Ventilator Options for COVID-19: Quality Trumps Quantity
date: 2021-03-30
journal: Annals of the American Thoracic Society
DOI: 10.1513/annalsats.202106-652le
sha: d5bd8266f587fd1782271ea40bb12e45725b963e
doc_id: 894904
cord_uid: kg6pzu7k

nan

From the Authors:

We appreciate the thoughtful response from Drs. Branson, Rodriquez, and Austin to our original manuscript on mechanical ventilation supply and options in the pandemic (1) . We actually agree with their concerns in regard to subpar ventilatory solutions, including intensive care unit (ICU) use of anesthesia machines. We further agree with their nuanced categorization of the oxylator and GO2VENT as automatic resuscitators rather than ventilators. Similar to anesthesia machines, they require the constant presence of an operator (2), lack the capabilities of a typical ICU ventilator, and lack the alarms or sophisticated monitoring that a typical ICU ventilator has, as we discussed in our manuscript and as Drs. Branson and colleagues further elaborate on in their response. These devices are not suitable replacements for an ICU ventilator under normal circumstances. We appreciate the authors' focus on avoiding misinterpretation and the opportunity to offer clarity across theirs and our response.

Unfortunately, although resourcing for ventilation around coronavirus disease (COVID-19) may be stable in the United States currently (and we recognize thankfully that much of the geographic United States never faced such resource shortages), that "relief" is not universal. Numerous supply and device shortages are presenting in areas of India, currently creating a crush of potential and actual lives lost that could otherwise be saved, and much of the world remains unvaccinated as COVID-19 continues to spread with more concerning speed as evidenced by the B.1.1.7, B.1.617, and other variants (3).

Our section on creating possible "new sources of potential ventilation" recognized that such considerations would be for challenged and scarce settings where the means of usual and acceptable care are not possible for every patient. We certainly do not "encourage use of devices which are ill-suited to the task" where the task is mechanical ventilation for an ICU patient, and when there are any of the alternatives we outlined-including high flow nasal cannula (HFNC), noninvasive ventilation, and of course a true ICU ventilator. In that same section we also spoke of modification of bilevel positive airway pressure machines, which, although not spoken to in the response, we also offer would be wholly unsuitable when usual resources are available.

But where the situation is indeed dire and any margin gained may translate to lives saved, we discussed these possibilities to leverage other various resources that may be available. As we carefully caveated in this section, these devices are essentially lastline options for very specific cases and may serve as bridges until better supply arrives. The oxylator device is described in the same manner in the paper by Jonkman and colleagues highlighted by the authors (2) . Such a scenario may be a hospital setting where all invasive and noninvasive measures are in use or awaiting transition and/or cleaning while further patients require immediate invasive ventilation. In lieu of other options, such patients undergo bag ventilation without a bridge in sight.

In a well-resourced U.S. setting, this situation virtually never happens. A patient who is intubated has a clean ventilator ready and immediately available. However, given ongoing events, it is not reasonable to assume that the same resources are available throughout the world. In these extremely few and rare scenarios, we presented these devices as possible resources to leverage as temporary bridges or stopgaps.

We profoundly agree with the authors that the potential for misinterpretation is significant. We do not think these measures provide a meaningful role in most settings. But as they are cheap, relatively easy to operate, and can serve an important role for a brief period of time in extremely stressed acute care settings, we thought they were worthy of discussion. In such dire circumstance, they may offer an opportunity to buy time, and through that, save lives.

Mechanical-ventilation supply and options for the COVID-19 pandemic. Leveraging all available resources for a limited resource in a crisis

A gas-powered, patient-responsive automatic resuscitator for use in acute respiratory failure: a bench and experimental study

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