How to use one ventilator to save multiple lives | Figure 1

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How to use one ventilator to save multiple lives

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One consequence of the #covid-19 pandemic is that hospitals around the world are facing a shortage of ventilators.

In this short video, emergency medicine physician Dr. Charlene Irvin Babcock from Michigan, U.S., demonstrates how to modify one ventilator to ventilate two or four patients simultaneously.

The technique is based on a feasibility study that Dr. Babcock co-authored, and which was published in Academic Emergency Medicine in 2006. While the concept has been demonstrated in other studies on animals and lung models, the technique has not been formally studied in humans. In October 2017, following the Las Vegas shooting, Dr. Kevin Menes used the same principles to ventilate two patients with a single ventilator.

Posted by Figure 1 on March 20,2020.

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\ \ May 27, 2020\ There have been reports that some patients with covid-19 develop neurologic symptoms. In April, a study appearing in JAMA found that patients with more severe cases of SARS-CoV-2 were more likely to develop neurologic signs including strokes, loss of consciousness (or changes in general levels of alertness) and injury to the muscles of the body. A new study in The New England Journal of Medicine adds to this body of knowledge.\ The researchers gathered data on 64 SARS-CoV-2 positive patients who had been admitted to an intensive care unit in France with acute respiratory distress syndrome, a life-threatening complication of many diseases including covid-19.\ Concerning findings included evidence of disease to the corticospinal tract of the central nervous system, which is responsible for voluntary muscles, in 67 percent of the patients. These patients were seen to have more brisk reflexes, muscle spasms at the ankle (known as "clonus"), and abnormal reflexes on the soles of the feet. Amongst the patients, two were found to have experienced a stroke, and of eight who were considered at high risk of seizures, one had an abnormal EEG (electroencephalogram) which demonstrated findings that, while abnormal, were not specific to a specific disease. Interpretation of these findings poses significant challenges. It remains unclear whether these neurologic findings are specific to SARS-CoV-2 (including inflammatory crises caused by cytokines, for example), or whether such findings are only being detected because the "magnifying glass" is being applied to patients in ICUs such as the one described in this study. It is known, for example, that prolonged critical illnesses that require ICU medicine are associated with changes in brain cognition and neurologic function. Some of these changes are caused by powerful medications that must be used to keep patients alive and some are caused simply by the fact that the human mind and body are not "designed" to function in an environment like an ICU.\ Shared with permission from Brief19, a daily review of #covid-19 research and policy.](https://app.figure1.com/case-detail/0eb40d0d-601f-4105-b221-35074cd9b447)

\ \ The 2019 Coronavirus outbreak was declared a global Public Health Emergency by the World Health Organization (WHO) on 30th January 2020.\ In order to ensure immediate access to relevant systematic reviews, a Cochrane Library Special Collection has been produced. This assembles Cochrane Reviews identified as most directly relevant to the management of people hospitalized with severe acute respiratory infections. It includes reviews that are relevant to the WHO interim guidance for the 2019 coronavirus outbreak (28 January 2020) as well as reviews identified as relevant by Cochrane Acute and Emergency Care.\ The Special Collection will be updated to ensure it remains applicable as the situation changes, and as WHO guidance evolves, and will also draw on the knowledge of Cochrane groups in affected regions. An additional collection of reviews addressing prevention and infection control measures will be developed separately.\ While the reviews in the Special Collection assess interventions that are referenced in the WHO interim guidance, the direct applicability of the evidence may be limited by the low proportion of people with viral infection enrolled in the primary studies.\ The Special Collection includes Cochrane Reviews on the following topics: fluid and vasopressor therapy; respiratory support and mechanical ventilation; weaning mechanical ventilation; managing hypoxaemia; pharmacological treatment; and nutrition in intensive care.](https://app.figure1.com/case-detail/1bc777a7-93d8-4d48-bf90-12f0b0eeb33d)

\ \ Two Patients In Study Died. Was That More Or Less Than Expected?\ April 17, 2020\ An "exclusive" article in the medicine and health publication STAT News states that data from patients with severe covid-19 "suggests" that patients are "responding" to remdesivir, an anti-viral medication made by Gilead that inhibits some viruses from replicating. The news item is based on a video describing of some of the findings of an ongoing study, which has no control group which was obtained by STAT. In the video, the lead physician overseeing the study at the University of Chicago states that thus far only two patients have died, out of 113 severe cases. However, in a previous study in China, zero patients with "severe" illness died (all deaths came from cases classified as "critical"). From that perspective, the news out of Gilead could equally be spun as concerning instead of "encouraging," as some experts have stated. Additionally, it is unclear just how "severe" these patients' illnesses are.\ The study does not include patients with multiple organ failure, the need for mechanical ventilation at the time of screening or for 5 or more days, lung bypass ("ECMO"), high levels of two important liver enzymes, and/or moderate to severe kidney disease. Severe patients are defined in this study as having oxygen saturations (measured "peripherally," using probes on the finger) of 94% or less, or requiring supplemental oxygen at time of screening. For context, many patients with emphysema routinely have oxygen saturations in the 88-95% and are able to function normally. Finally, as the study in question has no control group, medical scientists will not be able to consider the emerging data as informative. However, randomized controlled trial data is expected to provide better information and may identify which, if any, patients benefit from the drug.\ \ Shared with permission from Brief19, a daily review of #covid-19 research and policy.](https://app.figure1.com/case-detail/2a8fa65a-146e-490a-94dc-4fa5eee11a3b)

\ \ Is chloroquine or hydroxychloroquine useful in treating people with COVID‐19, or in preventing infection in people who have been exposed to the virus?\ What is the aim of this review?\ COVID‐19 is an infectious respiratory disease caused by a coronavirus called SARS‐CoV‐2. If the infection becomes severe, people may need intensive care and support in hospital, including mechanical ventilation.\ Drugs used for other diseases were tried out in COVID‐19, and this included chloroquine, used for malaria; and hydroxychloroquine used for rheumatic diseases, such as rheumatoid arthritis or systemic lupus erythematosus. We sought evidence of the effects of these drugs in treating people ill with the disease; in preventing the disease in people at risk of getting the disease, such as health workers; and people exposed to the virus developing the disease.\ Key messages\ Hydroxychloroquine does not reduce deaths from COVID‐19, and probably does not reduce the number of people needing mechanical ventilation.\ Hydroxychloroquine caused more unwanted effects than a placebo treatment, though it did not appear to increase the number of serious unwanted effects.\ We do not think new studies of hydroxychloroquine should be started for treatment of COVID‐19.\ What was studied in the review?\ We searched for studies that looked at giving chloroquine and hydroxychloroquine to people with COVID‐19; people at risk of being exposed to the virus; and people who have been exposed to the virus.\ We found 14 relevant studies: 12 studies of chloroquine or hydroxychloroquine used to treat COVID‐19 in 8569 adults; two studies of hydroxychloroquine to stop COVID‐19 in 3346 adults who had been exposed to the virus but had no symptoms of infection. We did not find any completed studies of these medicines to stop COVID‐19 in people who were at risk of exposure to the virus; studies are still under way.\ The studies took place in China, Brazil, Egypt, Iran, Taiwan, North America, and Europe; one study was worldwide. Some studies were partly funded by pharmaceutical companies that manufacture hydroxychloroquine.\ What are the main results of our review?\ Treating COVID‐19\ Compared with usual care or placebo, hydroxychloroquine:\ · clearly did not affect how many people died (of any cause; 9 studies in 8208 people);\ · probably did not affect how many people needed mechanical ventilation (3 studies; 4521 people);\ · may not affect how many people still tested positive for the virus after 14 days (3 studies; 213 people).\ We are uncertain whether hydroxychloroquine affected the number of people whose symptoms improved after 28 days.\ Compared with other antiviral treatment (lopinavir plus ritonavir), chloroquine made little or no difference to the time taken for symptoms to improve (1 study; 22 people).\ Compared with usual care in one study in 444 people, hydroxychloroquine given with azithromycin (an antibiotic) made no difference to:\ · how many people died;\ · how many needed mechanical ventilation; or\ · time spent in hospital.\ Compared with febuxostat (a medicine to treat gout), hydroxychloroquine made no difference to how many people were admitted to hospital or to changes seen on scans of people's lungs; no deaths were reported (1 study; 60 people).\ Preventing COVID‐19 in people exposed to it\ We are uncertain whether hydroxychloroquine affected how many people developed COVID‐19, or how many people were admitted to hospital with COVID‐19, compared with those receiving a placebo treatment (1 study; 821 people).\ Compared with usual care, hydroxychloroquine made no difference to the risk of developing COVID‐19, or antibodies to the virus, in people exposed to it (1 study; 2525 people).\ Unwanted effects\ When used for treating COVID‐19, compared with usual care or placebo, hydroxychloroquine:\ · probably increases the risk of mild unwanted effects (6 studies; 1394 people);\ · may not increase the risk of serious harmful effects (6 studies; 1004 people).\ When given along with azithromycin, hydroxychloroquine increased the risk of any unwanted effects, but made no difference to the risk of serious unwanted effects (1 study; 444 people).\ Compared with lopinavir plus ritonavir, chloroquine made little or no difference to the risk of unwanted effects (1 study; 22 people).\ When used for preventing COVID‐19, hydroxychloroquine probably causes more unwanted effects than placebo, but may not increase the risk of serious, harmful unwanted effects (1 study; 700 people).\ How confident are we in our results?\ We are confident about our results for how many people died and moderately confident about how many needed mechanical ventilation. We are moderately confident about the unwanted effects of hydroxychloroquine treatment, but less confident about our results for serious unwanted effects; these results might change with further evidence.\ How up‐to‐date is this review?\ We included evidence published up to 15 September 2020.](https://app.figure1.com/case-detail/47eaf351-8332-42a9-9ffc-cd099dc20b03)

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