How Do Ventilators Work, and Why Is There a Shortage?



During your favorite medical show, you’ve probably heard an ER doctor give an order to intubate. That means the patient is about to be placed on a ventilator to help them breathe. As the globe faces the COVID-19 crisis, ventilators are becoming a necessary part of many patients’ care. Here’s why U.S. governors are clamoring for the medical devices and why social distancing is so important.

What do ventilators do?

Ventilators are medical machines that help patients breathe. They both push oxygen into the lungs and remove carbon dioxide. The air enters the lungs through a breathing tube, with one end hooked up to the machine and the other going through the mouth or nose down to the windpipe. The procedure to put the tube in is called intubation. A “trach” tube, short for tracheostomy, is one inserted through a surgically made hole in the windpipe.

Philips

Ventilators have been around, in less sophisticated forms, since the late 19th century. They were widely used during the polio epidemic in the 1950s, in the form of iron lungs. Over the decades, ventilators have become smaller and more sophisticated. Now, they’re often used during surgeries to support a patient’s breathing while they’re under anesthesia.

Ventilators are also necessary for patients with acute respiratory distress syndrome (ARDS). This condition can be a side effect of other illnesses, such as pneumonia, and is caused when fluid builds up in the lungs’ air sacs and pulmonary surfactant (a foamy substance that reduces surface tension) breaks down, so that lungs can’t fully inflate. Ventilators help supply extra oxygen in this case and give the lungs time to heal.

Why do COVID-19 patients need ventilators?

Ventilators are not a treatment for any disease; they are considered life support. The reason healthcare workers need them for COVID-19 patients is that many with the illness are having trouble breathing.

The reason many people infected with COVID-19 develop breathing difficulties has to do with little proteins called cytokines. These are small proteins that are released when there’s an infection, as part of the body’s immune response. Blood and other fluids flow to the source of the infection, causing inflammation. A cytokine storm is caused by an excess of these proteins, which in turn leads to hyperinflammation, which can be fatal. SARS and MERS, two coronaviruses related to COVID-19, have both caused cytokine storms in patients. This reaction could be producing some of the more severe respiratory symptoms in certain people with COVID-19.

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When doctors see signs of a patient going into respiratory failure — like an increase in breathing rate and higher CO2 levels in the blood — they will put patients on ventilators. It can take weeks for a patient with COVID-19 to start breathing on their own again, according to The Guardian.

Some doctors are now questioning if certain patients with low blood oxygen levels actually need ventilators, according to Stat. Instead, they might benefit from oxygen masks or other less invasive measures before turning to a ventilator.

Why is there a shortage of ventilators?

While the exact numbers aren’t known, estimates are that between 10% and 25% of COVID-19 patients require breathing assistance. There are over 395,000 cases of the illness in the U.S., and around 160,000 ventilators, according to the Center for Health Security at Johns Hopkins University, plus  12,700 in the National Strategic Stockpile. The ventilators in use aren’t going to be solely used for COVID-19 patients, either; they’re also needed for people who end up in intensive care units for other reasons.

“The reality is there is absolutely not enough,” Andreas Wieland told The New York Times back in mid-March. He’s the chief executive of Hamilton Medical in Switzerland, one of the biggest ventilator manufacturers in the world. In early April, Washington state returned 400 ventilators to the stockpile, so states with rising cases of COVID-19, like New York, could have them. One reason to flatten the curve is to help share limited resources throughout the country.

Only a few U.S. companies make ventilators, including General Electric. Over the past couple of decades, the government has tried to commission low-cost, portable ventilators to stockpile for emergencies, but the projects haven’t panned out. The larger, more expensive machines are complicated to manufacture and have lots of parts, which is why it’s not easy to suddenly ramp up production and why experts have been warning of a shortage for years.

On April 8, the Department of Health and Human Services announced it will pay General Motors $489 million to make 30,000 ventilators, and Philips will receive $646.7 million to produce 43,000 ventilators. The first batch of 2,500 won’t be ready until the end of May, according to Reuters.

In the meantime, GE workers are demanding factories up production, and a 3D printing company is suggesting hospitals in need create a ventilator substitute.

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