Shared Ventilation in the Era of COVID-19: A Theoretical Consideration of the Dangers and Potential Solutions.

Publisher: Daedalus Enterprises for the American Association for Respiratory Therapy Country of Publication: United States NLM ID: 7510357 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1943-3654 (Electronic) Linking ISSN: 00201324 NLM ISO Abbreviation: Respir Care Subsets: MEDLINE

Publication: <1983-> : Dallas, TX : Daedalus Enterprises for the American Association for Respiratory Therapy
Original Publication: Philadelphia : Lippincott, c1971-

Coronavirus Infections*/epidemiology ; Coronavirus Infections*/therapy ; Pandemics* ; Pneumonia, Viral*/epidemiology ; Pneumonia, Viral*/therapy ; Respiration, Artificial*/adverse effects ; Respiration, Artificial*/instrumentation ; Respiration, Artificial*/methods ; Respiratory Mechanics* ; Ventilators, Mechanical*/standards ; Ventilators, Mechanical*/supply & distribution; Practice Patterns, Physicians'/*trends; Airway Resistance/physiology ; Betacoronavirus/isolation & purification ; COVID-19 ; Computer Simulation ; Equipment Design ; Humans ; Risk Assessment ; SARS-CoV-2 ; Tidal Volume/physiology

Background: The use of shared ventilation, or the simultaneous support of multiple patients connected in parallel to a single mechanical ventilator, is receiving considerable interest for addressing the severe shortage of mechanical ventilators available during the novel coronavirus pandemic (COVID-19). In this paper we highlight the potentially disastrous consequences of naïve shared ventilation, in which patients are simply connected in parallel to a ventilator without any regard to their individual ventilatory requirements. We then examine possible approaches for individualization of mechanical ventilation, using modifications to the breathing circuit that may enable tuning of individual tidal volumes and driving pressures during either volume-controlled ventilation (VCV) or pressure-controlled ventilation (PCV).
Methods: Breathing circuit modifications included a PEEP valve on each expiratory limb for both VCV and PCV, an adjustable constriction and one-way valve on the inspiratory limb for VCV, and a pressure-relief valve for peak inspiratory pressure reduction on the inspiratory limb for PCV. The ability to regulate individual tidal volumes using these breathing circuit modifications was tested both theoretically in computer simulations as well as experimentally in mechanical test lungs.
Results: In both the simulations and experimental measurements, naïve shared ventilation resulted in large imbalances across individual tidal volume delivery, dependent on imbalances across patient mechanical properties. The proposed breathing circuit modifications for shared VCV and shared PCV enabled optimization of tidal volume distributions. Individual tidal volume for one patient during shared VCV was sensitive to changes in the mechanical properties of other patients. By contrast, shared PCV enabled independent control of individual patient-received ventilation.
Conclusions: Of the shared ventilation strategies considered, shared PCV, with the inclusion of in-line pressure-relief valves in the individual inspiratory and expiratory limbs, offers the greatest degree of safety and lowest risk of catastrophic mechanical interactions between multiple patients connected to a single ventilator.
Competing Interests: Dr Kaczka has disclosed relationships with Zoll Medical Corporation and Monitor Mask. Mr Branson has disclosed relationships with Mallinckrodt, Ventec Life Systems, and Zoll Medical Corporation. Drs Herrmann and Kaczka are co-founders and shareholders of OscillaVent, and Dr Hawley is an employee of OscillaVent. The other authors have disclosed no conflicts of interest.
(Copyright © 2020 by Daedalus Enterprises.)

Keywords: COVID-19; coronavirus; differential lung ventilation; mechanical ventilation; shared ventilation; surge capacity

Date Created: 20200508 Date Completed: 20200715 Latest Revision: 20201218

20221213

10.4187/respcare.07919

32376612