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Management of Adults with COVID-19
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The Society of Critical Care Medicine (SCCM), American Association for Respiratory Care (AARC), American Society of Anesthesiologists (ASA), Anesthesia Patient Safety Foundation (ASPF), American Association of Critical-Care Nurses (AACN), and American College of Chest Physicians (CHEST) issue this consensus statement on the concept of placing multiple patients on a single mechanical ventilator.
Issued: March 26, 2020, 12:00 p.m.
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The Society of Critical Care Medicine (SCCM), American Association for Respiratory Care (AARC), American Society of Anesthesiologists (ASA), Anesthesia Patient Safety Foundation (APSF), American Association of Critical-Care Nurses (AACN), and American College of Chest Physicians (CHEST) issue this consensus statement on the concept of placing multiple patients on a single mechanical ventilator.
The above-named organizations advise clinicians that sharing mechanical ventilators should not be attempted because it cannot be done safely with current equipment. The physiology of patients with COVID-19-onset acute respiratory distress syndrome (ARDS) is complex. Even in ideal circumstances, ventilating a single patient with ARDS and nonhomogenous lung disease is difficult and is associated with a 40%-60% mortality rate. Attempting to ventilate multiple patients with COVID-19, given the issues described here, could lead to poor outcomes and high mortality rates for all patients cohorted. In accordance with the exceedingly difficult, but not uncommon, triage decisions often made in medical crises, it is better to purpose the ventilator to the patient most likely to benefit than fail to prevent, or even cause, the demise of multiple patients.
Background: The interest in ventilating multiple patients on one ventilator has been piqued by those who would like to expand access to mechanical ventilators during the COVID-19 pandemic. The first modern descriptions of multiple patients per ventilator were advanced by Neyman et al in 20061 and Paladino et al in 2013.2 However, in each instance, Branson, Rubinson, and others have cautioned against the use of this technique.3-5 With current equipment designed for a single patient, we recommend that clinicians do not attempt to ventilate more than one patient with a single ventilator while any clinically proven, safe, and reliable therapy remains available (ie, in a dire, temporary emergency).
Attempting to ventilate multiple patients would likely require arranging the patients in a spoke-like fashion around the ventilator as a central hub. This positioning moves the patients away from the supplies of oxygen, air, and vacuum at the head of the bed. It also places the patients in proximity to each other, allowing for transfer of organisms. Spacing the patients farther apart would likely result in hypercarbia.
Spontaneous breathing by a single patient sensed by the ventilator would set the respiratory frequency for all the other patients. The added circuit volume could preclude triggering. Patients may also share gas between circuits in the absence of one-way valves. Pendelluft between patients is possible, resulting in both cross-infection and over-distension. Setting alarms can monitor only the total response of the patients’ respiratory systems as a whole. This would hide changes occurring in only one patient. The reasons for avoiding ventilating multiple patients with a single ventilator are numerous.