Ventilators and Their Use

CHAPTER 1

Introduction to Ventilators and Their Use

In the spring of the year 2020 the word ventilator became a household word. This was because of the coronavirus pandemic that was causing thousands of additional people to need ventilators to try to survive the virus.

This book is about ventilators and the strange environment surrounding ventilators. Life support mechanical ventilators are complex medical devices that are typically used in the Intensive Care Unit (ICU). Mechanical ventilation is often initiated in the Emergency Room (ER).

People who have loved ones on ventilators have all sorts of questions and concerns about the well-being of their loved one. They have a strong desire to know what is going on in an environment that is nearly as foreign as the Space Station. The purpose of this book is to provide that information expediently and understandably; and in great depth for those who have the time and inclination to explore this astounding endeavor called artificial mechanical ventilation.

This book is organized as a quick, easy reference manual to address all questions that may come to the mind of family members and loved ones using ventilators. This first chapter contains a Quick Reference, with simple clear bullet points addressing the issues in each chapter.

The following chapters explore this same topic in greater depth that will likely be challenging for the average person, but the intention is that it is understandable to anyone who is willing to dig in deeply. This book is primarily intended for lay people, although it may be of benefit to healthcare providers too.

The content in chapters 2 through 9 is arranged in order of what happens to people placed on a ventilator. Chapter 2, why do we use a ventilator in the first place? Chapter 3, what are ventilators? Chapter 4, who should be on a ventilator, or not? Chapter 5, how to put a person on a ventilator. Chapter 6, how to make changes to the ventilator while the patient is on it. Chapter 7, what are quality processes that protect ventilator patients? Chapter 8, how to discontinue or wean from the ventilator. Chapter 9, with all this knowledge we look at how specific diseases are typically managed on ventilators.

Regarding Chapter 6, if it seems too complex and difficult, please don’t give up. Continue onto chapters 7, 8, and 9 which are less difficult to understand, and contain very important additional information.

This book is the author’s best effort at sharing his knowledge, observations and opinions about ventilators and ventilator patient care; therefore, there are no references to medical journals. This is not a medical text. This is not a peer-reviewed scientific document. The information is meant to be true, science-based and to not include misinformation. The author is not trying to convince anyone of anything. Even though this book may sometimes seem like a technical manual, it is not. Do not go out and try to operate a ventilator after reading this book. Running a ventilator takes an ICU professional team and all the resources that implies. Finally, this book is for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment.

This is not a book about ventilation of newborns and small children. There are many differences between mechanical ventilation of babies and larger people.

Having stated what the book is not, the author is a registered respiratory therapist and Doctor of Public Health. He has many years of experience in direct ventilator patient care in intensive care units. His knowledge of ventilator patients and families is front line. He has consulted with the largest ventilator manufacturers in the world as well as smaller ventilator companies in the development of new mechanical ventilators. In addition, he is a National and international speaker on the topic of mechanical ventilation at medical conferences.

Ventilators are called by other names like respirators, breathing machines, mechanical ventilators, or life support machines. Life support mechanical ventilators are not to be confused with air conditioners and fans for blowing air that are sometimes referred to as ventilators. Ventilators are called respirators, not to be confused with face mask devices that filter air or provide clean air in dusty or hazardous environments.

For clarity and simplicity, we will use the term ventilator.

Prior to the 2020 COVID-19 in the USA there were an estimated 10,000 people on ventilators daily. Every year we have 300,000 thousand people on ventilators. It needs to be borne in mind that in most acute care medical centers the average length of time a person spends on a ventilator is about 3 to 5 days. On one hand this average ventilator length of stay (LOS) is made smaller by a shorter length of ventilator stay of about one day or a few hours for many patients with healthy lungs who have had a successful major surgery and only spend a few hours or perhaps overnight on the ventilator. On the other hand, this average length of stay is increased and drawn-out to 3 - 5 days by most of the rest of the patients who spend five days to two weeks on ventilators for very serious medical/ surgical conditions. In addition to a very small number of people who need to remain on the ventilator for a period of several weeks to months. Usually after a person has been on a ventilator for more than one month they are considered a chronic ventilator patient which is not the primary subject of this book.

COVID-19 patients with Acute Respiratory Distress Syndrome (ARDS) are reported to spend 14 - 21 days on ventilators. This can be much longer or shorter depending on the specifics of each patient.

This information must not be misinterpreted, just because the average patient stays on the ventilator about 3 - 5 days does not mean that they come off the machine alive. There are two ways to come off the ventilator: 1) breathing spontaneously and alive or 2) not breathing and dead. The survival rate for ventilator patients can be very different from medical center to medical center and ICU to ICU depending on the types of patients admitted, criticality and type of the patients’ diseases, the types of procedures performed, the amount of attention to end-of-life issues, the quality of medical care services provided, and policies regarding referral to more advanced institutions.

The overall estimated survival rate for a ventilator patient is 70 to 90%. For the sickest patients with Acute Respiratory Distress Syndrome (ARDS), it is 55 - 80% survival. COVID-19 patients often have ARDS. There are reports of 90% fatality among COVID-19 ventilator patients in New York City, Florida and China. In general, the sickest patients do the worst; the least complicated patients do much better. In some excellent intensive care units, the very sickest patients may have a better survival rate. At the same time some ventilator patients will not survive no matter where they are. They are just too sick and have too many body systems failing simultaneously to survive.

The opposite of survival rate is death rate or mortality rate. For ARDS the 25 to 45% mortality rate is worse than Russian roulette with a six-shooter, (approx. 16% chance of death). But this is more complicated than just the numbers. Just because a person survives their time on the ventilator does not say anything about their subsequent quality or quantity of life.

It is worth reminding ourselves that many ventilator patients have a healthful outcome, and go on to live many years of productive enjoyable life. Had they not been placed on a ventilator they would surely be dead.

Quick Reference for Chapter 1: Introduction

What are these machines?

Ventilators are very complex, electronic devices that control air and oxygen to blow breaths into a person to keep them alive. They are not all the same.

How do they work?

Simply put they are like a fireplace bellows, bicycle tire pump, or air mattress pump. But they are not simple, and usually don’t contain pistons or bellows. There are a bunch of valves, connectors, tubes, and control knobs to regulate settings and alarms. The ventilator mixes oxygen and air and blows breaths into the patient.

When are ventilators used?

Anytime a person cannot breathe enough to stay alive. These are life support machines. They don’t cure people. They just keep you alive until your underlying condition gets better, and you can breathe again by yourself.

Why would I want to be put on a ventilator?

Because you want to stay alive and think you have a chance of getting well if kept alive by the ventilator for a while.

When should I not go on a ventilator?

If your condition is terminal and you won’t get well, it is probably better to die peacefully with family and friends with you, in palliative care.

How does it feel to be on a ventilator?

If a person is awake and has no pain killers, he/she feels terrible. Physically, you can’t breathe, speak, eat, drink and you have to lie in bed. You can’t get out to go to the bathroom, and must have a bedpan, bladder tube or diaper. You have to depend on others for everything. You may be in a lot of pain or have to take powerful medications. Mentally, you may be worrying about your loved ones, being a burden, or not being able to work or pay the bills.

Is it really that bad?

No, because the physician will provide the patient with pain killers and appropriate sedation to make the situation much more tolerable.

What is the chance of surviving being on a ventilator?

Survival depends on many factors most important of which is the reason the person was initially placed on the ventilator. Survival is usually higher than 50%. In many cases nearly 100%. With diseases like ARDS caused by COVID-19 the survival is sometimes as low as 10 - 40%.

How much do we have to pay for a patient on a ventilator?

If you have excellent insurance coverage, it could be free. If you don’t have insurance, it costs a lot. ICU charges, physician fees, medicine, lab tests, ventilator charges and supplies may be between $20,000 and $40,000 per day.

If I don’t have that kind of money, can the hospital refuse? No, absolutely not. It is against the law, as well as against common decency. This should never happen.

If I cannot pay, what happens?

Whoever is responsible for the bill may go bankrupt, or if they don’t have assets and the bill goes unpaid, the hospital loses money. Hopefully, the hospital won’t go bankrupt. This is why everyone needs healthcare insurance. No one should have to go bankrupt or be hounded by bill collectors to save their life or their loved ones’ lives.

Why does it cost so much?

Because you are mainly paying for the nurses, doctors and respiratory therapists who are running the ventilator, and expensive medicine, expensive tests and very expensive supplies.

If I am on a cheaper ventilator, do I pay less?

No, the pay is mainly for the health care workers, medicine, tests, and supplies to run the ventilator.

How much does the hospital make on a ventilator patient?

If the hospital gets the patient off the ventilator in a day or so, they might make a few thousand dollars. If the patient is on the ventilator longer than a week, it becomes very costly and the hospital is likely to lose money.

Who determines hospital charges and payments?

The hospital determines their charges, but don’t get what they charge. Medicare and Medicaid determine what they will pay, and that is all the hospital gets. Other private insurance companies may pay more or less than Medicare and Medicaid depending on their coverage. Private people paying cash are expected to pay the whole bill but are usually given some discount if paid within a reasonable time.

How do ventilators affect people whose lives they save or prolong?

If the patient is on a ventilator for a short time and properly sedated, they may not remember anything and breathe just fine thereafter.

If the patient is super sick and on the ventilator for a long time, they can have PTSD and breathing problems for the rest of their life.

What about the families of these patients?

Families can visit the patients if the patient is not either highly infectious or immunocompromised. Meaning, if the patient can give the disease to others easily, or the patient is too weak to fight any germs the visitors bring in, visits may be denied. If the family is sick, they should stay out.

Who operates ventilators?

Respiratory therapists operate the ventilators according to physicians’ specific orders. Nurses take care of the patient’s overall problems and work with the respiratory therapists. Respiratory therapists should have a National Credential and a State License. This is the same with doctors and nurses.

Who are all the people working in the Intensive Care Unit (ICU)?

The ICU doctors are called intensivists, ICU nurses are amazingly competent and highly skilled nurses. Respiratory therapists operate the ventilator working closely with the intensivist and ICU nurse. There are also lab techs, x-ray techs, dietitians, specialist physicians, cleaning staff, pastors, nursing and healthcare students in the ICU.

Who do we ask questions and talk to about our loved one?

The team leader and the main source of information is a doctor. The other health care staff can answer questions related to their work. They should all have basically the same story.

How can I tell who is who in ICU?

The healthcare workers should all have visible ID badges and introduce themselves. It is ok to ask if it is hard to tell. It is a good idea to write down who you spoke to and what they said. It can get very confusing.

Why do some people say they don’t want to be on life support or want unplugged?

Usually they are thinking that they are going to die and don’t want to prolong the agony. Some people are misinformed and think everyone on a ventilator is brain dead. This is ignorant. When it comes down to dying of suffocation or going on a ventilator most people who have a decent chance to get well will choose the ventilator.

What if I really don’t want to be on a breathing machine?

You need to have clear legal documents and instructions to your family, friends and the medical community to not save your life. It is a decision that is extremely difficult/almost impossible to make if you are already on the machine and the physician doesn’t think you are going to die. You need to be very clear and have a POLST (Physician Orders for Life-Sustaining Treatment) and Advanced Directive. A POLST can be made by asking your primary physician and letting them know of your wishes. Advanced Directives is probably best made with advice of an attorney.

What if someone is brain dead and on a ventilator?

They can be taken off, only after it is clearly determined that their brain is dead. There are clear tests to determine brain death. More than one physician has to agree that the tests are correct before the ventilator is removed.

Quick Reference for Chapter 2: Why use a ventilator?

Why do we need to use a ventilator?

Any reason a person cannot breathe enough to stay alive. These are life support machines. They don’t cure people. They just keep you alive until your underlying condition gets better, and you can breathe again by yourself.

Why would I want to be put on a ventilator?

Because you want to stay alive and think you have a chance of getting well if kept alive by the ventilator for a while.

How do we normally breathe?

Normally our diaphragm muscle contracts and sucks air in through our nose and mouth, the air down the windpipe into our lungs. This sucking is a pressure less than room pressure and is called negative pressure. Normal breathing is negative pressure respiration. Normally we breathe out by just relaxing our muscles.

How does the ventilator breathe people?

Ventilators blow air in through some kind of tube or sealed mask. A ventilator is like an air mattress pump, fireplace bellows, air compressor, or bicycle tire pump. They use positive pressure to blow the air into the person. Ventilators use positive pressure respiration. Ventilators do not breathe out; they just let the air come out passively like normal breathing.

Why does the physician sometimes use medical coma?

Medical coma is the use of sedatives and perhaps paralytic drugs to make the ventilator patient relax and not resist the machine. Medical Coma has the advantage of being reversible in a few hours when the medical team decides it is best for the patient.

More specifically, why do people need a ventilator?

People need a life support ventilator for one or more of the following reasons:

Overall reason: The patient cannot move enough air in and out of their lungs by themselves.

General reasons:

1.They cannot get enough oxygen from their lungs into their blood.

2.Their normal breathing tubes (bronchial tubes) are obstructed, too narrow or blocked.

3.Their lungs or chest wall are too stiff, leathery or fibrous.

4.Their central stimulus to breathe from the brain is impaired or absent.

5.Their breathing muscles are too weak to get enough breath.

6.Their blood going to their lungs is not matching with the air being breathed in.

The doctor may know in advance that this person will have respiratory failure. There are many specific diseases and causes of these general problems, but it all comes down to these six conditions