Arizona in a rush to acquire ventilators

Officials anticipate surge in patients by summer

Arizona is in a race to secure thousands more ventilators to adequately prepare for what could be a surge of coronavirus patients in April and May.

Ventilators can be lifesaving devices in the new coronavirus pandemic because they provide breathing assistance for someone who is seriously ill from pneumonia and is no longer able to inhale and exhale on their own.

State health officials say they’ve identified about 1,000 ventilators in Arizona and are working to find more. An analysis released this week by The Commonwealth Fund, a nonprofit foundation that supports independent research on health policy, placed Arizona’s rate of full-feature mechanical ventilators at 20.1 per 100,000 people, close to the national average of 20.5.

Arizona is just weeks ahead of what could be a peak in COVID-19 cases in mid-to-late April, with hospitalizations peaking in May, according to Dr. Cara Christ, the Arizona Department of Health Services director.

State officials are using the time to secure ventilators — crucial to treating the most critically ill patients, yet in short supply in other areas of the U.S. and around the world where the disease has affected large numbers of people.

“We anticipate we are somewhere around 1,000 ventilators statewide,” Christ said this week. “What we’re hoping is to get up to 4,500 to 5,000.”

Christ said the state is looking at following U.S. Food and Drug Administration guidance on repurposing anesthesiology devices used in outpatient procedures to safely provide ventilation for COVID-19 patients. The Arizona Department of Health Services has also put in a request to the federal government for 5,000 additional ventilators.

Connecting a patient to a ventilator is more invasive than giving someone oxygen. A ventilator requires a tube to be inserted into the windpipe in a process called intubation. The tube is what’s attached to the mechanical ventilator, the machine that helps the patient breathe, which can also send oxygen concentrations at higher-than-normal pressure to help keep the patient alive.

That Commonwealth Fund study listed New York state has having 23 ventilators per 100,000 people, which is above the national average. Yet New York Gov. Andrew Cuomo this week took to Twitter to say that ventilators are that state’s, “greatest challenge” as it experiences surge of patients.

Arizona’s coronavirus situation is not as serious as New York’s. New York’s cases as of Thursday had reached 30,811, including 285 deaths. Cuomo on March 25 tweeted that the state has 11,000 ventilators but needs 30,000.

The U.S. is still early in its COVID-19 outbreak, but most of the modeling and data is assuming 40% of the U.S. will be infected, according to Dr. Ashish Jha, Dean for Global Strategy at the Harvard T.H. Chan School of Public Health and Director of the Harvard Global Health Institute.

Forty percent of Arizonans works out to about 2.9 million people who could become infected, though the illness varies greatly in severity and some cases have no symptoms at all. Those infections could occur over the next six to 18 months, he said.

It’s possible a vaccine against the new coronavirus could exist in 18 months, or even sooner, he said this week during a teleconference about health care capacity and COVID-19 hosted by the Commonwealth Fund.

The telltale symptoms of COVID-19 are a fever, cough and shortness of breath. While about 80% of cases are mild or asymptomatic, an estimated 20% will be more severe. Based on early evidence found in a study of 1,099 laboratory-confirmed COVID-19 cases out of Wuhan, China, ventilation was needed in about 2.3% of cases.

Using data in the study from China, if 40% of Arizonans develop COVID-19, that would mean roughly 65,900 patients will need ventilation.

In northern Italy, health care workers have struggled with finding enough ventilators to treat a large influx of patients with COVID-19. In one report, a priest with COVID-19 gave up his ventilator for a younger patient, also infected with the virus. The priest later died.

“Italy, that has been hit the hardest, is giving us a very painful picture of decisions that have to be made,” aid Phoenix pulmonologist Dr. Thomas Ardiles, an assistant professor at the University of Arizona College of Medicine Phoenix.

Ardiles said he’s never run into a situation where a ventilator was unavailable to a patient who needs one. But it’s a “very unique situation” right now,” he added.

“We are looking at every possible option. We are looking at a way to connect multiple people to one ventilator. We’re looking at makeshift with anesthesia machines,” Ardiles said.

Ardiles, who treats patients at Banner University Medical Center—Phoenix, said he’s heard talk of ramped-up manufacturing to make more ventilators, but so far he has not seen any tangible results.

“And the thing is, when this thing hits, it’s going to hit really hard and fast. We may need a lot of ventilators in a couple of weeks. It could be really bad,” he said.

“In general, the expected surge is going to be far greater than what hospitals in the United States have. This is not just an Arizona problem,” Ardiles said. “If the surge is what is expected, there’s a very high chance we are going to run out of ventilators.”

In severe cases, the virus causes pneumonia, impairing breathing to a degree where patients either cannot sufficiently breathe on their own, or cannot breathe on their own at all.

That’s when a patient will need a ventilator. First, they need to be intubated, which means a tube is put down their throat, and a ventilator machine attached to that tube is used to help them breathe.

There’s no good data of how long a COVID-19 patient on ventilation will need to be attached to a ventilator, but clinicians believe on average it’s at least a week, Ardiles said. In general, most patients are weaned from the ventilator as their condition improves.

If a patient’s lungs get so damaged that they don’t work, even with assistance, some hospitals have the ability to use an external lung machine known as ECMO — extracorporeal membrane oxygenation. Banner University Medical Center Phoenix has seven ECMO machines, but some hospitals don’t have any.

And it takes a lot of staffing to operate ECMO, Ardiles said — at least two nurses per shift, per machine. If seven ECMO machines are running, that works out to 56 nurses per day.

“The ventilator is an assistant to your own lungs. But your lungs are still good enough to breathe,” Ardiles said. “There’s time during peak flu season we use all our ECMO machines.”

The Department of Health Services on Thursday updated the community transmission level of COVID-19 in the state to widespread after the tally of cases climbed to 508 in 13 counties. The state is reporting eight deaths due to COVID-19. The numbers likely are not reflecting the actual number of cases in the state because of limited testing availability. Many people with COVID-19 symptoms in Arizona say they are unable to get a test.

More positive cases are expected, though Christ said the public can help prevent an unmanageable surge of cases by social distancing — staying at least six feet away from other people when in public — by frequent handwashing, staying home when possible, disinfecting objects and surfaces, and using telemedicine whenever possible.

Evidence so far is showing COVID-19 is both more contagious and more deadly than the seasonal flu. There is no vaccine against COVID-19 and no known effective treatment, either.

Ventilators, which are sometimes also known as respirators, began with the polio epidemic but have become much more sophisticated over the years, Ardiles explained.

They’re commonly used for patients who have overdosed and people who have been in a trauma and can’t breathe on their own,. People who are extremely ill with the flu often need ventilators, too.

“The lungs do two things — they bring oxygen in and then they remove carbon dioxide. For you to bring the oxygen in, you are using your muscles to bring the air in. Healthy lungs have no problem getting healthy oxygen to your blood,” he said. “I can tell the ventilator, give the patient 20 breaths at this amount of volume, at this amount of pressure and the machine will do it,”

In anticipation of a surge of COVID-19 patients, Gov. Doug Ducey ordered all elective surgeries halted in the state as a way of conserving medical supplies like ventilators and personal protective equipment.

Harvard’s Jha said if 40% of Americans get infected over the next six months, the U.S. could need as many as 400,000 ventilators. The estimate of how many exist in the U.S. right now is a wide range, from 60,000 to 160,000.

“Whatever our range is, it’s going to be clearly inadequate,” Jha said, adding that even if there are enough ventilators, they will not do any good if there aren’t enough health care professionals to take care of patients and to operate them.

“Overall, where we are as a country is we are starting to see New York as really the canary in the coal mine of starting to get in trouble with ventilators, personal protective equipment, enough doctors, nurses and beds,” he said. “This will roll across the country in the next two, three four months.”

In a situation where there are not enough ventilators to go around, there are ethical decisions to make. It’s a problem communities around the country are trying to figure out.

“Our hope is that with containment, we won’t be as bad as Italy,” Ardiles said. “But if we are half as bad as Italy, it’s still going to be really bad.”

That’s why the term “flatten the curve” is so important, he emphasized.

An article published March 23 in the New England Journal of Medicine titled “Fair Allocation of Scarce Medical Resources in the Time of Covid-19” offered recommendations to guide what it termed the “rapidly growing imbalance between supply and demand for medical resources in many countries.”

The article says health workers should be prioritized and that resources should not be allocated on a first-come, first-served basis, and that the same principles should be applied for all COVID-19 and non-COVID-19 patients.

Critical interventions such as testing personal protective equipment, intensive care unit beds, ventilators, therapeutics and vaccines should go to frontline health care workers and others who care for ill patients as well as people who keep “critical infrastructure running,” particularly workers with a high risk of infection whose training makes them difficult to replace.

“If physicians and nurses are incapacitated, all patients — not just those with COVID-19 — will suffer greater mortality and years of life lost,” the article states.