Review of - Positive-Pressure Ventilation Equipment for Mass Casualty Respiratory Failure

Today I will review the document “Positive-Pressure Ventilation Equipment for Mass Casualty Respiratory Failure”. This is available for free as html or PDF at
http://www.upmc-biosecurity.org/website/resources/publications/2006_orig-articles/2006-06-15-positivepressureventilationformasscasualtyrespfailure.html
The authors are: Lewis Rubinson, Richard D. Branson, Nicki Pesik, and Daniel Talmor

This document discusses the need for additional ventilators for a mass casualty event including an influenza pandemic. They discuss the need to stockpile additional ventilators for such an emergency. They also acknowledge that it would be very expensive to stockpile and maintain enough full-featured ventilators to be adequately prepared for such an event, so they discuss how positive pressure ventilators (PPVs) with fewer alarms and capabilities could also be used to supplement the existing stocks in time of emergency.

In my opinion, this is a very well researched and prepared article. Many of the issues documented in this article have in fact shaped the aims of the Pandemic Ventilator Project as well. It deals at length with the advantages and disadvantages of various types of ventilators for use in mass casualty respiratory failure. The emergency ventilators we are designing at the Pandemic Ventilator Project are not meant to compete with or replace regular commercial ventilators, but are meant as a backup in case authorities do not stockpile adequate numbers ahead of time.

The use of improvised ventilator equipment during the polio epidemic in Copenhagen in 1952 is discussed. They had only 4 devices available, but had to ventilate as many as 70 persons at a time. They designed and built a number of devices that were manually operated by medical students and saved many lives that would otherwise have been lost. This is a great example that innovative ideas, methods and pragmatic thinking can be used in times of crisis to save lives.

(For additional information on the use of alternative ventilators in the Polio epidemic, see my previous post http://panvent.blogspot.com/2008/01/everything-old-is-new-again.html )

They then discuss how the use of PPVs requires highly trained and skilled health professionals, and that even in normal times, the number of skilled professionals and equipment is sometimes in short supply. In addition to increasing the physical supply of PPVs, there will also have to be plans in place to be able to extend the capabilities of the health care professionals. There is a discussion of different ways to stretch the existing supply of ventilators. There are details of various disaster scenarios and how they will affect the need for PVPs.

They give a good overview of the logistics of ventilator stockpiling and airway management. Endotracheal intubation is preferred. There is a chart that details the various types of alternative Ventilators and their characteristics. The text provides a detailed analysis of the advantages and disadvantages of each type.

They then reiterate the expected shortage:
“Even with significant state and regional investments in PPV caches, there will likely be a shortage of available PPV equipment during a severe influenza pandemic. Standardized approaches to prioritize allocation of scarce resources such as ventilators must be considered for such events.”

They close with this ominous statement:
“Even though not enough PPVs could be stockpiled to ensure that each patient with ARF has a ventilator during a severe influenza pandemic, the additional capacity afforded by reasonably sized caches can help a significant number of patients survive. This additional PPV equipment must be purchased within the context of a rigorously developed strategy to provide a coordinated medical response to catastrophes. Without such equipment, many patients may die despite having survivable clinical conditions.”

The Pandemic Ventilator Project exists to supply a design for a ventilator that can be built from readily available components to fill that last shortfall. I wonder what the writers of this document think of the Pandemic Ventilator Project? I wonder if they are even aware of it? This document was written nine months before the Pandemic Ventilator Project was started. They cite the use of jury-rigged ventilators constructed during the polio epidemic in Copenhagen as an example of how lives can be saved by using alternative ventilators, but then they recommend that only FDA approved devices be used. In fairness, I do not see how any planner working under the existing liability framework can recommend anything other than an FDA approved device. It is only when an actual crisis arrives, when they are faced with triaging the available ventilators to do the greatest good for the greatest number of people that real alternative solutions can be considered.

A Personal Account of Home Made Ventilator Saving a Life

My post from last week about homemade ventilators used during the polio epidemics in the 1940s and early 1950s (Everything Old is New Again) generated some response. I received a personal account of a ventilator being quickly made for a child during a polio outbreak in Marquette Michigan. This is an account I got from Joan and Don Miller in Marquette, who generously let me reprint it here.



THE IRON LUNG IN MARQUETTE

These are some recollections of mine regarding the iron lung that I saved from my grandfather Max Reynolds belongings. It appears that the story I remember takes place in the late 1930's here in Marquette during the polio epidemic. I will start out with a bit of background on the gentleman and then relate the story of this device.

Grandfather Max came to Marquette as a civil engineer with an explosives company. He married into the Peter White family, one of the founding fathers of Marquette. As time went along Grandfather got very involved with what then was St. Lukes Hospital- now Marquette General Hospital, The Michigan Crippled Children's Clinic, and Bay Cliffs Health Camp. He also pursued two of his most cherished hobbies- boating and photography. The boating interest lead to the building of the Lake Superior Yacht Yard along with it the shop where many things were created and built.

Maxwell K. Reynolds became a director and chairman of the board at the hospital, then a small nonprofit hospital. So he was very interested in the day to day operations of the hospital. When the polio sickness arrived, he got started creating and building the Iron Lungs. I'm not really sure where he picked up the ideas, but he was a very inventive and creative person. So he guided his staff in making a number of these devices. Some of the lungs he made were built out of old oil drums, boxes, or about anything else he could find.

One day the hospital called with an urgent request for a lung. Apparently, they had a patient that required help quickly, and could he help. Max said he would provide a device. He went quickly to the old railway station and found an old refrigerator box- made of plywood in those days. He got that to the Shop and the crew started putting together the unit I still have. A door was made on one side, secured with window sash locks. The neck hole was secured with a rubber knelling pad with hole to fit the youngsters neck. Next, a source of vacuum, so grandmas vacuum cleaner was connected to the box. The air was let into the box with a simple plug valve that would be operated by an attendant to control the child's breathing. Later they tried a phonograph as an actuator, but that required some extra time to perfect. So the story goes, from the first call to the time the unit was delivered was 4 hours!

I guess there are not too many people around now that can assist with this accounting. This is as I recall, and I must add that grand pa Max died when I was about 8 years old. He had many talents and tried to get me started on some of them. I only wish that we had a bit more time, since he was quite a guy!

Recalled by Peter W. Frazier, grandson to Maxwell K. Reynolds, Marquette, Michigan



There is a similar account in the Marquette Monthly of Sep 2006, Back Then.

Link here:
The Wooden Lung, Fighting polio with boxes and vacuum cleaners. by Becky Kratz