Dear Editor,
As the ongoing COVID-19 crisis is spreading from developed into developing nations, a shortage of ventilators in ICUs can be expected during peak prevalence. Sharing a ventilator among patients has been put forward as a rescue solution [1, 2]; in this setting, the so-called pairing of patients with similar characteristics is needed [3–5]. We have developed a modified shared ventilator design that allows for individualization of tidal volumes and driving pressures, positive end-expiratory pressure (PEEP), and inspired oxygen fraction (FiO2) [6], which can thus substantially individualize the delivered breaths, removing the need of pairing (see Fig. 1).
Fig. 1.
Individualized shared ventilator setup in an in vivo model. The ventilator we used was a Datex Ohmeda s/5 Aespire, T-connectors split expiratory and inspiratory circuits. The rotatory valve (Sisto-16RGA) is placed in the inspiratory limb to restrict pressure and thus tidal volume to the subject with the highest lung compliance, and an in-line PEEP valve (Intersurgical, ref. 2207000) is added to the expiratory limb of the circuit to set PEEP individually. Side-stream supply of additional oxygen can modulate the FiO2 that is delivered to each patient. One-way valves (Intersurgical, ref. 1921000) prevent cross-contamination
We have now successfully used this ventilator setup in an in vivo model in a pair of ventilated sheep with different lung compliance, further supporting the potential of this shared ventilator setup as a lifesaving intervention in a crisis setting.
After ethical approval, two healthy Swifter sheep (62 kg and 60 kg, 1 year old) received general anesthesia (buprenorphine-sevoflurane), intubation, arterial catheter, and a C-section. After baseline blood gas and respiratory mechanics measurements, both sheep were connected to a single ventilator. Animal 1 had a lung compliance of 38 ml cmH2O− 1, while animal 2 had a lung compliance of 28 ml cmH2O− 1, differences in compliance could be explained by their position. Ventilator settings and measurements are shown in Table 1. The targeted tidal volume of the shared ventilator was set by adding together the individual tidal volumes of animal 1 (600 ml) and 2 (800 ml), creating a combined tidal of 1400 ml. We measured individual airway pressures, with a fluid-air interfaced pressure transducer (Edwards Lifesciences, Irvine, USA), and individual end-tidal CO2 (etCO2) levels (see Fig. 1). We then partially closed the inspiratory flow for animal 1 until the measured etCO2 levels for each animal were similar to those measured at baseline. This titration was successfully achieved within a few breaths, and the total set tidal volume could be distributed accurately among the two animals. With the added in-line individual PEEP valve, animal 2 received a PEEP of 7 cmH2O, whereas the other received 3 cmH2O of PEEP. The individually measured airway pressures demonstrated that the set PEEP levels were successfully achieved for each animal. FiO2 could be adjusted as expected, with one animal receiving an FiO2 of ~ 0.3 and the other ~ 0.8 with added O2 to its breathing circuit during a short test period. Adequacy of ventilation and oxygenation in this setup was demonstrated with repeated blood gas measurements. Both PaCO2, PaO2, and pH values remained within normal range, thus we can assume that the individual tidal volumes before and after sharing the ventilator were similar. Hemodynamic parameters remained unchanged from baseline during the shared ventilator period. The animals were sacrificed after 3 h of mechanical ventilation.
Table 1.
Ventilator settings and measurements of in vivo individualized shared ventilation
| Individual ventilation | Shared ventilator | |||
|---|---|---|---|---|
| Animal 1 | Animal 2 | Animal 1 | Animal 2 | |
| Ventilator settings | ||||
| Tidal volume (ml) | 600 | 800 | 1400 | |
| PEEP (cmH2O) | 3 | 4 | 3 | 7 |
| FiO2 | 0.3 | 0.3 | 1.0 | |
| I/E ratio | 1:2 | 1:2 | 1:1.5 | |
| Respiratory rate (min−1) | 20 | 20 | 20 | |
| Measured ventilatory values | ||||
| PEEP (cmH2O) | 3 | 5 | 4 | 7 |
| Ppeak vent (cmH2O) | 18 | 32 | 31 | |
| Ppeak circuit (cmH2O) | 19 | 18 | ||
| etCO2 | 31 | 33 | 32 | 29 |
| Blood gas values | ||||
| pH | 7.54 | 7.54 | 7.47 | 7.49 |
| PaO2 (mmHg) | 112 | 230 | 443 | 376 |
| PaCO2 (mmHg) | 31 | 30 | 39 | 36 |
| Hemodynamic values | ||||
| BP (mmHg) | 76/43 | 83/38 | 73/40 | 84/36 |
Table 1 shows the settings of the ventilator per animal and for the shared ventilator in a volume-controlled ventilation. In animal 2, inline PEEP was applied; in animal 1, the flow restriction with our valve was applied to distribute the pressures as desired among the two animals.
We demonstrated the potential to modulate delivered tidal volumes and pressures, PEEP and FiO2 in a shared ventilator setup in this in vivo model. The added ventilator circuit modifications are inexpensive and readily available or can be 3D-printed. This setup has allowed to safely ventilate a pair of animals with different lung compliance with a single ventilator, while monitoring and adjusting individual airway pressures and tidal volumes. However, I/E ratios and respiratory remain identical, and supplemental monitoring is required for safety reasons. We must stress that this setup is only to be used temporarily in a crisis setting while arranging for safer and more structural alternatives. The lung compliances were similar to what is frequently seen in ARDS. We think that this is a relevant step in the progressive development of a shared ventilator solution, but further research needs to be done to better understand its full potential in treating patients with COVID-19.
Acknowledgements
We would like to thank Prof. Dr. Jan Deprest and his lab personnel in facilitating this experiment.
Abbreviations
- PEEP
Positive end-expiratory pressure
- FiO2
Inspiratory fraction of oxygen
- I/E
Inspiratory/expiratory time ratio
- Ppeak
Peak pressure
- vent
As measured by ventilator
- Indiv
Individually measured on circuit
- etCO2
End-tidal carbon dioxide
- PaO2
Partial pressure of oxygen, arterial
- PaCO2
Partial pressure of CO2, arterial
Authors’ contributions
Authorship was based on the ICMJE guidelines. All authors contributed to the study conception and design. Material preparation were performed by MS, TB, MM, LJ, and TS. The data collection and analysis were performed by MS, MM, HP, LJ, and TS. The figure and tables were designed and edited by HP, MS, and TS. The first draft of the manuscript was written by TS and MS. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Funding
The authors received no specific funding for this work. Hannah Pinson acknowledges a fellowship from the Research Foundation Flanders (FWO), under grant no. 11A6819N.
Availability of data and materials
All data generated or analyzed during this study are included in this published article and are shown in Table 1.
Ethics approval and consent to participate
Approval by the Ethics Committee for Animal Experimentation of the Animalium of KU Leuven, Belgium (P066/2020,) was obtained.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Neyman G, Irvin CB. A single ventilator for multiple simulated patients to meet disaster surge. Acad Emerg Med. 2006;13(11):1246–1249. doi: 10.1197/j.aem.2006.05.009. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Paladino L, Silverberg M, Charchaflieh JG, Eason JK, Wright BJ, Palamidessi N, et al. Increasing ventilator surge capacity in disasters: ventilation of four adult-human-sized sheep on a single ventilator with a modified circuit. Resuscitation. 2008;77(1):121–126. doi: 10.1016/j.resuscitation.2007.10.016. [DOI] [PubMed] [Google Scholar]
- 3.Pearson SD, Hall JB, Parker WF. Two for one with split- or co-ventilation at the peak of the Covid-19 tsunami: is there any role for communal care when the resources for personalised medicine are exhausted? Thorax. 2020;75:444–445. doi: 10.1136/thoraxjnl-2020-214929. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Tonetti T, Zanella A, Pizzilli G, Irvin Babcock C, Venturi S, Nava S, et al. One ventilator for two patients: feasibility and considerations of a last resort solution in case of equipment shortage. Thorax. 2020;75(6):517–519. doi: 10.1136/thoraxjnl-2020-214895. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Beitler J, et al. Ventilator sharing during an acute shortage caused by the COVID-19 pandemic. Am J Respir Crit Care Med. 2020. 10.1164/rccm.202005-1586LE. [DOI] [PMC free article] [PubMed]
- 6.Stiers M, Mergeay M, Pinson H, Janssen L et al. Individualized mechanical ventilation in a shared ventilator setting: limits, safety and technical details., 27 May 2020, PREPRINT (Version 1) available at Research Square [+10.21203/rs.3.rs-31765/v1+]. [DOI] [PMC free article] [PubMed]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
All data generated or analyzed during this study are included in this published article and are shown in Table 1.