约翰斯·霍普金斯大学紧急事件准备办公室主任加比·凯伦告诉《纽约时报》:“我们可能面临的最严重、最可怕的事情是对需要使用呼吸机的患者进行定量配给或分诊治疗。”
在武汉新冠疫情爆发的早期,当地医疗系统也不堪重负,出现了呼吸机短缺。因此武汉所在的湖北省的死亡率高于中国其他地区。
哈佛大学、约翰斯·霍普金斯大学和南京医科大学的研究人员最近的一项研究认为,如果美国出现类似的疫情,即有一个城市的感染者和危重患者比例与疫情中心武汉相同,即使与武汉一样采取严格的封城措施,美国的ICU需求也将超出医院容量。
该项研究称:“超出医院的医疗卫生服务能力,还会导致治疗质量下降,如无法使用呼吸机等,”从而出现更多死亡病例。
美国医疗保险和医疗补助服务中心主任和联邦新型冠状病毒工作组成员塞玛·维尔马上周在接受福克斯新闻频道的电视采访时,被问到一旦病例大幅增加,美国是否有足够多的呼吸机和ICU床位。对此,维尔马拒绝回答。主持人玛莎·麦卡勒姆问维尔马能否向全体美国人保证不会出现医疗用品短缺,维尔马避而不答。
维尔马回答说:“这就是为什么总统采取了这种大胆果断的措施。”她提到了一些“减缓策略”,例如对欧洲的旅行禁令等,但没有提到呼吸机的问题。
专业人员短缺
呼吸机的绝对数量是此次疫情期间人们担心的问题之一;另外一个问题是经过培训的呼吸机操作人员的数量。
兰特在2015年参与的这项研究发现,假如美国可以投入13.5万台呼吸机,呼吸治疗师将成为“短缺资源”。
兰特说道:“这些治疗师在治疗COVID-19患者的第一线。他们也可能染病,所以医护人员短缺,可能导致[呼吸机]无法使用。”
美国呼吸护理协会首席商务官提摩西·R·迈尔斯表示,美国目前有约15万名持证呼吸治疗师。美国劳工统计局的数据显示,呼吸治疗师是美国增长最快的职业之一,预计2018年至2028年期间该职业的就业增长率将达到21%,相比之下所有职业的平均就业增长率只有5%。
在美国,呼吸治疗师需要获得认证呼吸治疗课程的副学士学位,并且必须通过国家资格认证考试。呼吸治疗师取得资格后可以申请执照,之后还需要在就业地点接受额外培训。美国除了阿拉斯加州以外,其他各州都要求呼吸治疗师持证上岗。
迈尔斯表示:“在所有医疗职业当中,只有呼吸治疗师需要接受机械辅助通气理论学习和临床培训。”持证的医护人员也可以提供机械辅助通气,但具体培训内容取决于各医院的政策。
在许多欧洲国家,呼吸治疗师不是一种单独的职业,因此由医生和护士负责这方面的工作,这“在大流行病期间,比如出现危重患者的COVID-19疫情,会给重症护理病房的医护人员增加工作负担。”英国目前安排已经退休的医生或者重新培训其他科室的专业人员操作呼吸机。
迈尔斯表示:“虽然美国有呼吸治疗师,因此可能不会加重护理人员的负担,但如果有被感染的医护人员检测呈阳性或者出现设备短缺,都会导致资源负担。”
呼吸机的生产商
美国呼吸机市场被多家大型跨国公司瓜分,如美敦力、德尔格、Vyaire Medical、哈美顿医疗公司(Hamilton Medical)、Getinge和飞利浦(Philips)等。
提到因新型冠状病毒大流行导致的需求激增,哈美顿医疗公司首席执行官安德烈亚斯·威兰告诉路透社:“可用的呼吸机与需求之间存在巨大缺口。”威兰称,为了完成中国、土耳其、美国等地的订单,哈美顿医疗公司已经将产量提高了40%。他说:“所有人都在下订单。”
Getinge发言人称,该公司2019年生产了1万台呼吸机。Getinge的呼吸机在瑞士生产,生产1台呼吸机需要两天时间。该公司生产便携式呼吸机、有创呼吸机和无创呼吸机等多种设备。
该公司发言人称:“在当前的关键情况下,全球呼吸机需求大幅增长,Getinge目前已经开足马力,全力满足客户的需求。”
美国是Getinge呼吸机的市场之一。该公司发言人确认新型冠状病毒疫情期间需求有所增长,但对当前季度的销售数据拒绝发表意见。
正常情况下,德尔格的呼吸机年产量也是1万台。该公司告诉路透社,德国政府上周订购了1万台重症监护呼吸机。
美敦力公司发言人表示,COVID-19期间,中国的呼吸机需求增加,公司将“满足全球所有客户的需求”,而且呼吸机生产没有受到干扰。
拉平曲线
兰特提到公共卫生专家和推特热门标签呼吁“拉平感染人数曲线”,以避免医院不堪重负。他说,美国的呼吸机最终是否足够,“依旧取决于[美国人]如何应对疫情。”
兰特表示:“首先需要采取的公共卫生措施应该是要求人们现在就实行社交隔离,以避免未来几天和几周医院系统的压力激增。”
托马斯·杰斐逊大学人口健康与卫生政策专家德鲁·哈里森在推文中表示,洗手、社交隔离和自我隔离等预防性措施非常重要。虽然这些措施无法完全避免感染,但可以推迟同期病例大幅增加,让医院有“准备和防控的时间”。
他说,这些措施可能决定患者“是能找到一个ICU床位[和]呼吸机还是在停车场的帐篷里接受治疗。”(财富中文网)
译者:Bi
For some critically-ill COVID-19 patients, mechanical ventilation can be the difference between recovery and death.
Ventilators assist or replace respiratory functions, pumping oxygen into the blood for vital organs. They are "the main supportive treatment" for patients in the critical stage of COVID-19, when the mortality rate is 61.5%, a Feb. 24 Lancet medical journalstudy found from a sample of 52 patients in a hospital in Wuhan.
In China, where the coronavirus first hit and the most cases have occurred, 6.1% of all patients became critically ill, while 5% required medical ventilation in intensive care, according to data from the World Health Organization.
But this life-saving equipment—and the trained specialists who operate it—are in finite supply.
On Monday, U.S. President Donald Trump alluded to the need for more of the devices, tellingstate governors they should obtain "respirators, ventilators, all of the equipment" themselves. "[The federal government] will be backing you," he said, "but try getting it yourselves."
Most hospitals' intensive care units or ICUs have enough ventilators to meet demand in a regular flu season but don't have extras in case demand suddenly jumps. A surge of COVID-19 infections in the U.S.—there were over 4,400 as of Monday—has experts worried that cases could overwhelm hospitals there and force doctors to implement triage systems to decide who gets ventilation treatment and who doesn't. In Italy, where there are too few ventilators, doctors are already grapplingwith this grim reality.
Countries try to cope
Critically-ill coronavirus patients require invasive mechanical ventilation. A tube is inserted into a patient's windpipe to provide lungs with oxygen and flush out carbon dioxide, ensuring that oxygen circulates in the blood so respiratory failure and organ failure do not occur.
Because these ventilation devices are reserved for patients at the most serious stage of illness—when their lungs stop supporting them—the equipment is housed in hospitals' ICUs.
ICU ventilators are bulky and expensive, so hospitals usually don't have a surplus. A Medtronic ICU ventilator can cost between $25,000 and $50,000, according to the company's website. One ICU ventilator manufactured by Germany company Draegerwerk weighs close to 130 pounds, including its wheeled trolley.
Italy has 3,000 ventilators, and it appears that's not enough, as hospitals are being forced to triage the rising number of critical cases. Total cases in Italy neared 28,000 on Tuesday, and almost 2,200 people have died, the second-highest number of deaths after China, where 3,200 have passed away.
Italy may have less than a quarter of the ventilators necessary to meet demand, Reuters reported on Saturday. It tendered for 5,000 ventilators; a spokesperson for medical technology company Getinge told Reuters that "a mix" of companies would likely fill Italy's order because no one company could do it alone.
The Italian government also askedthe country's sole ventilator manufacturer, Siare Engineering, to increase production from 125 ventilators a month to 500 per month.
There's worry at the WHO that Iran is also critically low on ventilators. A WHO official said in early March that doctors and nurses in Iran were concerned they did not have enough medical equipment, including ventilators, to treat patients. Iran has one of the highest numbers of COVID-19 cases in the world at nearly 15,000, even before taking into account the concerns that cases are going unreported.
Some companies that supply ventilators have stopped deliveries to Iran because banks are refusing to carry the payments, the Wall Street Journalreported. U.S. government sanctions on Iran do not directly apply to humanitarian aid, but many banks do not want to facilitate payments to Iran,hindering its ability to purchase life-saving medical equipment like ventilators.
U.K. Prime Minister Boris Johnson on Monday urged manufacturing firms and even carmakers like Jaguar to mobilize to produce as many ventilators as possible. The U.K. has 5,000 ventilators but will need "many times more than that" if cases continue to rise, the health secretary said.
A stockpile in the U.S.
The U.S. had enough ventilators to meet demand during the swine flu outbreak of 2009 and 2010,a report from the Centers for Disease Control and Prevention said, but the number of patients who required them then was no greater than recent seasonal flu numbers.
One 2015 study published in the Disaster Medicine and Public Health Preparedness journal found that a maximum of 135,000 ventilators could be put to use in the U.S. in the event of a public health crisis. The estimate was based on the number of ICU beds, ventilators in hospitals, and respiratory therapists.
The 135,000 estimate would meet demand during a moderate outbreak like the 1958 or 1968 flu pandemics, wherein 65,000 people would need ventilation, according to a 2018 analysis by the Johns Hopkins Center for Health Security (JHCHS).
Included in that total is the U.S.'s Strategic National Stockpileor SNS of medical resources,first launched in 1999 as a precaution against bioterrorism threats. An estimated 10,000 ventilators are in that reserve. (The official number is not publicly disclosed.) Health care facilities can request supplemental ventilators from the stockpile through local and state public health departments; state governors then request federal assistance. A spokesperson for SNS said the agency is not able to discuss "specific requests for products at this time."
But even that additional supply "might not suffice to meet demand during a severe public health emergency," the CDCsaid in a white paper three years ago.
If COVID-19 reaches the level of a severe outbreak—like the 1918 pandemic, in which675,000 Americans died—the JHCHS study estimates that 742,500 people in the U.S. would need mechanical ventilation, far outstripping the health system's estimated capacity.
"It is most likely that in areas [of the U.S.] where COVID-19 infections are widespread, hospitals will not have enough ICU beds and ventilators to treat all of the critical cases," said Timothy Lant, one of the authors of the 2015 study.
The virus's spread in the U.S. is still unclear due tothe continued lack of testing, Lant said. "There are many, many people with cold, flu, and COVID symptoms that are not being tested still," he said.
Areas with apparent widespread community transmission— Washington State, New York, Boston, and California—as well as other places where infections may be going undetected, "will see shortages," Lant said. "[T]hings are likely to get worse day by day."
Some states, like Minnesota, have existing "crisis standards of care" for public health crises, outlining ways to allocate ventilators to patients based on health status and age. Such directives provide guidance on how doctors should confront the kinds of triage scenarios hospitals in Italy are dealing with right now.
"The biggest, most dreadful thing we might face is rationing or triaging who gets ventilators," Gabe Kelen, the director of the Office of Critical Event Preparedness at Johns Hopkins University, told the New York Times.
In theearly days of the outbreak in Wuhan, China, the health care system was overwhelmed, and ventilators were in short supply. As a result, the death rate in Hubei Province, where Wuhan is located, was higher than the rest of China.
Should a "Wuhan-like" outbreak occur in the U.S.—with a city seeing the same share of infection and critical cases as the epicenter of the outbreak—ICU needs could exceed hospital capacity, even with social distancing measures as strict as the lockdown in Wuhan, says a recentstudy by researchers at Harvard University, Johns Hopkins University, and Nanjing Medical University.
"Exceeding health care capacity may also lead to decreased quality of care, such as not being able to get access to a ventilator," which would lead to more deaths, the study said.
In a Fox News television interview last week, Seema Verma, the administrator of the Centers for Medicare and Medicaid Services and a member of the federal coronavirus task force, would not saywhether the U.S. has enough ventilators and ICU beds for a surge in cases. When host Martha MacCallum asked Verma if she could assure Americans that there is no shortage of the supplies, Verma dodged the question.
"That is why the president has taken such a bold and decisive action," Verma responded, citing "mitigation strategies" like the travel restrictions on Europe, with no mention of ventilators.
A shortage of specialists
The absolute number of ventilators is one concern amid the outbreak; another is the number of workers trained to operate them.
The 2015 study Lant coauthored found respiratory therapists to be the "limiting resource" that capped ventilator availability in the U.S. at the estimated 135,000.
"As these individuals are in front of patients with COVID-19, they are likely to get sick too, so that [ventilator] may not be able to be used due to health care workforce shortages," Lant said.
There are currently around 150,000 licensed respiratory therapists in the U.S., said Timothy R. Myers, chief business officer for the American Association of Respiratory Care. It's one of the fastest-growing professions in the U.S., with a projected employment growth rate of 21% between 2018 and 2028, compared to the 5% average for all occupations, according to data from the U.S. Bureau of Labor Statistics.
In the U.S., respiratory therapists require an associate's degree from an accredited respiratory care program, and they must pass a national crediting exam. After they are credentialed, they apply for a license—all U.S. states except Alaska require one—and then receive additional training at their place of employment.
"Respiratory therapists are the only medical profession to receive didactic and clinical education on the art and science of mechanical ventilation," Myers said. Licensed physicians and nurses are also permitted to provide mechanical ventilation, Myers said, but training depends on individual hospitals' policy.
In many European countries, respiratory therapist is not its own profession, so doctors and nurses assume the responsibilities, creating "an additional workload burden on an intensive care staff during a pandemic like COVID-19 with critically ill patients," Myers said. The U.K., for its part, is currently bringing doctors out of retirement and retraining specialistsin other fields to use ventilators.
"While that burden of care does not necessarily exist in the United States with respiratory therapists, a compromised staff that has tested positive or a lack of equipment can create a resource burden," Myers said.
Companies behind the machines
Several large multinationals, including Medtronic, Draegerwerk, Vyaire Medical, Hamilton Medical, Getinge, and Philips dominate the ventilator market.
"There's a huge discrepancy between available ventilators and the need," Andreas Wieland, chief executive of Hamilton Medical, told Reuters, referring to the uptick in demand caused by the coronavirus pandemic. Wieland said Hamilton has increased production by up to 40% in response to orders for ventilators from China, Turkey, the U.S., and elsewhere. "[E]veryone is ordering," he said.
Getinge made 10,000 ventilators in 2019, a company spokesperson said. Getinge ventilators are made in Sweden, and production time is two days. The company makes a range of devices,including portable, invasive, and non-invasive ventilators.
"In critical situations like this there is a global increased demand for ventilators and Getinge's production is currently up to full speed to supply our customers," the spokesperson said.
Getinge sells ventilators to the U.S. market, and the spokesperson said demand has increased during the coronavirus outbreak but could not comment on sales numbers for the ongoing quarter.
Draegerwerk's normal annual production is also 10,000 ventilators. The company told Reuters that the German government placed a single order for 10,000 intensive care ventilators last week.
A spokesperson for Medtronic said ventilator demand in China increased during the COVID-19 outbreak, and said Medtronic "is meeting all current customer demand globally" and has not experienced disruptions to ventilator production.
Flattening the curve
Whether the U.S. ultimately has enough ventilators "still depends on what [Americans] do" to respond, Lant said, citing calls by public health experts and a trending Twitter hashtag to "flatten the curve"of infections so hospitals don't get overwhelmed.
"The public health priority should be for people to enact social distancing techniques now to avoid surges on the hospital system in the coming days and weeks," Lant said.
Preventative measures like hand-washing, social distancing, and self-quarantine are crucial—they might not prevent cases outright, but they will delay a surge of simultaneous cases and give hospitals "time to prepare and manage," Drew Harris, a population health and health policy expert at Thomas Jefferson University, said on Twitter.
Such steps, he said, may be the difference "between finding an ICU bed [and] ventilator or being treated in the parking lot tent."