Coronavirus doctor’s diary: The oxygen supply problem

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Bottlenecks track the fight against the corona virus. At Bradford Royal Infirmary (BRI), only six employees a day can still be tested for the virus. The consultants have made their own personal protective equipment and are looking for – like Dr. BRI's John Wright reports on ways to save oxygen.

April 6, 2020

We're about a week from the estimated peak of the epidemic. Our mainstay of treatment is simply keeping the patient breathing, and we are concerned with two problems – ventilators and oxygen.

It has become clear that the UK is fairly low on the international ventilator table. Even though we place hasty orders for more, it seems to be going a bit and we are concerned that our order will not arrive in time to reach the Covid 19 summit.

However, there is growing evidence that a simple machine used by sleep apnea patients (snoring and breathing disruption) in their own bedrooms can be an effective alternative. And Dr. Tom Lawton, one of our brilliant intensive consultants, managed to get 100 of them in the hands of a local manufacturer.

Oxygen is the other priority.

Manufacturers work 24/7 to keep up with demand, but hospitals are simply not built to provide the flow of oxygen required to hold so many patients on ventilators – and we find that our infectious " red zones "only this can take a maximum of 10 ventilated patients before the oxygen flow drops and triggers an alarm.

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Victor de Jesus

Prof. John Wright, physician and epidemiologist, is the director of the Bradford Institute for Health Research. He has looked after patients with epidemics around the world, including cholera, HIV and Ebola outbreaks in sub-Saharan Africa. Over the next few weeks, he will report to the BBC on how his hospital, the Bradford Royal Infirmary, deals with Covid-19.

Read his first two diary entries: Why do people steal hospital supplies? and make decisions about life and death

When we ordered additional coronavirus case treatment equipment, we expected the surge to occur in May, but Covid-19 has proven to be more communicable than predicted and the climax comes much earlier. The additional fans will not be here in time.

The type of non-invasive ventilation that appears to work best in Covid 19 patients is called continuous positive airway pressure (CPAP). However, some hospital CPAP devices use 50 liters of oxygen per minute for a single patient. This has never been a problem since oxygen is usually not scarce. In Italy, however, it became a problem because many patients had to be ventilated.

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The army was drafted to supply hospitals with oxygen

"One of the problems is that while beds have oxygen next to them, we have never needed such a large flow of oxygen on the ward," says Tom Lawton. "We have about 250 liters per minute for each ward and about 3,000 for the hospital – which, in turn, has never been a problem. But if you use 50 liters per minute for each patient, that's suddenly the case." five in a ward and 60 in a hospital – and we need more than that.

"It's not just us, it's also hospitals across the country – they weren't designed to use that oxygen."

Watford General Hospital announced a critical incident on Saturday as it approached the point where it would not have been able to oxygenate patients who needed it.

Listen to John Wright

  • John Wright records from the BBC Radio 4 medical center NHS at the forefront
  • You can listen to the next episode on Tuesday, April 7, at 11:00 a.m., view the first two episodes online, or download the podcast

In search of ways to work around the problem, Tom worked with Leeds University on a 3D printed valve that could be attached to the hospital ventilators to reduce oxygen consumption.

He also began to look into CPAP devices that were used to treat sleep apnea at home. These keep the air in a mask at a constant pressure to keep the user's airways open. They have to be reused to provide oxygen for hospital use, but they consume much less of it than traditional hospital ventilators.

Tom called a local company to check availability.

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Tom Lawton

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Tom Lawton tests a continuous positive pressure device that is normally used for sleep apnea

"They said: & # 39; Yes, we have 2,000, how many do you want? & # 39; & # 39; he says." And so our plan is to start at 100 and see if if we use it early enough during a patient's stay, we can prevent people from deteriorating and having to go to the more complex ventilators and intensive care unit. "

We tested them over the weekend and there is evidence from China and the US that they appear to be effective. They only help inflate your lungs, and that seems to be beneficial.

They are also very simple, which means that no large amount of training is required.

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John Wright

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The first delivery of simple CPAP devices

Debbie Horner, the Covid-19 intensive care planning consultant who is now back at work after becoming infected with the virus, says that hospital doctors across the country took a deep breath when they heard that Italy running out of oxygen.

"One of the problems we didn't initially know we would have is the diameter of the tubes that come to the hospital," she says. "So it's not just the total amount of oxygen that the hospital has, but also how much you can put to bed? Or how many beds can you supply with oxygen at the same time?"

We had to think about how patients should be distributed "based on the size of the tubes" in the hospital, she says.

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A patient's oxygen supply is adjusted in a hospital in Colmar, France

What everyone wants to avoid with this type of planning is the situation in Italy, where hospitals have not been able to provide intensive care to all patients due to lack of equipment or staff.

However, a lot of thought has been given to how we will deal with this situation when it arises.

"One of the things we want to do at this hospital is to make sure that when we get to that point, every single clinician is supported not only by other clinicians in the workshop, but also by another group of senior doctors and clinicians Hospital, "says Debbie Horner.

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Tom Lawton

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3D printed Venturi valves developed in Italy (left) and Leeds (right) – the design is published on the Internet

"There are also discussions about regional and national ethics committees to help hospitals make this decision-making process so that all of them make decisions using the same framework."

This is new territory for us. There is a feeling of fear of possibly having to repeat some of the decisions made in Italy.

Hopefully it won't reach that point.

consequences @ Docjohnwright on twitter

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