Carta científica
Sharing a single ventilator (“In vitro”)
Compartir un ventilador (“In vitro”) para dos pacientes
Sancho Rodríguez-Villara,b,
Autor para correspondencia
sancho.villar@nhs.com
Consultant in Intensive Care Medicine, King's College Hospital NHS Trust Foundation, London. UK.
Consultant in Intensive Care Medicine, King's College Hospital NHS Trust Foundation, London. UK.
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London, United Kingdom" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Honorary Senior Clinical Lecturer in the GKT School of Medical Education, Faculty of Life Sciences & Medicine at King's College London. London, United Kingdom" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Consultant in Intensive Care Medicine, King's College Hospital NHS Trust Foundation, London. UK." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Compartir un ventilador (“In vitro”) para dos pacientes" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 679 "Ancho" => 905 "Tamanyo" => 68123 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Heat and moisture exchanger (HME) filters were placed for each patient to provide heating and humidification as well as, a flow and pressure sensor and capnograh, at least in one of the two connections to increase the level of monitoring and safety.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">One of the main current difficulties that all intensivist is facing during this pandemic crisis is the lack of ventilators around the world. Some institutions have begun to use all resources available to face unprecedented ethical decisions in the developed countries such as direct palliative routes. Sharing a ventilator is technically possible and has been tested only in controlled, experimental models using test lungs or animals for brief periods.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In 2006 Greg Neyman and Charlene Babcock Irvin and Paladino<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1–2</span></a> described how a single ventilator may be quickly modified to ventilate four simulated adults for a limited time. However, in each instance, Branson, Rubinson, and others have cautioned against the use of this technique.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">3–5</span></a> As pointed out by six organization including the Society of Critical Care Medicine and the American Society of Anesthesiologists, there are significant technical challenges that must be overcome.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> Such a strategy should only be considered as an absolute last resort, judged against the alternatives of long term “hand bagging” or death.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> However, we do know that many institutions are evaluating this practice, and protocols are being developed and tested, and in some places, preliminarily implemented in major cities, such New York has been using it since almost the beginning. On March 24, 2020, The Food and Drug Administration (FDA), granted an Emergency Use Authorization for modifications of a host of ventilator-type devices to be used during the COVID-19 pandemic.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The novel idea was not initially conceived to ventilate ARDS/COVID19 patients. In the last several past weeks, we modified and tested this system (“in vitro”) at King's College Hospital NHS Trust Foundation, to be able to ventilate two patients with a standard ICU ventilator.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Two sets of standard ventilator tubing (Hudson) were connected to a single ventilator (tested in each model of a ventilator, Puritan-Bennett, 840 series and a Servo I Maquet) via two “T-tubes” (one on the patient inflow limb of the circuit, and one on the patient exhaust limb). Each “T-tube” was attached to a microfilter (total of four) to isolated both patients and the ventilator (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). Finally, a heat and moisture exchanger (HME) filter was placed for each patient to provide heating and humidification (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">One of the clear advantages with pressure-control ventilation, it is that in the case of a change in the respiratory mechanics of one patient, the second is not affected and there is less dependence on ideal body weight, sex and the compliances of the lung. Also, with a flow/pressure sensor to measure the expiratory tidal volume (VTe), the inspiratory peak and mean airway pressures, with the capnography placed, at least in one patient, the monitoring and safety increase considerably. Other variants with extra features and potential better improvements have been also released recently by colleagues around the world, but we must declare that we have not tested these variations in our laboratory.</p><p id="par0030" class="elsevierStylePara elsevierViewall">We are aware that there are no available randomised control studies to support this approach with full guarantees, however, in our current times where the professional is taking ethical decisions extremely difficult it may be considered as a good alternative as “compassionate treatment” or as a “bridge” for the time being.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Declarations section</span><p id="par0035" class="elsevierStylePara elsevierViewall">Ethics approval and consent to participate: “Not applicable”.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Consent for publication: “Not applicable”.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Author Contributions</span><p id="par0045" class="elsevierStylePara elsevierViewall">S. R. V was the main study “in vitro” researcher and who draft the manuscript.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Funding</span><p id="par0050" class="elsevierStylePara elsevierViewall">Financial support, including any institutional departmental funds, was not sought for the study.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflict of interests</span><p id="par0055" class="elsevierStylePara elsevierViewall">All faculty and staff who are in a position to control or affect the content of this paper have declared that they have no competing financial /commercial interests at all.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Declarations section" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Author Contributions" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Funding" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interests" ] 4 => array:2 [ "identificador" => "xack489548" "titulo" => "Acknowledgements" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0070" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0030" ] ] ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1597 "Ancho" => 905 "Tamanyo" => 101354 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Two sets of standard ventilator tubing (Hudson) were connected to a single ventilator (tested in each model of ventilator, Puritan-Bennett, 840 series and a Servo I Maquet) via two T-tubes (one on the patient inflow limb of the circuit, and one on the patient exhaust limb). Each T-tube was attached to a microfilter (total of four) to isolated both patients and the ventilator. Especially if the circuit do not have in place non-return valves.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 679 "Ancho" => 905 "Tamanyo" => 68123 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Heat and moisture exchanger (HME) filters were placed for each patient to provide heating and humidification as well as, a flow and pressure sensor and capnograh, at least in one of the two connections to increase the level of monitoring and safety.</p>" ] ] 2 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 34688602 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:5 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A single ventilator for multiple simulated patients to meet disaster surge" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "G. Neyman" 1 => "C. Irvin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1197/j.aem.2006.05.009" "Revista" => array:6 [ "tituloSerie" => "Acad Emerg Med." "fecha" => "2006" "volumen" => "13" "paginaInicial" => "1246" "paginaFinal" => "1249" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16885402" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0045" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Increasing ventilator surge capacity in disasters: ventilation of four adult-human-sized sheep on a single ventilator with a modified circuit. <span class="elsevierStyleItalic">Resuscitation</span>" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "L. Paladino" 1 => "M. Silverberg" 2 => "J. Charchaflieh" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "2008" "volumen" => "77" "paginaInicial" => "121" "paginaFinal" => "126" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0050" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Use of a single ventilator to support 4 patients: laboratory evaluation of a limited concept" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R. Branson" 1 => "T. Blakeman" 2 => "B. Robinson" 3 => "J. Johannigman" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Respir Care." "fecha" => "2012" "volumen" => "57" "paginaInicial" => "399" "paginaFinal" => "403" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0055" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A single ventilator for multiple simulated patients to meet disaster surge" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R.D. Branson" 1 => "L. Rubinson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Acad Emerg Med." "fecha" => "2006 Dec" "volumen" => "13" "paginaInicial" => "1352" "paginaFinal" => "1353" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0060" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Use of a single ventilator to support 4 patients: laboratory evaluation of a limited concept" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R.D. Branson" 1 => "T.C. Blakeman" 2 => "B.R. Robinson" 3 => "J.A. Johannigman" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Respir Care." "fecha" => "2012 Mar" "volumen" => "57" "paginaInicial" => "399" "paginaFinal" => "403" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0065" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "The Society of Critical Care Medicine (SCCM), American Association for Respiratory Care (AARC), American Society of Anesthesiologists (ASA), Anesthesia Patient Safety Foundation (APSF), American Association of Critical-Care Nurses (AACN), and American College of Chest Physicians (CHEST) issue this consensus statement on the concept of placing multiple patients on a single mechanical ventilator. March 26, 2020." ] ] ] 6 => array:3 [ "identificador" => "bib0070" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Recommended Strategies from the U.S. Public Health Service to Optimize Provision of Mechanical Ventilation. Point number 8 of the document. March 30, 2020." ] ] ] 7 => array:3 [ "identificador" => "bib0075" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "U.S. Food and Drug Administration. Emergency Use Authorization [cited Mar 24, 2020]. Available at: https://www.fda.gov/media/136423/download" ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack489548" "titulo" => "Acknowledgements" "texto" => "<p id="par0060" class="elsevierStylePara elsevierViewall">Harvey Kelleway and Jonathan Saka technicians at King's College Hospital NHS Trust Foundation for their time and input.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/02105691/0000004400000008/v1_202010310735/S0210569120301601/v1_202010310735/en/main.assets" "Apartado" => array:4 [ "identificador" => "53" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Cartas científicas" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/02105691/0000004400000008/v1_202010310735/S0210569120301601/v1_202010310735/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569120301601?idApp=WMIE" ]
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| 2021 Agosto | 86 | 67 | 153 |
| 2021 Julio | 70 | 51 | 121 |
| 2021 Junio | 85 | 43 | 128 |
| 2021 Mayo | 76 | 67 | 143 |
| 2021 Abril | 174 | 106 | 280 |
| 2021 Marzo | 161 | 58 | 219 |
| 2021 Febrero | 99 | 35 | 134 |
| 2021 Enero | 115 | 26 | 141 |
| 2020 Diciembre | 131 | 35 | 166 |
| 2020 Noviembre | 129 | 25 | 154 |
| 2020 Octubre | 86 | 16 | 102 |
| 2020 Septiembre | 94 | 30 | 124 |
| 2020 Agosto | 101 | 32 | 133 |
| 2020 Julio | 130 | 45 | 175 |
| 2020 Junio | 311 | 64 | 375 |
| 2020 Mayo | 164 | 83 | 247 |
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