 Hi everybody, welcome to another COVID-19 update with the Patient Safety Movement Foundation. I'm Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, and I'm so excited to be joined today by Dr. Steve Barker and Dr. Butch Lowe from the University of Florida. Dr. Steve Barker is the Chief Science Officer at Massimo and is a board member at the Patient Safety Movement Foundation. He's also Professor Emeritus of Anesthesiology at the University of Arizona. Hi, I'm Steve. Thank you. It's good to be here. I'm delighted to have with me my friend and colleague, Dr. Butch Lowe. Dr. Lowe is a Professor of Clinical Anesthesiology at the University of Florida in Gainesville. He is a recognized expert in anesthesia technology, computing, and human factors. Welcome to our webinar, Dr. Lowe. Good to have you. Thanks a lot, Steve. Good to be here. Thanks. This question is going to be exactly what is an anesthesia machine and how is it different from the mechanical ventilators that we use today in the intensive care unit? That's a good question, Steve, and it's an important question because during this COVID crisis there are not enough ICU ventilators to go around and so there has been a movement by the American Society of Anesthesiologists to make anesthesia machines available to be used as ICU ventilators, but anesthesia machines are not designed to be ICU ventilators and so there's some considerations that need to be taken into account before they can be used in that way or to use them in that way. Anesthesia machines have sort of evolved over the years. When they were first used back before the 1950s, they didn't even have ventilators on them. Patients breathed spontaneously or were ventilated by hand by the anesthesiologists, but today's anesthesia machines all have ventilators as one of their components and especially over the past 10 years the ventilators themselves have become quite advanced and have a lot of the modes of ventilation and monitoring that you would find in an ICU ventilator. So they are more and more capable to ventilate ICU patients. There are some important differences. The anesthesia machine has a breathing system that is very different from that of an ICU ventilator. If you think of how an anesthesiologist would squeeze a bag to ventilate a patient's lungs, the anesthesia ventilators really are more automated bag squeezers and so there is the patient gas that the patient breathes and there's what's called drive gas which the ventilator pumps into a chamber to essentially squeeze a bag and that's how most anesthesia breathing circuits are built in all anesthesia machines. There's an attempt to try to have the patient rebreathe some of the gases that they previously exhaled and the reason for that is to preserve not use up a lot of anesthetics. So when used in the operating room we try to conserve the amount of anesthetics used by using techniques called low flow but in the ICU we know it's not a good idea because over long durations the anesthesia machine just starts to have problems with humidity build up within the anesthesia machine and consumption of disposables that become a problem. A very important difference between an anesthesia machine and an ICU ventilator is that anesthesia machines were designed to be used with an anesthesiologist or an anesthesia provider right by that machine at all times. The alarms are set up for that machine is intended to be restarted every day to be used on the patients for that day. It can't be connected to a central monitoring station so the whole user interface is not designed for use in an unattended way the way an ICU ventilator is so those are the two major things. Given those differences between an anesthesia machine and an ICU ventilator how will we have to short term modify these machines before we can use them to ventilate COVID patients and who should make those modifications and given all of these differences who should be supervising the use of these machines in an ICU on COVID patients. We are already doing that throughout the country especially in the places that have been hardest hit anesthesia machines have been taken into ICUs and used to ventilate patients for the long term and it takes some forethought and preparation anesthesia machines typically have a lot of other monitors mounted to them and computers mounted to them that are already present in the ICU and so those need to be removed. Some of the connections to pipe gases need to be considered where they're available how the connections are going to be made things like that. So there's some preparation involved that usually involves clinical engineering and with oversight or some input from anesthesiologists to know how to make those conversions and then once the machines in the ICU it really needs to be attended to and watched over by an anesthesia provider and that can be an anesthesiologist a nurse anesthetist a anesthesiologist assistant and in most cases it's usually a team of these people who are present 24 seven at least available if there are any problems and rounding on the machines to check for problems do maintenance type things that need to be done anesthesiologists and other anesthesia providers are being pulled from their usual duties to do this most places are not doing elective surgeries right now and so those providers are available to be used in that way. Right that's a very good point you mentioned problems these are machines that are designed to ventilate patients for maybe a few hours and we're going to suddenly start using them for days at a time what specific problems would you expect with the use of this technology in such a different setting are there potential medical errors associated that we should be concerned about making this adaptation. Well one of the main safety issues that we are worried about is that because the breathing circuit is different for an anesthesia machine and because the patient re-inhales gases that they previously exhaled quite differently from an ICU ventilator that there's more worry that the anesthesia machines could contaminate future patients because the patient with COVID exhales into that breathing circuit and then you bring in another patient and they potentially can re-inhale pathogens that have been exhaled by a previous patient. We are recommending and everybody's doing this putting high efficiency filters into the breathing passageways of the of the anesthesia machine to filter out viruses and we've actually recommended that those be located in two locations in the breathing circuits the two filters both multiply the efficiency and also in case one fails you have the second present all the time but those filters especially over the long term tend to get clogged and can cause some problems and these are issues that are really a bit unique to this whole situation. We are learning as we go in some ways and being as careful as we can. The user interface issue is also interesting we have had respiratory therapists or ICU physicians who think oh here's this new machine I can just set what I want I know how to work a ventilator I'm just going to put the changes I need in for this patient because they don't know the machine for instance in one case made some changes that they wanted the patient to have in their ventilation but didn't go through the steps in confirming that on the machine and so those changes didn't happen. We are being as careful as we can about this but certainly there is opportunity for error. Yeah I think we should stress that it is a different machine it's very much like a pilot climbing into a very different airplane than the one he has been trained in. You mentioned sterility my last question we have all heard proposals that perhaps in a stressed situation and that one anesthesia machine could be used to ventilate more than one patient. What do you think of that idea? When in last ditch efforts people will do what they can to save a patient it's very hard not to provide care to somebody simply because there's not enough equipment. Anesthesia machines are I think a good first line there are devices called transport ventilators there are ventilators of a sort used for CPAP for patients with sleep apnea at home and people are coming up with simple ventilators that can be made easily or cheaply so the US is doing what it can to make as many ventilators available as possible but a last line is to put more than one patient on a ventilator. I say that's a last line it's a solution fraught with problems and unfortunately the potential is there that in trying to save one patient you might actually hurt more than one patient. It's very difficult to ventilate one patient with a ventilator with all of the monitors that come with it it monitors what's happening with one patient. As soon as you start trying to ventilate more than one patient you lose your monitoring because you can only monitor what's happening with both patients and can't really tell what's happening with one versus the other. There is a big problem that you can over ventilate one patient and under ventilate the other patient and of course infection cross contamination is also an issue it becomes a very difficult. It has been done but in my mind is a last-ditch effort and should be done with extreme caution and a number of societies came together last week and spoke out about doing it unless absolutely necessary and because we're talking about anesthesia machines anesthesia machines because of their breathing circuit they are probably less able to ventilate multiple patients they're less suitable for that use just the way the breathing circuit is built not to mention that they're sort of the new guys on the block in the intensive care unit so if more than one patient were to be ventilated at time I would suggest not using an anesthesia machine for that purpose. I think your point is excellent and I believe we both feel exactly the same on this that should be considered a extremely last-ditch alternative and hopefully we'll never have to do that so butch this has been an excellent interview we've learned a lot do you have any final conclusions or recommendations before we close? Unfortunately the hospitals that are dealing with large numbers of COVID patients are really in battlefield mode unfortunately it will increase the number of errors made it's just the nature of how things are people are stressed they're doing things that they're not used to they're scared it's not a good time to be a patient in a hospital I guess that's an important take-home message is that that's why as much as possible the hospitals are trying not to care for patients unless they absolutely need it. Well that's certainly true and I guess I would add that it's also not an easy time to be a doctor or a care provider but we are rising to this occasion we have shown people are doing amazing things we are doing amazing things and I'm proud of everybody for what they're doing and I'm proud of the patient safety movement for their part in this so that's you know we will get through this together this kind of effort and thank you so much for your help. I will add that there are resources available for anesthesiologists hospitals that want to use anesthesia machines as ICU ventilators the American Society of Anesthesiologists website has a lot of material and we are going to start a helpline that the American Society of Anesthesiologists is funding so that people with questions anesthesiologists with questions of how to do this can talk with an expert and get some direct advice from another colleague. That's wonderful and and tips and and help like this is exactly what we want to help provide at the patient safety movement foundation. So thank you both for your time today and I look forward to talking to you soon.