CPAP use for Coronavirus mitigation & severe pneumonia

[SuperSleeper]

I'm starting to get emails from people (3 today, 2 yesterday) concerned about Coronavirus (COVID-19) asking about how CPAP, Bi-Level, ASV and other machines might be used to help ventilate Coronavirus patients who might develop a case severe pneumonia.  Of course, hospital ventilators and treatment by the established medical community remains the standard for treating any severe respiratory illness where pneumonia develops.

That said, as this virus is now a global pandemic, as was seen in China and some other countries, the national healthcare systems can easily become overwhelmed and unable to treat all patients in a hospital setting.   There are, after all, a limited number of ventilators and intensive care rooms available.

So this thread is intended not as medical advice.  Always consult with your own doctor and I would recommend that you take their advice very seriously, especially with regard to this pandemic.

I'm opening this thread to help provide some group wisdom for the people who are contacting me about this issue, and this thread is so that a discussion can begin on the possibility of using CPAP or related machines for assistance at home in pneumonia mitigation should standard healthcare options become inaccessible or overwhelmed.

Those of you who have posted your thoughts in other threads on this subject, please feel free to re-post your information in this thread so we have a centralized discussion area.

Again, we are doing this as a community service, and posts in this thread should not be considered as any sort of "medical advice" to our members.



EDIT:  Please make sure you read my entire POST #6 here in this very thread.

Also, a request:

I would suggest that you read this thread prior to replying in it.  You don't have to click on every link or watch every video, but please at least have a basic understanding of what prior members have already posted and discussed.  If you don't want to make the time to do that, then I would suggest that you may wish to reconsider posting in this thread.

ADDITIONAL INFORMATION ADDED APRIL 16, 2020:

NOTICE:

COVID-19 Forum now open

The new COVID-19 Forum is now open and viewable for all registered Apnea Board members.  To view the new forum, you must be signed into your Apnea Board forum account.  If you don't yet have a forum account, you can sign up for one free-of-charge, by clicking HERE.

The new forum is viewable from the Main Forums page.  The direct link is here:

http://www.apneaboard.com/forums/Forum-COVID-19-Forum


NOTE:  While every member can view the COVID-19 Forum, the "working group" members are the only ones who can post replies in the new forum.  

The "working group" is primarily comprised of senior Apnea Board members.  Qualified individuals, such as verified health care professionals and others may be added to this group as we proceed.  If you feel as though your medical background qualifies you to help out in this forum, please send a Personal Message (PM) to SuperSleeper and we will consider giving you posting rights for the COVID-19 forum.

It is our hope that the working group can take the best ideas from the huge COVID-19 thread on the Main Forum and other places and (hopefully in cooperation with some medical professionals) prepare some general guidelines for people who have no choice but to  self-treat at a time when hospitals and clinics become overwhelmed.

It is our desire to develop a set of practical protocols for people to provide an austere method for self-treatment at home using CPAP, Bilevel, ASV and related machines in the event that standard hospital care becomes unavailable.

For those not in the working group, please continue to post your ideas in the large COVID-19 thread on the Main Forum, as many folks from the working group keep up with what's posted there.  In this way, you can help them progress towards the final goal, and your ideas and suggestions may be integrated into the protocols.

Several members have requested  to have a more organized place to present the best ideas to our members, since the huge thread on the Main Forum is understandably difficult to read through.  The new forum is designed to create a more focused consensus opinion for using these machines and other related equipment, supplies and techniques to fight COVID-19 as best we can, in a home setting.

If anyone has questions about the new forum, feel free to post a reply in this thread.  Please do not use this thread to post COVID-19 information or ideas.  Those should go in the huge COVID-19 thread in the Main Forum (HERE).





WARNING:

As always, NONE of the information in the COVID-19 Forum is is to be considered as "medical advice".  If possible, you should always consult with a health care professional prior to changing anything with regard to your sleep apnea or coronavirus treatment, including settings on your CPAP machine.

That said, this COVID-19 Forum was created for a "worst-case" scenario when traditional health care options are no longer available to us due to medical systems being overwhelmed.  Your primary course of action should always be to contact your local health care professionals if you contract COVID-19, as long as those resources remain available to you.  Information posted in this forum is personal opinion only, and not necessarily a statement of fact.

[SarcasticDave94]

Personal experience expressed here: I had pneumonia last July and I have an ASV. My ASV was found to be less effective while pneumonia was being treated after I got out of the hospital, where I was there for about a week for treatment and observation.

I would suggest that these CPAP class of machines are not going to be as good of an approach or alternative to going to the hospital and then if the RT decides an NIV ventilator is deemed necessary they can mask you then.

[Sleeprider]

This discussion has several existing threads on the forum, and I'll try to consolidate some of my responses here. 

CPAP is a fixed pressure device that may make breathing more comfortable when you have a cold or flu because it keeps the positive end expiratory pressure (PEEP) high enough to keep the alveoli expanded.  Especially as lungs begin become congested with fluid, this greathly helps maintain function and capacity.  Bilevel devices have different inhale and exhale pressure (IPAP/EPAPich is known as Pressure Support (PS).  Bilevel devices also keep lungs expanded with PEEP, and they also do part of the physical work of respiration.  At a pressure support of 8 to 12 cm H2O, nearly all the work of respiration is accomplished by the positive ai pressure.  Non-invasive ventilation (NIV) provided by ST (spontaneous/timed), ASV (adaptive servo ventilators, or VAPS (Volume Assured Pressure Support) inclues bilevel pressure support and a backup rate that can trigger IPAP without without spontaneous effort by the patient.  There is no question taht in non-acute respiratory illness, greater comfort is experienced by some of us. Some people theorize that NIV might help the outcome of critically ill patients with pneumonia.  So far that theory remains unsubstantiated as described in teh article below.

Enjoy!  https://www.sciencedirect.com/science/ar...4114004043

The role of noninvasive positive pressure ventilation in community-acquired pneumonia

Abstract
Background
Despite the increasing use of noninvasive positive pressure ventilation (NIV) in the treatment of critically ill patients with respiratory failure, its role in the treatment of severe community-acquired pneumonia (CAP) is controversial. The aim of this study was to assess the use of NIV in patients with CAP requiring ventilation who are admitted an intensive care unit.

Methods
A retrospective cohort study of all consecutive patients admitted to 3 tertiary care, university-affiliated, intensive care units from January 2007 to January 2012 with the principal diagnosis of CAP and requiring positive pressure ventilation was carried out. The primary outcome was acute hospital mortality. Univariable and multivariable analysis were performed to assess the association between mode of ventilation and death as well as factors associated with failure of NIV.

Results
A total of 229 patients were admitted, with 20 patients excluded from the analysis because of do-not-resuscitate orders. Fifty-six percent of patients were initially treated with NIV. Of those, 76% failed NIV and required intubation and invasive ventilation. After adjusting for confounders, no difference in mortality was seen between patients who received NIV as first-line therapy in comparison with patients who received invasive ventilation (odds ratio [OR], 1.63; 95% confidence interval [CI], 0.81-3.28; P = .17). Multivariable analysis demonstrated a trend toward increased NIV failure for the patients who had higher Acute Physiology and Chronic Health Evaluation II scores (P = .07) and vasopressor use at 2 hours after initiation of positive pressure ventilation (OR, 7.5; 95% CI, 1.8-31.3, P = .006). In an adjusted analysis, patients who failed NIV had an increased odds of death when compared with patients who were treated with invasive ventilation (OR, 2.2; 95% CI, 1.0-4.8; P = .03).

Conclusion
Noninvasive pressure ventilation is frequently used in CAP but is associated with high failure rates. Mortality was not improved in the group of patients who received NIV as first-line therapy despite clinical characteristics that might have suggested a more favorable prognosis. Given the high rates of NIV use, high failure rates, and the hypothesis generating nature of the data in this study, further randomized studies are needed to better delineate the role of NIV in CAP.

[SarcasticDave94]

On the NIV class of machines: as far as I know these are the only breathing devices that can go over an IPAP of 30; example a ResMed Stellar can hit 50, and I think an Astral can go to 60 FWIW.

Even so as Sleeprider's info indicates, even an NIV may not be as useful for this purpose than one may think.

[SuperSleeper]

This is likely the same topic, but I'll post an email that I received today:

Please send any up to date briefs on CPAP utilisation / optimisation in Coronavirus / community managed severe pneumonia.

I pointed the person who wrote this email to this thread, so if someone would like to respond, please do so.

[SuperSleeper]

OKAY, folks, I'm going to step up the request on this.  Let me explain WHY I AM DOING THIS.

Please read this post in it's entirety, or you will not understand what I'm asking.  It's a logical progression of thoughts & ideas that will not make sense if you simply scan through it all quickly.

I am not trying to "scare" anyone, nor am I trying to get you to panic in any way.  What I am suggesting is that we start now to prepare for certain likely events, and use our "patient-empowerment" movement and apply what we've learned about CPAP and overall breathing issues to this pandemic, and more importantly, do our best to mitigate the effects COVID-19 might have upon our own lives.

Apnea Board is all about helping one another, and this very issue of possibly using CPAP, BiPAP, ASV etc. to mitigate coronavirus-induced pneumonia might be a VERY IMPORTANT in the days to come.  We may have no other choice than to try our best to figure out a way to use or alter these machines to at least mitigate the effects of pneumonia as best we can.   This is especially important for older people.

What do I mean by that?  Read on...

FACT:  In the U.S. alone, some estimate that we have a bit over 75,000 hospital-grade ventilators, most of which are CURRENTLY now being used.  That's it-- only 75,000 or so.  There ARE NO additional ventilators available.  They are expensive units that take a long time to manufacture.  When the number of patients who need hospital ventilation exceeds 75,000 here in the U.S. what will happen?

FACT:  When someone develops pneumonia and needs to be placed in "intensive care" on a ventilator, there is also a number of hospital staff that must be present to accompany that intensive level of care.   Hospital staff are already stretched thin as it is.  Where will the additional trained & experienced staff come from to administer treatment to an ever-increasing number of patients who need that level of care?

FACT:  As the pandemic progresses, the sheer number of patients who develop severe cases of pneumonia caused by the coronavirus will increase AT AN EXPONENTIAL RATE.  That, in fact, is what is already happening.  It starts off small, but slowly, steadily grows.  The first phase of expansion doesn't involve that many people... but wait for a bit and it will become mind-boggling as to how quickly a pandemic virus can infect nearly everyone on earth, if it goes on for a long time.   Most people cannot get their head around what an "exponential growth rate" actually means.  They may think they know, but many times they simply do not fully understand the concept, since it is very counter-intuitive to the way humans think.

For those who know a bit of math and how rapidly the spread can happen, you will soon figure out that unless absolutely SEVERE measures are taken, or the virus burns itself out, the coronavirus can and will likely spread to the vast majority of the population within a few months.  In hard-hit "red zones", it could spread to the vast majority in those regions in a few short weeks..

For a really good 2-minute video to explain the concept of "exponential growth".  I encourage you to watch it before reading the rest of this post:






Now that you have viewed how quickly exponential growth rates can lead to pandemic virus spread, you're prepared for my next statement...

FACT:  The current overall death rate for people infected with COVID-19 seems to be between 3% and 5% on average.  That's the figures currently.  As we all have heard, as you age, that number goes up.  For people who are in their 60's, it's likely around 5% right now.  If you're in your 70's, it's around 8% currently.  If you're over 80, the death rate is around 15%.  Now, if you have additional other health issues, that adds to your risk.  If you have certain pre-existing conditions (such as diabetes, cardiovascular disease, chronic respiratory disease, high blood pressure, etc), you can add anywhere between 5 to 10 percent onto your age group risk.

That means that if I'm 60 and have diabetes, the death rate is no longer 5%, but anywhere between 10 to 15%.  If I'm 70 and have high blood pressure, the risk of me dying from COVID-19 goes up to between 13% and 18%.  Keep in mind, these death rates are rates that currently exist in the early stages of this pandemic, when we have a solid capacity for hospitalizing and treating those at-risk patients in hospitals that have no severe staff shortages and where ventilators are somewhat available.   What happens to that death rate risk when thousands upon thousands get severely infected and are in need of those hospital services?  I'll tell you what happens-- they can't get adequate treatment and the death rate goes WAY, WAY UP.

FACT:   Okay, assuming that hospitals will get overwhelmed during this pandemic (which WILL happen, and is already starting to happen in many areas), the hospitals simply must prioritize ("triage") who gets put on the limited supply of ventilators that are necessary to help recover from severe pneumonia.  What will happen when we have 100,000 patients who need ventilators, and the 75,000 ventilators in the U.S. are already in use?  They can sometimes "double-up" with certain ventilators, essentially using one ventilator on two people for a limited period of time.  Okay, even if they do that, that might take us up to 150,000 people getting some degree of ventilation, right?  Now, now what happens when we start getting over 150,000 people with severe pneumonia?  Answer:  the hospitals will have to turn people away.  They won't be able to treat everyone.  And it's likely that they will prioritize young people to the front of the line for those existing ventilators, since they have a better chance of surviving the virus.  What does that mean for older people who need a ventilator?  Answer again:  older people will simply be told to "tough it out at home as best you can".

NOW, this is where the patient-empowerment movement can step up to the plate.

IF there is no other choice for older people... if they simply must self-treat at home... the HUGE QUESTION that I'm trying to get folks thinking about is this:

IS THERE ANY POSSIBLE WAY TO USE EXISTING CPAP, Bi-level or ASV machines to provide a small degree of ventilation that might just be enough to help that marginal coronavirus patient with pneumonia over the hump and not become a statistic?

YES, I know that it's not the best method for helping in ventilation.  I know that hospital ventilators are really the only solid and proven equipment to provide pneumonia patients with the degree of ventilation that they need.  I'm not talking about "best" methods here at all.  What I'm talking about is coming up with a method for using our existing home machines to help AT LEAST TO SOME DEGREE, even if it's a very small degree of help.

I don't want to crowd this thread with peer-reviewed studies, op-eds, professional doctor's type advice here, because their advice is always going to be "get to the hospital now" if you've got severe pneumonia.  That's good advice today, but as we progress into the pandemic, we may not be able to "get to the hospital" at all.    Advice based upon today's existing medical infrastructure is NOT what I'm asking for here in this thread.

Instead, I'm asking for a logical, brain-storming thread on ways in which we CAN use our current machines or modify them in some way to help someone in our household who may develop severe pneumonia, but who (due to the medical systems getting overwhelmed) cannot be placed in a hospital bed or put on a hospital-grade ventilator.

Hope that makes it clear what I'm asking for.  I don't want people saying "THAT'S IMPOSSIBLE", or "It just won't work!".  I don't want people saying, "It's not even worth your time to try to treat pneumonia with a CPAP machine, because it would do no good at all".  I'd like us to discuss in a worst-case scenario, attempting to USE WHAT WE HAVE to treat ourselves, when an overwhelmed medical system cannot do so.

The time is coming to FORGET about what is perceived as "impossible", "useless" or "ineffective" methods for treating ourselves.  Those types of statements tend to be defeatist in their scope and close the mind to possibilities that people just haven't thought of yet.

I want this thread to be about the GREAT MINDS of Apnea Board coming together as a community to address this issue head-on.  Look, it's certain that CPAP machines provide higher pressures to the patient, at least enough to open a collapsed airway.  I know these machines provide nowhere near the pressures that are used in hospital-grade ventilators.    We all know that.

But at some point, we may have to WORK WITH WHAT WE HAVE on hand.

Let's face it, we are now entering a major world-wide state-of-emergency where the "normal" ways of doing things are GOING AWAY FAST.

I'd like us to rise above the "normal" and think about what CAN be done, not about what CAN'T be done.  Is there any way to modify a CPAP to help in ventilation?  Is there any way to somehow create our own ventilator using a vacuum cleaner?  Don't laugh at that!  Dr. Colin Sullivan, the inventor of CPAP machines created the very first CPAP machine using a vacuum cleaner.  Crude?  Yes, but it worked to reduce apnea events.  Vacuum cleaners provide much more pressure than today's CPAPs, Bi-levels or ASVs... that is for certain.  Can we do something similar?

We have an emergency situation on our hands.  We need to start thinking "outside the box" as they say.

Thoughts?  Ideas?  Possible solutions?  Let's start applying our collective knowledge to this rapidly-approaching problem if we can.

[sheepless]

hoo! I admire your passion & leadership on this. sorry to say, I got nothin', except to use the machine because it's probably better than nothing? or, how about running 2 or more machines in series? I've long since forgotten my high school physics. would several connected machines together increase potential pressure?

[slowriter]

So we don't think settings can be changed on our existing xPAP devices to mitigate breathing problems associated with pneumonia; increasing min pressure and EPR/PS, for example?

[Gideon]

Fact. All CPAPs increase breathing efficiency. They resolve many oxygen desats eliminating the need for supplemental oxygen. We also see evidence of this in those individuals who suffer from treatment emergent Central apnea in the increased washout of CO2 triggering the event.

We know from our. Work with Treatment Emergent Central Apnea that increased Pressure Support provides increased breathing efficiency.

A Hallmark of a ventilator is its ability to force a breath, typically with a higher pressure.

Pneumonia is the presence of fluids in the lungs. This is what the EMT, Paramedic, nurse, or doctor listen for and will put you on somewhere between 2 and 8 liters of oxygen depending on their evaluation, are you cyanotic, how bad? Cyan is blue. In short the treatment is to increase Breathing efficiency

So we have 3 methods of increasing breathing efficiency, oxygen supplement, CPAP, or both.

So now the question becomes which CPAP models and how to apply it.

I suggest to look at COPD as a model to apply and adapt.

The last issue is how to distribute these machines for the off book treatment of a Pandemic?

[slowriter]

Fact. All CPAPs increase breathing efficiency. They resolve many oxygen desats eliminating the need for supplemental oxygen. We also see evidence of this in those individuals who suffer from treatment emergent Central apnea in the increased washout of CO2 triggering the event.

Is it possible pneumonia would impact this increased washout of CO2, so that people with bilevels might benefit from, and be able to tolerate, higher PS?