ATLANTA—These days the news media buzzes with stories about COVID-19 and what happens to patients who are hospitalized and on ventilators. A lot of information is circulating on ventilators and care of patients with COVID-19, but how much is correct and does the average person understand it?
Georgia State University talked to the experts on its campuses for firsthand information on what these machines do and how respiratory therapists use them to care for patients.
We hear a lot about doctors and nurses caring for COVID-19 patients. Who else is involved in patient care?
Caring for COVID-19 patients takes a healthcare team. Physicians provide direct care and nurses often serve as care coordinators, but other disciplines are involved. For example, research shows that patients who spend several days on a ventilator, as some COVID-19 patients do, can become very weak. Rehabilitation plays a big role in returning these patients to health and function, so physical therapy and occupational therapy are extremely important. Dietitians make sure the patients are receiving the nutritional requirements needed to fight the disease. And respiratory therapists support the patients’ ability to breathe.
– Ralph “Chip” Zimmerman, Ph.D., R.R.T., R.R.T-N.P.S., clinical director and coordinator of interprofessional education in the Lewis College.
What specifically do respiratory therapists do to combat the COVID-19 outbreak?
Respiratory therapists (RTs) understand how to manage airways, administer specialty gases, manage mechanical ventilation and deliver pharmacologic agents. They assess, treat and care for patients with acute respiratory failure, sometimes using oxygenation and ventilation, and care for patients with pneumonia, sepsis and adult respiratory distress syndrome.
Respiratory therapists are specialized healthcare practitioners with training and expertise in the use of mechanical ventilation in emergency, critical care and long-term care settings. RTs are licensed and specialty board credentialed. They work together with critical care physicians and nurses to develop treatment strategies.
The RTs education and clinical experience include assessing patients’ oxygenation, ventilatory and hemodynamic status as well as recommending care based on the results of laboratory tests and medical imaging. The RT is also skilled at anticipating other needs of critically ill patients such as nutritional support, prevention of ventilator associated pneumonia, hemodynamic support and end-of-life care.
– Douglas Gardenhire, Ed.D., R.R.T., R.R.T.-N.P.S., F.A.A.R.C., chair and clinical associate professor and Chip Zimmerman, Ph.D., R.R.T., R.R.T-N.P.S.
What does a ventilator do and why is it needed?
A mechanical ventilator replaces the role of the diaphragm to fill the lungs with fresh air. It is a sophisticated machine that regulates the flow of air into the lungs of a patient in respiratory failure. In emergency departments and intensive care units, it is routinely used to increase oxygen, normalize carbon dioxide, decrease the work of breathing or aid in addressing cardiac instability. A mechanical ventilator has numerous settings to meet the needs of a patient and are determined based off a patient’s lung characteristics.
– Brent Murray, M.S., R.R.T., clinical assistant professor
Why do respiratory therapists manage mechanical ventilators?
Respiratory therapists (RTs) are educated to understand the dynamic characteristics of the lungs and pathologies that affect the lungs. RTs must master compliance (stretchiness) and resistance (opposition to flow) during their education and training. Different pathologies will affect the characteristics of the lungs in different ways. A patient’s physical form (height and weight) also impacts these characteristics.
RTs management of a mechanical ventilator is dependent on understanding airway anatomy, gas flow and lung physics. They provide management of the ventilator to ensure patient safety and effective ventilator performance. RT students extensively study the different modes of mechanical ventilation and strategies that work best with different disease states. RTs are the only professionals to receive formal education in how to use and manage a mechanical ventilator. At Georgia State, students take nearly 1,000 hours of classroom, laboratory and clinical training with a mechanical ventilator. Because of this education and training, RTs are uniquely able to recognize the progression and respond accordingly to patients experiencing COVID-19.
– Douglas Gardenhire, Ed.D., R.R.T., R.R.T.-N.P.S., F.A.A.R.C., chair and clinical associate professor and Brent Murray, M.S., R.R.T., clinical assistant professor
I’m concerned about my child getting sick. Are there ventilators for kids? Is special training required to take care of a child on a ventilator?
As respiratory therapists, we have extensive training in ventilator management. Many respiratory therapists also have a neonatal-pediatric specialist certification. RTs with these credentials have had extensive training in managing children in need of any respiratory support, from those needing oxygen to those unable to breathe on their own and in need of a ventilator.
– Laryssa Frederick, M.S., R.R.T., R.R.T.-N.P.S., R.P.F.T., clinical instructor
What is CPAP and how can it help COVID-19 patients?
A CPAP is a non-invasive machine that uses a mask or nasal cannula (a lightweight tube inserted into the front of the nose) to deliver a high flow of heated, humidified and filtered air, producing continuous positive pressure in the airways. The positive pressure helps open the airways, upper airways which include passages from the nose and mouth down to the windpipe and continues to lower airways in the lungs. It helps increase the size of the lung sacs where oxygen is transferred into the blood stream.
Recent evidence showed some COVID-19 patients suffer from hypoxemic respiratory failure, failure caused by the lack of oxygen in the bloodstream. Impaired delivery of oxygen has been identified as a common problem, leading to low levels of oxygen in the bloodstream in the management of COVID-19 patients. CPAP devices improve this impairment in COVID-19 patients because they enhance areas responsible for oxygen transferred into the bloodstream, possibly preventing the patient from needing a mechanical ventilator.
– Samuel Shan, M.S., R.R.T., R.R.T.-N.P.S., R.R.T.-A.C.C.S., clinical instructor
I grew up in the era of polio and the “iron lung.” Can these types of machines be used to care for COVID-19 patients?
Iron lungs will not work for patients suffering from severe COVID-19 infections. Polio interrupted the connection between brain and diaphragm and while some polio patients did have pneumonia, it was not the principal issue. The iron lung functioned on the same principle of normal breathing, creating negative pressure inside a sealed chamber which resulted in air entering the lungs. For the most part, the lungs themselves did not have any change in their dynamic characteristics.
COVID-19 pneumonia physically changes the composition of the lungs. The consolidation of fluid in the lungs will not respond with low pressure generated by the iron lung. Normal lungs only need between -3 to -5cmH2O of pressure to generate air exchange. This is what negative pressure ventilators are designed to do. COVID-19 patients need much more pressure to overcome compliance and resistance changes in the lungs. The lungs of a COVID-19 patient will be a heterogenous mix of normal and consolidated lung tissue making mechanical ventilation very difficult.
– Douglas Gardenhire, Ed.D., R.R.T., R.R.T.-N.P.S., F.A.A.R.C., chair and clinical associate professor and Brent Murray, M.S., R.R.T., clinical assistant professor
The news reports that some patients with COVID-19 are being “proned.” What is proning and why is it done?
The term “proning” or prone positioning is the position of a patient’s body on the stomach. Typically, when patients are admitted to the hospital they lie on their back in a supine position. This can be a problem because blood in the lungs is gravity dependent and lungs are designed to take advantage of gravity dependence. There are a greater number of lung sacs, known as alveoli (gas exchange) units, in the bases of the lungs where most of the blood lies when in the upright position. When patient lay on their backs with an elevated head, the blood tends to pool on the back side.
Prone positioning redirects the blood to alternative lung segments to increase blood oxygen levels. Placing a patient on the stomach, prone positioning, is accomplished by physically flipping the patient or placing the patient on a specially designed bed called a RotoBed that inverts the patient in a safe and controlled manner. Placing patients in a prone position has been used for a condition referred to as ARDS (adult respiratory distress syndrome) and is being used as a treatment for COVID 19.
– Brent Murray, M.S., R.R.T., clinical assistant professor
With many patients receiving several days of mechanical ventilation, how will that affect the individual’s life after recovery from COVID-19?
One of the complications associated with prolonged ventilator care is extreme physical weakness. Somewhere between 30-70 percent of people who are on a ventilator for more than five days will experience this weakness. This weakness is characterized by an inability to walk and dress. Early mobilization can prevent this weakness but it is a resource intensive strategy where healthcare practitioners must physically move the patient into a variety of poses. The crisis due to COVID-19 is placing a strain on intensive care medicine, making it difficult to mobilize these patients.
– Kyle Brandenberger, Ph.D., assistant professor
Does smoking and/or vaping increase the risk of COVID-19?
Both smoking and vaping are risk factors for acquiring COVID-19 and developing more severe symptoms from COVID-19 compared to non-smokers and those who do not vape. Smoking and vaping cause disruptions to lung function and immune response, which predispose individuals to respiratory illnesses.
– Rachel Culbreth, Ph.D., M.P.H., R.R.T., assistant professor