Ventilator/ Bipap

Doglady

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Does anyone know what the difference is between the ventilators needed for covid-19 and the bipap machines used for PALS? Just curious.
 

KarenNWendyn

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The ventilators for Covid do all the work of breathing for the patient. The machine takes over. The patient has to have an endotracheal tube down their windpipe to connect to the ventilator. This ventilator would be similar the type used by an advanced ALS patient with a tracheostomy. Hospital patients only get a tracheostomy if the need for ventilation is expected to be over 3 weeks.

A BiPAP still requires the patient to initiate a breath. It just makes it easier to breathe in and out. Virus particles might be more easily aersolized with a BiPAP.
 

KateEmerson

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I do believe a number of PALS have a Respironics Trilogy that they use in the BiPap mode which is the same machine my husband used as a full ventilator with a trach. Other PALS have machines that are only BiPaps. To my knowledge hospitals don't use Trilogys but I've wondered if they might if they run short on ventilators in this crisis.
 

lgelb

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One clarification -- a BiPAP on S/T mode will initiate a breath whenever the minimum respiratory rate set is not being met. But, unlike a ventilator, the pressure or volume of air won't reach the full settings with a BiPAP if the person doesn't have enough ability to carry it through. That's why settings need adjustment -- up or down -- as ALS progresses.

With invasive ventilation, the machine does all the heavy lifting, no matter how little respiratory effort is left.

A Trilogy with a trach would serve to treat the ARDS seen with Covid to an extent, but it doesn't have as high a pressure range as straight-up ventilators do.

Even BiPAPs or CPAPs with a narrower pressure range could be of some help depending on the stage of the disease, and various schematics for repurposing xPAPs to work without the mask or with filtration on the mask, to avoid spreading the virus are under consideration. Intubation involves a lot more potential spread than xPAP, though, on the whole.

I don't know how far out of the "legal supply chain" hospitals are willing to work right now, but if you have a BiPAP or CPAP to spare and know somewhere it could be of use, it's worth considering.
 
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mytmouz

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Due to my insurance turning me down for a Trilogy style machine and cough assist, even though the tests show I need it, the rep that provides the machines brought me loaners. She said that hospitals were reaching out for them, in a worst case scenario. She wanted to be sure I had one, in case I got worse, as there may be none when it hits the fan...
 

nona

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I have been wondering this same thing. Thanks for the helpful information everyone!
 

Doglady

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Yes, it’s nice to understand this better.
 

Jimi

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I can only speak for what I have experience with, as one with ALS who has required NIV to live for the past 2 years. I adjust all 3 of the machines I use myself. I can't breathe on my own, but I can still initiate a breath while awake. When sleeping, my ability to trigger a breath (from the bipap or trilogy ) is so weak that I am dependent on the machine to initiate the breath. I have the breaths per minute and time per breath adjusted comfortably for me and sleep well every night. The trilogy and my Respironics system one bipap machine both possess enough pressure for me. They also both have the ability to work automatically based on preset tidal volume settings (called AVAPS). This is supposed to allow them to adjust on the fly to the patient. I have been much more comfortable setting my own pressure and timing. The trilogy has more adjustments available, but in my case does not preform any better than the AVAPS bipap for sleeping. I do feel safer using the trilogy at night because of the built batteries and alarm. In theory the trilogy should be more reliable.
During the day I use a Respironics dreamstation bipap pro. This is just a dumb bipap machine with no backup rate. I prefer this because it has enough pressure for me, it is also very smooth in its air delivery. Most importantly, because while awake I can still trigger the breaths, it makes eating, drinking and talking much easier to coordinate. I have an external battery on the dreamstation that I have tested and it lasted 22.75 hours. (I have 5 batteries just in case). Actually had a power outage that lasted for 13 hours about a month ago. Would have been a real problem for the trilogy and it's 6 hours battery life (could have got another 3 hours from the cough assist battery)
I'm sure I didn't use all the proper terminology or even describe this very well. But my point is that if a machinist with no degree can comfortably survive on adjusting his own bipaps with ALS, than it probably isn't as complicated as the professionals would like you to think. Sorry for the boring rant..... I just always read about all the confusion and then feel like people get so discouraged when they think it is so complicated. I feel that if your life and comfort depends on the equipment, that you should not rely on someone else.
I'm pretty sure that a trilogy (can go up to 40cm h2o !!) could be setup to help Corona virus patients. I wouldn't be surprised if they are hard to come by soon. I'm glad to know that even if my trilogy breaks, that I can still survive on a bipap and sleep comfortably on a bipap with the appropriate backup rate. Hopefully someone will feel the need to correct my rather unprofessional views, but maybe someone will find this useful
 

KarenNWendyn

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I heard a pulmonologist speak on the news yesterday and he was saying a noninvasive ventilation setup could cause aeresolization of the virus and spread it. So no matter what type of ventilator is actually used for Coronavirus patients, they need to be hooked up to it via a closed system. This is why patients who have poor oxygenation breathing room air or oxygen through a nasal cannula or face masks will be intubated with a breathing tube.
 

Jimi

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Good point regarding closed loop. I would think that there would be a way to filter the output air in a similar way to the filtering of the input. I'm sure some people much more savvy than I are already thinking of ways to adapt what we have
 

Doglady

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Yes, good information Jimi and Karen. So, it would take careful set-up and intubation to make a trilogy work as a ventilator for covid-19 patients. What about an ALS patient with a trilogy already who gets covid-19 and is still at home. Would it provide some breathing support ? Maybe yes? But would be dangerous for others who would be exposed to the virus?
 

KarenNWendyn

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What about an ALS patient with a trilogy already who gets covid-19 and is still at home. Would it provide some breathing support ?
Yes, I’m sure it would help that situation greatly. However, the situation with Covid is often pneumonia, meaning the lungs fill up with inflammation. This compromises oxygen exchange. So supplemental oxygen would be needed. Very ill patients eventually go into respiratory failure where they need very large amounts of oxygen and need the ventilator set up to take over breathing. The moment to moment adjustments and oxygen delivery is best done in an intensive care unit setting.
 

KarenNWendyn

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I’m going to add some important thoughts here. If an ALS patient who already has respiratory insufficiency due to ALS were to contract Covid AND get pneumonia as a result, the odds of surviving it would be very, very low. It’s on all of us to think about what we would want done in that situation. If emergency services are called, they will do “everything” to try to save you including endotracheal intubation and transport to the hospital. If you survived, there would likely be residual lung damage and you might not be able to be extubated (taken off the ventilator and have the tube removed). Hopefully most of us have Advanced Directives in place to specify our wishes.
 

lgelb

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Yes, there are plans available to adapt the BiPAP to a closed loop system. And actually, based on the latest research, continuous pressure (CPAP or running a BiPAP as a CPAP, easy to do) may be the best play. There has been some sanity restored on this, so they are bringing all xPAPs into the mix, and I've attached one way of doing it.

In practice, hospitals around the country, particularly in hot spots, are no or slow-coding COVID-19 patients who don't have ALS, so as Karen says, it would be wise to ensure your wishes are known and you have a plan in the home setting, assuming you'd rather spend your last hours there than elsewhere.
 

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