The COVID-19 pandemic has led to a potential shortage of life-saving mechanical ventilators. The purpose of this study is to determine whether a novel simpler to device, the automated bag-valve-mask (BVM) compressor, can be used to provide assisted ventilation temporarily to patients in need. This includes patients with COVID-19 lung infection and respiratory failure. If successful, this would increase the pool of total available ventilator hours to alleviate any shortage.
This study will be performed in the emergency department and ICU's of Massachusetts General
Hospital (MGH). Thirty patients requiring mechanical ventilation will be enrolled. The design
is a case series with repeated measures analysis. All patients will receive the experimental
treatment as well as conventional ventilation and unassisted oxygenation as observed prior to
initiation of mechanical ventilation. The compressor used will be manufactured by Spiro LLC /
10xbeta based on the open source MIT design. The device is powered by an uninterrupted power
supply from a standard electrical outlet and it alarms if unplugged.
The patient will be moved into a negative pressure room. After patients with respiratory
failure are intubated and stabilized on a conventional ventilator, they will receive 15
minutes of artificial respirations with the automated compressor with the conventional
ventilator standing by. They will be returned to the conventional respirator after this
period, or sooner if necessary. The endotracheal tube will be briefly clamped during the
rapid transition from one device to another to minimize aerosolization of any viral particles
and to retain any PEEP.
If the initial study period demonstrates successful respiratory support, then the procedure
may be repeated once with doubling of the automated compressor treatment time to 30 minutes.
There will be a minimum 15-minute observation period with conventional mechanical ventilation
between the two study periods. Additionally, there will be one hour of data collection after
the study periods. The total duration of the two intervention periods, the intervening period
and data collection is two hours. The primary outcome is arterial oxygenation.
Patients are chemically paralyzed to facilitate intubation as part of standard care.
Rocuronium is typically used for intubating chemical paralysis in the MGH emergency
department. It has a half-life of 66 minutes. A single repeat bolus will be provided if
needed to ensure chemical paralysis for the duration of the study. If the patient is already
intubated and no longer chemically paralyzed, than one bolus of rocuronium, and a second as
needed, or just a temporary increase in ongoing sedation will be provided to minimize
spontaneous respiration. The airway circuit will be continuously monitored with a separate
pressure and flow monitor (Nico) with recorded digital output throughout the experiment.
Device: Mechanical ventilation with the automated BVM compressor
Mechanical ventilation is accomplished with a device that mechanically squeezes a manual bag valve instead of by hand. The rate and volume of compression are adjustable, and the device has appropriate alarms and safety features.
Inclusion Criteria:
- Patient may be diagnosed with Covid-19 based on clinical presentation and available
laboratory studies including specific Covid-19 testing.
- Patient with imminent respiratory failure or status post respiratory failure receiving
mechanical ventilation, or requiring mechanical ventilation for airway protection or
other cause.
- Evidence of no pulmonary disease, or mild to moderate ARDS based on:
- fraction of inspired oxygen (FiO2) ≤ 60% with arterial oxygen saturation > 90%
- positive end expiratory pressure (PEEP) ≤ 12 cm H20
- Using an adaptive trial design, the first 10 patients must require mechanical
ventilation for reasons other than COVID-19 infection such as airway protection due to
overdose, seizure, stroke, or trauma. The next 10 patients may have COVID-19
infection, but must demonstrate lung compliance ≥ 40 ml/cm H2O. If these 10 patients
demonstrate a satisfactory course associated with treatment, then the final 10
patients may have lung compliance ≥ 30 ml/cm H2O. Satisfactory treatment course will
include, at a minimum: oxygen saturation > 90%, with PEEP ≤ 12 cm H2O.
Exclusion Criteria:
- Lack of informed consent from patient, if deemed having capacity, or from surrogate if
not
- Too medically unstable to participate in study per treating clinician
- Patients requiring more than one vasopressor medication for blood pressure support
- Age > 65 years
- Clinical evidence of acute coronary syndrome (ACS) including angina, or ECG evidence
of acute ischemia or dysrhythmia
- Chronic lung disease including chronic obstructive pulmonary disease (COPD), pulmonary
fibrosis, or pulmonary hypertension
- Gross laboratory abnormalities including, when available: liver function tests (LFT) >
5x normal, C-reactive protein (CRP) > 200 mg/L, ferritin > 2000 µg/L, creatine
phosphokinase (CPK) > 3x normal, D-Dimer > 2500 ng/ml
- Previously enrolled subject
- Children
- Pregnant women
- Estimated body mass index (BMI) greater than 30
- Prisoners
Keith A Marill, MD, Principal Investigator
Massachusetts General Hospital