05 May 2020

Coronavirus Deaths using Ventilators, BiPAP and CPAP

“By failing to prepare, you are preparing to fail.”
- Benjamin Franklin (American Politician, Scientist, Publisher, Diplomat – 1706 – 1790)

At the date of writing this blog post, Coronavirus or COVID-19 has caused over 250,000 deaths. Ventilators, BiPAP and Bilevel and CPAP machines have been used in the treatment of patients. The deaths of many patients have been due to various factors including high pressure settings and high tidal volume being used on the Ventilators. BiPAP and Bilevel machines should have been used in the early stages of COVID-19 for a patient and for ventilators to be used only when the patient’s medical condition became critical. 

To avoid confusion, BiPAP is a Registered Trademark owned by Philips Respironics. Bilevel refers to all other brands such as ResMed. 

Many reasons have been put forward for the number of deaths including shortage of ventilators, China and the World Health Organization (WHO), political leaders and senior health authorities of various countries and lack of personal protective equipment (PPE). 

An additional reason for the number of deaths is due to the lack of education and training of the sleep and respiratory medical specialists. I am not criticising the individual emergency health care doctors, nurses and other workers who have worked tirelessly with lack of personal protective equipment during the COVID-19 pandemic to save lives. 

In a previous blog post on 15 March 2020, Lack of Coronavirus Ventilators: Use Bilevel and CPAP, I advised that a number of common symptoms of COPD (chronic obstructive pulmonary disorder) are similar to those of COVID-19. This is the reason why I believe serious consideration should be given to using a bilevel auto adjusting pressure machine with oxygen (where necessary) should there be a shortage or lack of ventilators. 

In the settings of my own machine I have used the principles of bilevel pressure being applied to COPD as detailed in the blog post Different Bilevel Settings Example. Note that I have used tidal volume of 6 ml/kg (or 6cc/kg) ideal body weight or predicted body weight. 

I understand that the medical protocol for ventilators being used initially during COVID-19 was the same as during ARDS (acute respiratory distress syndrome). Based on literature, the tidal volume was 4 ml/kg to 8 ml/kg predicted body weight and maximum pressure of 30 cmH2O. 

From late March 2020 with the use of BiPAP and Bilevel machines in the early stages of COVID-19 for a patient rather than a ventilator, the medical protocol for tidal volume is 4 ml/kg to 6 ml/kg and maximum pressure of 20 cmH2O as detailed in a White Paper by Syneos Health.  

It can be seen that both the tidal volume and maximum pressure have reduced substantially when using BiPAP and Bilevel machines instead of ventilators. Overusing ventilators has led to the deaths of patients and to many news articles in April 2020.  

An example of the articles published was on 28 April, 2020.

"A frontline nurse working in New York on coronavirus patients claims the city is killing sufferers by putting them on ventilators, advocating against them. COVID-19 patients are placed on ventilators rather than less invasive CPAP or BiPAP machines due to fears about the virus spreading. The ventilators have high pressure, which then causes barotrauma, it causes trauma to the lungs." 

In a YouTube video posted, a New York emergency room doctor Cameron Kyle-Sidell said:

'I've talked to doctors all around the country and it is becoming increasingly clear that the pressure we're providing may be hurting their lungs. It is highly likely that the high pressures we're using are damaging the lungs of the patients we are putting the breathing tubes in. We are running the ventilators the wrong way and calling for the protocols to be changed. COVID positive patients need oxygen, they do not need pressure.” 

An example of another news article was published on 21 April 2020. 

"Starting this month, a few physicians have voiced concern that some hospitals have been too quick to put Covid-19 patients on mechanical ventilators, that elderly patients in particular may have been harmed more than helped, and that less invasive breathing support, including simple oxygen-delivering nose prongs might be safer and more effective."

"There is a growing recognition that some Covid-19 patients, even those with severe disease as shown by the extent of lung infection, can be safely treated with simple nose prongs or face masks that deliver oxygen. The latter include CPAP (continuous positive airway pressure) masks used for sleep apnea, or BiPAP (bi-phasic positive airway pressure) masks used for congestive heart failure and other serious conditions."

"For one thing, the thick mucus-like coating on the lungs developed by many Covid-19 patients impedes the lungs from taking up the delivered oxygen." 

"In our personal experience, hypoxemia (low blood oxygen) … is often remarkably well tolerated by Covid-19 patients, in particular by those under 60. The trigger for intubation should, within certain limits, probably not be based on hypoxemia but more on respiratory distress and fatigue." 

As noted in the previous blog post; mucus, respiratory distress and fatigue are also symptoms of COPD and the established treatment is to use BiPAP and Bilevel machines. A ventilator is to be used when the patient is critical and having very severe breathing issues.  

When I wrote the blog post, I thought there was only a shortage of ventilators for use by critical care patients. I was very surprised to learn that medical workers were using ventilators for the majority of patients being admitted to hospital with COVID-19. This included those patients in the early stages of COVID-19 where a BiPAP machine with oxygen (where necessary) would have been sufficient. 

In addition, there would seem to be sufficient BiPAP and Bilevel machines available at a far lower cost than ventilators. These machines are in daily use by many people with sleep apnea around the world. 

In another news article, it was mentioned that:

“While mechanical ventilators do not produce aerosols, they carry other risks. Intubation requires patients to be heavily sedated so their respiratory muscles fully surrender. The recovery can be lengthy, with a risk of permanent lung damage.”   

How did the situation happen where the medical protocols are wrong and many people have been put on Ventilators and died when BiPAP and Bilevel were sufficient?

The sleep and respiratory medical specialists must take part of the responsibility and the blame for Coronavirus or COVID-19 ventilators causing deaths and any permanent lung damage to patients. One of the main reasons is due to the lack of education and training of the sleep and respiratory medical specialists.  

On the blog pages Why is CPAP Compliance Rate Low? and Secrets to Success: Answer is FREE, I mention that there is an estimated 80% or more than 15 million people who are non-compliant, failing and non-successful on sleep apnea therapy. The sleep medical specialists and the equipment suppliers say that the high non-compliance and failure may be due to the patient. They take little responsibility for the high non-successful rate of patients. 

From various articles and from my own personal experience and from others detailed on the various sleep apnea forums (listed on right hand side), it is clear that a number of the medical specialists and others working in the sleep industry are arrogant, lacking any understanding of the issues that patients are facing and above all, have a lazy attitude to educating themselves and their patients as to how sleep apnea therapy and BiPAP and Bilevel and CPAP machines truly work.

The lack of education and training of these specialists is highlighted on the blog page Guide to Success using CPAP and Bilevel. I spoke to 3 medical practitioners regarding the high non-successful rate of patients and the reasons why they may be non-compliant and failing. All 3 medical practitioners gave the same 2 reasons:

1. The pressure is too high; and 

2. The machine does not work. That is, many patients felt that there was no improvement in their continued sleepiness and fatigue. 

From the news articles quoted above, you can see that these two reasons are the same issues that medical workers are facing with patients during the COVID-19 pandemic. Unfortunately, in the current pandemic, many people have died or will have permanent lung damage. 

Support for the 2nd reason above, is a comment made by Professor Susan Redline, Professor of Sleep Medicine at Harvard Medical School. 

“…it is estimated that as many as 10% of patients with sleep apnea have some degree of continued sleepiness/fatigue despite what seems to be optimal treatment of their sleep disorder.” 

Refer to the blog article on My Apnea forum “6 months in, why don’t I feel better?” 

This point was also referred to in an article by Dr Steven Park which looks at CPAP compliance craziness.

As mentioned, there is an estimated 80% or more than 15 million people who are non-compliant, failing and non-successful on sleep apnea therapy. Each day on the various sleep apnea forums, there are hundreds and hundreds of people at any one time for 24 hours every day seeking answers to overcome sleep apnea therapy side effects and issues.

The medical specialists do not understand how sleep apnea therapy and the various sleep apnea machines truly work. A great example of the lack of understanding is how to stop CPAP air through the eye tear duct and coming out of the eyes. This is in addition to the many CPAP side effects and issues such as insomniaweight gain and tiredness and lacking energy issues when AHI (number of apnea events per hour) is less than 1.0.

The sleep specialists have had many years to work out how to overcome and stop these issues for the patient as the CPAP machine was invented 40 years ago by Dr Colin Sullivan in 1980. 

How can the specialists and other medical workers use ventilators, BiPAP and Bilevel and CPAP machines when they do not understand how they truly work? How will they be able to apply these machines successfully to the patients during the COVID-19 pandemic?

On the blog post Elite Athletes Need Bilevel, I advised that in my younger years, I played a lot of competition sport. I am totally aware that it is critical for an elite athlete to maximize their performance and be able to perform on any given day at their best. Just 1% to 2% from your best may be the difference between winning and losing the game.

Should an elite athlete not perform successfully at university, state or club level then it is highly likely that athlete will not be able to perform successfully at international level when representing their country. 

The sleep and respiratory medical specialists have not performed successfully treating sleep apnea for patients during normal times before the pandemic. During the COVID-19 pandemic, how will the specialists and other medical workers be able to perform successfully with many patients, especially those that have both COVID-19 and sleep apnea or other serious health issues? 

In a 2018 study, it was held that nearly 1 billion people or 20% of the total world’s population may have obstructive sleep apnea between the ages of 30 and 69 with 5 or more events per hour (AHI). The number of affected individuals was highest in China, USA, Brazil and India.

Based on global cases of COVID-19 of more than 7.0 million at 7 June 2020; more than 1.4 million people or 20% have COVID-19 and obstructive sleep apnea! It is estimated 80% of patients who have been diagnosed with sleep apnea may have obstructive sleep apnea. Obstructive sleep apnea is when the throat muscles obstruct your upper airway, blocking air from entering and leaving your lungs.  

Add in the remaining 20% of patients who have other types of sleep apnea including Central Sleep Apnea (CSA) and complex sleep apnea (both obstructive and central apnea), the total cases with both COVID-19 and sleep apnea is more than 1.75 million! This number will increase further given many patients are elderly and over the age of 69 years.

The specialists will have to deal with a lot of patients and make many decisions under enormous pressure in very quick time. At the same time, they need to understand how to apply the ventilator or BiPAP and Bilevel or CPAP machine to the patient. The decisions must be accurate and correct otherwise the specialists may put the patient’s life at risk.

In the current pandemic, you can see the potential for a lot of mistakes and for many deaths and permanent lung damage to patients to occur. In addition, how much anxiety, stress, pain and suffering have patients had which may have contributed to their death or permanent lung damage?

This is due to the specialist and other medical workers using a ventilator and not a BiPAP and Bilevel machine during the early stages of COVID-19 for a patient. It is also due to a lack of education and training and an understanding how these various machines truly work.

The lack of education and training of the medical specialists has been highlighted in recent Facebook posts.    

Professor Ron Grunstein – Sleep Disorder Specialist

12 November 2019

“I would argue its not just GPs who need more education, its also the specialists that the GPs refer to! The guidelines for sleep medicine training are sup=optimal and need to be updated.”

Integrated Sleep Health

3 March 2020

“We actually need more intelligence in humans first. Its time to ramp up training in sleep medicine in Australia to 2 year training for all medical specialties. The ridiculous situation of requiring exposure to only 30 non-respiratory sleep medicine cases to become a "sleep medicine practitioner" is dangerous and completely out of touch with modern requirements. Sleep specialists need training in obesity management, psychiatry, neurology not just respiratory sleep disorders.”

As demonstrated by the evidence provided, it is highly likely the medical specialists and other medical workers will not be able to perform successfully during the pandemic. For this reason, I believe the sleep and respiratory specialists must take part of the responsibility and the blame for Coronavirus or COVID-19 ventilators causing deaths and any permanent lung damage to patients. This is due to the lack of education and training of the sleep and respiratory medical specialists.

I finish this blog post with one final question for you to reflect on:

How many lives would have been saved and what would be the number of people not running the risk of a lengthy recovery and permanent lung damage due to intubation IF the Sleep and Respiratory Specialists had better education and training? 

My concerns with some of the medical protocols being used and mistakes that I believe are being made during COVID-19 are also detailed on the following blog posts:

Should you be having side effects and issues with your sleep apnea therapy; CHANGE what you are doing so that you can wake up feeling refreshed and energized each day.

“Have courage. Be adventurous and Go for it! Overcome your fear.”
- Mrhelpful