NC has a surplus of ventilators. What happened to the shortage everyone feared?
As COVID-19 began to emerge in the United States last winter, hospitals in North Carolina scrambled to make sure they had enough mechanical ventilators, machines that provide life-saving oxygen to people who have difficulty breathing on their own.
The concern was shared nationwide. The headline in a New York Times article published in mid March seemed to sum up the situation: “There Aren’t Enough Ventilators to Cope With the Coronavirus.” Soon the federal government was enlisting the help of manufacturers, including carmakers Ford and General Motors, to make more of them.
Fears of a shortage led the N.C. Division of Emergency Management to order 500 ventilators, on top of the roughly 250 already in the State Medical Response System’s inventory. Meanwhile, the state Department of Health and Human Services began tracking the supply and use of ventilators by hospitals on its COVID-19 dashboard, along with other critical supplies such as N95 masks and available beds in hospital intensive care units.
But what the dashboard shows is that ventilators have never been in short supply in North Carolina. Since March, according to DHHS, less than 30% of the more than 3,000 ventilators at hospitals across the state have been in use on any given day. None of the ventilators in the state’s stockpile have been needed.
“Ventilators is something we’ve not had a shortage of and not had to worry about,” said Dr. David Kirk, director of pulmonary and critical care medicine at WakeMed.
There are two main reasons why North Carolina has an abundance of ventilators instead of the shortage that was feared a few months ago.
The first is that even now, with the total number of confirmed coronavirus cases topping 146,000, the COVID-19 outbreak never surged in North Carolina the way it did last winter in China, Italy and New York City. The sudden spikes in those places left some hospitals short of not only ventilators but also beds, staff and personal protective equipment such as masks and gowns.
Dr. Shannon Carson, chief of pulmonary diseases and critical care medicine at UNC Medical Center in Chapel Hill, credits the steps people in North Carolina took to stay home and remain physically distant from each other.
“The key aspect here was community response in the spring to reduce viral transmission, to reduce the total number of cases,” Carson said. “And that will continue to be the key.”
The second reason has to do with the use of ventilators. Carson and other doctors say they’ve gotten better at treating COVID-19 and keeping patients off ventilators, which are considered a last-resort measure with side effects that can slow recovery.
Ventilators involve placing a tube down a patient’s throat to get oxygen directly to the lungs, and that usually requires the patient be heavily sedated or placed in an induced coma. Being sedated for days or weeks can increase the risk of infections, blood clots, delirium or hallucinations, and muscle weakness from being immobile, said Dr. Daniel Gilstrap, a pulmonologist at Duke Health and a professor at Duke University School of Medical.
“All of those things are going to mean probably a longer stay in the ICU and complications that come from that,” Gilstrap said.
In addition, the ventilator itself can further injure the lungs, even as it provides life-saving oxygen. So-called ventilator-induced lung injury comes in various forms, including trauma caused by over-inflating the lungs.
“We have a lot of protocols once they’re on the ventilator to try to prevent that,” Carson said. “But the best way to prevent ventilator-induced lung injury is to keep them off the ventilator.”
Treatment of COVID-19 improves
The slow buildup of coronavirus cases in North Carolina gave doctors time to learn how to treat COVID-19, which has helped reduce the need for ventilators.
Mandy Cohen, the state Secretary of Health and Human Services, says doctors have been able to keep people from requiring ICU care through the wider use of the antiviral medicine remdesivir and the steroid dexamethasone, which reduces inflammation caused by the virus. Cohen has also cited increased use of “proning” or placing patients on their stomachs, which has been found to help them breathe and take in more oxygen and in some cases avoid the need for ventilators.
And for patients who do need supplemental oxygen, hospitals increasingly use masks or plastic hoods that provide oxygen at higher pressure through the nose and mouth, instead of through a tube down the throat.
“What we discovered was some of the less aggressive forms of supplying oxygen were going to work just as well,” said Gilstrap at Duke. “Our practices have changed as we learned more.”
Based on reports from China, where coronavirus first emerged last winter, doctors expected that half of the COVID-19 patients in the ICU would be breathing with the help of mechanical ventilators, said Kirk at WakeMed. Now it’s more like a third of them, and Kirk gives much of the credit to the steroid dexamethasone.
Ventilators save lives
For all the efforts to keep people off ventilators, doctors say they’re essential to keeping some COVID-19 patients alive.
Nader Atari of Cary spent 15 days on a ventilator during a two-month stay at WakeMed this spring. The virus attacked his lungs and prevented him from getting enough oxygen to his body.
“Without the ventilator, I would have died,” Atari said after a therapy session at WakeMed’s outpatient rehab center.
Press coverage and chatter on social media raised questions about the effectiveness of ventilators in treating COVID-19 patients this spring. Much of that has been fueled by early studies from China, Europe and New York that suggested a majority of COVID-19 patients on ventilators died.
Later studies, including one in Boston, put the death rate at well under 50%. But Kirk doesn’t think researchers will ever be able to tease out whether mechanical ventilators work better or worse than less-invasive methods because ventilation is almost always considered an extreme measure needed to keep very sick patients alive.
“What will happen is there will be studies that show that patients that didn’t need life support are doing better,” he said. “Well, duh.”
Orders add to the abundance
Kirk said WakeMed stocked up on ventilators after the H1N1 flu pandemic in 2009 when it realized that its supply was tight. To prepare for COVID-19, WakeMed did a quick inventory of its ventilators.
“We had such abundance,” Kirk said. “We have ventilators in places where we didn’t think we had ventilators.”
“Just as a citizen and not a doctor,” he added, “I’ve never understood why we told car companies to make ventilators.”
In April, the American Hospital Association and the federal government created the Dynamic Ventilator Reserve, to let hospitals with excess ventilators loan them to those who need them. A spokesman for the association said more than 3,000 ventilators are listed on the nationwide exchange but only recently have any hospitals asked for one. The spokesman estimates that “dozens” have been shared through the program.
After looking at their own inventories, many hospitals in North Carolina ordered new ventilators. The UNC Health System, for example, ordered more than 250 to supplement its existing supply, Carson said. Only 42 of those new ventilators had arrived by late July, but the delay didn’t matter, he said. Of the roughly 330 ventilators available at UNC’s 11 hospitals statewide, less than 100 were in use, he said.
Carson said UNC would run out of skilled nurses and respiratory therapists to operate the ventilators before it runs out the machines themselves.
“We can buy a machine,” he said, “but you can’t go to the store and buy a skilled critical care nurse.”
Meanwhile, the state Division of Emergency Management has received about 430 of the 500 ventilators it ordered in March for $5.6 million, or about $11,000 each, said spokesman Keith Acree. That same month, hospitals concerned about their supplies asked the state for 293 ventilators, Acree said.
But many of those requests were later withdrawn, and in the end none of the 750 ventilators owned by the state Division of Emergency Management or in the State Medical Response System stockpile have been needed.
But Carson doesn’t think having a surplus of ventilators is a bad thing.
“We are reminded ever more frequently of how quickly and suddenly these respiratory disease pandemics can arise and how quickly they can travel across the globe,” he said. “So I should expect this surplus will remain the norm both for health care systems like ours and the state. We just have to not get complacent if things are quiet for five years.”
This story was originally published August 19, 2020 at 5:30 AM with the headline "NC has a surplus of ventilators. What happened to the shortage everyone feared?."
