14 Apr 2020

A view of COVID-19 from the frontlines and the importance of ventilator surveillance

By John Zaleski

Emergency medical healthcare personnel certainly understand what respiratory emergencies look like. A preceptor of mine used to drum into our heads that our job was to “stop the dying.” I would say that while most frontline physicians, nursing, and allied health staff are trained to recognize the signs, if there is one place where respiratory depression, distress, and failure is experienced most, it is in the emergency department and in the pre-hospital setting. In any given week I am called on to identify and treat many cases of respiratory distress. Just this past week alone most of those cases involved some concern over the novel coronavirus (SARS-CoV-2), better known as causing the popularly named COVID-19 illness. Such patients are referred to as patients under investigation (PUI). Even patients who do not meet the PUI criteria are to be treated with caution, which requires care providers to don personal protective equipment (PPE) and includes medical treatment protocols designed to protect the patient, healthcare providers, and the public.

Patients with genuine respiratory distress and borderline respiratory failure are experiencing a true emergency which mandates response in seconds. Patients lapsing into respiratory failure quickly evolve into cardiac arrest and, if no intervention is undertaken, death follows. Federal and State medical authorities have widely publicized the symptoms to be watchful for (fever, shortness of breath, sore throat, cough), and many who contract the illness will experience these symptoms, often manageably; but there are those who are immunocompromised or less healthy who can devolve into acute respiratory distress, including pneumonia, who require hospitalization and therapeutic support in the form of artificial mechanical ventilation.  The COVID-19 outbreak has drawn much attention – rightly – to the need for respiratory support and the devices that provide that support. The key is rapid intervention and maintenance of airway patency and oxygenation.

Monitoring these patients while on mechanical ventilation is essential as a life sustaining function. Fluid buildup in the lungs as a consequence of the effects of infection can interfere with the ability of the mechanical ventilator to function properly and for necessary perfusion to take place in the lungs; telltale signs such as increasing airway pressure, reduced ventilated lung volume, and decreasing arterial oxygen saturation all require immediate intervention. Furthermore, unintended endotracheal tube extubation, which can and does occur, requires immediate response and intervention in seconds, not minutes.  Hence, busy staff who are otherwise engaged require notifications when such events occur.

Of great concern is the protection of healthcare personnel. I am under orders to wear personal protective equipment (PPE) for any questionable patient under investigation. My N-95 mask, visor, nitrile gloves and gown are the barriers between infection and protection. Procedures for disinfecting can be onerous, and the concern over bringing the disease home are paramount.

The ability to reduce or limit the exposure of the clinical staff to the patient for routine monitoring is important for safety of the clinical staff.  Bear in mind, there is still a great need to be at the bedside with the patient. The use of telemonitoring is not widespread and cannot substitute for hands-on requirements. These patients are very high touch. Yet, anything that can assist in providing earlier or rapid notification of events helps to ensure that there is a fighting chance to save a life.

As both a clinician and a data scientist for a health technology company, it is clear to me that this unfortunate pandemic has made it no longer an option for hospitals to ignore technology that help and protect overwhelmed clinicians manage the strain of the impossible caseloads caused by COVID-19.  The monitoring and management of key physiologic parameters necessary to sustain life is available and this ailment demonstrates clearly how such ventilated patient surveillance can directly influence our ability as clinicians to better manage and intervene on behalf of our patients.

Capsule recognizes that it has a corporate duty, as part of its ventilator surveillance function, to assist care providers in safely managing patients who are acutely ill and require life-sustaining therapies such as mechanical ventilation. Through the use of continuous monitoring, surveillance, and identifying patients at risk for further decompensation, Capsule’s ventilated surveillance workstation assists clinicians in this mission.

John Zaleski is Head of Clinical Informatics for Capsule Tech, Inc. He has written on the topics of clinical surveillance over the years, has authored multiple texts on medical device data and its use in clinical decision making, and his experience in the use of technology in high acuity monitoring and therapy spans more than three decades. In addition, John Zaleski is an active pre-hospital clinician and volunteers as an emergency medical technician. He holds a Ph.D. from the University of Pennsylvania where he developed a novel method for weaning post-operative coronary bypass patients from mechanical ventilation. He is also the named inventor or co-inventor on 8 U.S. patents related to medical device technology.

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