BY PAMELA FAYERMAN
When the COVID-19 pandemic struck, there was generalized panic about whether Canada would have enough mechanical ventilators, ICU beds and healthcare professionals for critically ill COVID patients.
As the world watched the situation unfold in China, Italy and Spain last winter, political leaders responded with bold plans to boost the domestic production of ventilators. In the U.S., President Donald Trump signed an order under the Defence Production Act compelling General Motors to produce ventilators for hard-hit hospitals. In Canada, Prime Minister Justin Trudeau announced a deal with four Canadian companies – Victoria’s StarFish Medical (StarFish Product Engineering Inc.), CAE Inc., Thornhill Medical Research Inc., and Ventilators for Canadians to produce 30,000 ventilators.
“We need a sustainable, stable supply of these products and that means making them at home,” Trudeau said in April.
A Vancouver startup company saw an opening and quickly assembled a team of engineers to design and manufacture a locally-made ventilator containing fewer than 60 components. Ocalink Technologies Inc., gained emergency Health Canada certification for its trademarked Pantheon Emergency Ventilator (PEV) and announced it was taking orders for its lifesaving technology. In Saskatchewan, university researchers collaborated with clinicians at a Saskatoon-based company that also designed and built an emergency use ventilator. The Saskatchewan Health Authority placed orders for 100 but so far, none have been used in hospitals.
In B.C., Corbin Lowe, co-founder and CEO of Ocalink told me last spring: “This is a very exciting time for Ocalink as our first manufactured units can now ship, and we can bring our made-in-Canada solution to the world…we are in the position to manufacture in large quantities and scale up to 1,000 devices a day despite a currently constrained global supply chain.”
Recently, I re-connected with Lowe to ask how many units were sold to hospitals. The answer? Zero.
While it seemed like the situation elsewhere dictated demand for more ventilators, Lowe said across North America, critical care physicians realized fairly early that only certain COVID cases required mechanical ventilator support and by May, the demand for mass production of new units waned.
“Ventilators are quite an invasive, traumatic experience for patients and, over time, physicians realized that COVID doesn’t mimic acute respiratory distress syndrome which often does require ventilators,” he said.
At Royal Columbian Hospital (RCH) where there are 30 ICU beds – 16 of them equipped with ventilators – there has never been a time during the pandemic when there weren’t enough ventilators. But questions about which COVID patients have required ventilators has always been given delicate consideration. RCH medical director Dr. Steve Reynolds said this in an interview today: “I know we had many discussions about getting more ventilators and there were lots of orders that went in across Canada. I even looked at different types as I joined the panic but to be honest, we leaned into it and we’ve been managing with what we have.”
Reynolds is leading a case series study to help answer which patients require highly invasive mechanical ventilation and other best practices for COVID patients. He agrees that as the pandemic progressed, doctors have learned from each other. And experiences in big metropolitan areas like New York influenced care decisions here, especially when it came to determining which patients needed mechanical breathing support.
Reynolds, a specialist in internal medicine, infectious diseases and critical care, has been working on inventions to improve diaphragm conditioning in patients on ventilators so they can be weaned off mechanical breathing perhaps a little faster, thus reducing the risk of ventilator-induced lung injuries and other life-threatening complications like pneumonia and infection.
While inflamed and infected COVID lungs may appear to look the same as those in patients with pneumonia or serious lung infections, too much ventilation pressure can be risky, not only to the lungs but to other organs as well. Up to 30% of patients on ventilators experience face permanent difficulties after they are weaned off ventilators, according to medical literature.
Medical device technology that Reynolds is involved in is called Lung Pacer. It features a nerve-stimulating catheter inserted intravenously to activate the phrenic nerve and strengthen the diaphragm muscle. Doctors in Germany have been the first to trial it in COVID patients. The device is being developed by Lungpacer Medical Inc., a Simon Fraser University spinoff company.
“Ventilators can hurt the lungs but we’ve shown that if you activate the diaphragm, it can help,” said Reynolds. Ventilators can also cause brain cell death because of interruptions in signals from the lungs to the brain. “It’s very much a use it or lose it scenario,” he added, referring to the fact that relying on mechanical ventilation can cause weakness or even atrophy in various organs. The lungs, for example, can become stiff and scarred (fibrotic) from the oxygen blowing into the lungs as opposed to inhaling and exhaling in normal (non-assisted) breathing.
One measure that has worked pretty well to improve respiratory function in COVID patients has been placing them face down, in what is called the prone position. There are no magic bullets with COVID treatments, but Reynolds said prone positioning has become “a neat thing.
“We sometimes call it tummy time. It’s pretty remarkable how it changes oxygen needs for some people.”
Another aspect of his research involves imaging of internal organs to show what happens in real-time when patients – ventilated or not – are flipped over into the prone position by teams of healthcare professionals. A whole bundle of this kind of research is being funded by the RCH Hospital Foundation and the TB Vets Charitable Foundation Professorship in Critical Care at Simon Fraser University.
While shortages of ventilators have so far not been a problem, Reynolds said there’s always a worry about enough staff to tend to hospitalized patients. Health Minister Adrian Dix regularly updates the number of vacant beds there are in the province, to reassure citizens that the hospitals aren’t overflowing. But as Reynolds said:
“A bed is not a bed is not a bed. Ventilating patients or caring for all those in the ICU, or in COVID units, requires huge health care teams. Nurses are bearing the brunt of this and they are exhausted.”
RCH is one of a few hospitals in the Fraser Health region providing critical care for COVID patients. More than 2,000 COVID patients have been admitted to Fraser Health hospitals since the pandemic began. That is nearly two-thirds of all the patients across B.C. who’ve been hospitalized with COVID.
Why COVID patients are placed in prone positions
Hospital provides virtual followup care to patients discharged from ICU