Massachusetts hospitals are scrambling to bring in more ventilators by almost any means possible, including buying and renting machines and repurposing other medical devices, in anticipation of an expected surge in critically ill coronavirus patients.
But limited equipment is not the only challenge: Ventilators generally need rooms with a piped-in oxygen supply and staff who know how to run them. Some hospitals are retraining operating room staff or calling back retired providers to avoid a looming ethical crisis: If hospitals don’t have enough ventilators, how do doctors choose which sick patients get them?
Doctors in the state’s largest hospitals said they have enough ventilators for the next couple of weeks. But they are worried about running out of the mechanical devices, which provide life-saving breaths to patients with acute respiratory failure, a serious symptom of COVID-19.
Those concerns came as figures released Tuesday showed that 1,159 people in Massachusetts had tested positive for the virus, an increase of 382 from the day before. Harvard University president Lawrence Bacow and his wife announced they are among the infected.
State officials said Tuesday that deaths in Massachusetts attributed to the virus had increased from 9 to 11 since Monday. And hospitals continued to see an uptick in patients confirmed to have the virus, or investigated for the illness.
So far, most patients admitted to Massachusetts hospitals with the illness have not required a ventilator, doctors said. In two large hospital systems, for example, about one-third of the 97 patients with COVID-19 were in intensive care units as of Monday; some of those patients require mechanical ventilation, but not all.
As state data continue to reveal the ominous spread of the virus, the number requiring ventilators is certain to grow. And doctors here said they believe Massachusetts is probably three to four weeks away from its peak number of residents becoming sick with the virus. Researchers at the Harvard T.H. Chan School of Public Health have forecast that if 20 percent of the state’s population gets infected, more than 24,000 patients — 2 percent of those infected — could require a ventilator at some point.
The exact number of fully equipped mechanical ventilators in the state is unclear, but one study suggests there are at least 1,400, which doctors say is far lower than the number needed, even when considering that not all patients will need them at once.
Meanwhile, manufacturers said they are rapidly increasing production of the machines, which push oxygen into and out of patients’ lungs through a tube inserted into the windpipe.
“The current focus is that we do everything we can to increase the supply so no one has to do without,’’ said Dr. Craig Lilly, vice chair of critical care operations at UMass Memorial Medical Center in Worcester. “I hope it’s enough.’’
UMass Memorial, which has 109 ventilators, mostly housed in intensive care units, is moving 30 additional ventilators from surgery suites to patient rooms that have oxygen supplies, and is awaiting 15 to 20 more from a vendor.
Brigham and Women’s Hospital in Boston has 233 ventilators and is expecting additional shipments in the coming weeks. Boston Medical Center has 120 machines and is requesting more from the Strategic National Stockpile through the state.
Massachusetts General Hospital has about 150 machines but expects to increase that number to 300 by repurposing existing technology like operating-room anesthesia machines. Partners HealthCare, the parent company of Mass. General and the Brigham, is renting and buying another 200. Orders are "trickling in,'' said Dr. Paul Biddinger, chief of emergency preparedness at Mass. General.
“I’m cautiously optimistic about the next week or two,’’ he said. “But I am very concerned about the approaching demand.’’
Massachusetts does not have the worst supply of ventilators in the country, but it also does not have the best. Estimates show that the state has 21.7 full-service ventilators per 100,000 residents — about 1,408 machines — slightly higher than the national average of 20.5 per 100,000 people. In two current hot spots of the pandemic, Washington only has 12.8 ventilators, while New York has 23.1.
These estimates are based on a 2010 paper from the American Medical Association during the H1N1 flu epidemic, and researchers said more recent information is hard to come by. The 2010 researchers estimated the number of full-service ventilators in the United States at more than 62,000 but that doesn’t account for increases in the past decade and other types of ventilators or ventilator-like devices that could be used in emergencies. So the actual number is likely higher.
“This is similar to many other features of our health care system,’’ said John Brownstein, chief innovation officer at Boston Children’s Hospital. “We have fragmented data so we don’t have a good understanding of the broad impact.’’
Ventilators are in high demand around the world. There have been media reports of doctors in Italy forced to ration a limited number of ventilators, directing them toward younger patients with a better chance of survival.
Doctors at Massachusetts hospitals said they have adopted policies, with help from ethicists, about how to ration ventilators if that nightmare scenario emerges. Biddinger said the goal of Mass. General’s policy is to use the technology to save the most lives. That may mean giving them to patients most likely to survive, while providing end-of-life care to those severely sick patients who are very likely to die even with this device.
"This is a question that everyone is thinking about,'' said Dr. Lewis Kaplan, president of the Society of Critical Care Medicine, which is working with three other groups of medical professionals to publish guiding principles in the next few days. "It’s a hard question to consider.'
He said doctors should not be making these decisions on their own, but with help of ethicists at their hospital. "When you have a 52-year-old patient with three comorbidities and a 57-year-old patient with two comorbidities, if you are a clinician facing the two of them and you have spoken to both of them, that is an almost untenable position to put that person in. That one person should not make that decision.''
In Massachusetts, the Baker administration has requested ventilators from the National Strategic Stockpile and placed orders for more, but state officials did not specify how many.
Meanwhile, locals hospitals continue to absorb new patients.
At Mass General, 29 patients, including 12 in the intensive-care unit, were admitted with confirmed cases of the virus, while more than 100 are awaiting test results. Beth Israel Lahey, a 12-hospital system, has 50 confirmed cases, with 14 in intensive care. It has more than 200 patients awaiting results.
Hospital staff with infections are growing. At the Brigham, 33 employees have been infected. The number of infected staff at Tufts has grown to 29, from 20 the day before. Nine employees at Mass General have tested positive.
Among equipment concerns, ventilators remains a top priority. In the United States and around the world, ventilator manufacturers including Medtronic, GE Healthcare, Vyaire Medical, and Royal Philips are ramping up production to meet the higher demand.
On Sunday, Philips announced plans to double production of hospital ventilators within eight weeks and increase it fourfold by the third quarter of 2020. On Tuesday, Ford Motor Co. and GE Healthcare announced they are teaming up to produce a simplified design of GE’s current ventilator, with manufacturing that could take place at both Ford and GE sites. And Vyaire, which typically makes 1,000 to 1,700 ventilators a month, has already doubled its output and aims to multiply production by a double-digit factor by the end of the year, according to spokesman Cheston Turbyfill.
Medtronic, which manufactures ventilators in Galway, Ireland, has boosted production by 40 percent since the beginning of the year, and it’s now manufacturing several hundred per week, according to spokesman John Jordan. It plans to more than double production in the next several weeks, making it a 24-hour, seven-day-a-week operation. “This is an all-out effort for us,” Jordan told the Globe. “We understand that this is an unprecedented challenge, and it requires an unprecedented response.”
Jordan confirmed that Medtronic has additional ventilators coming to Massachusetts.
There are limits on how quickly ventilator makers can ramp up production. To begin with, ventilator manufacturing requires a complex global supply chain, which is particularly strained in this worldwide pandemic. Medtronic, for example, uses more than 1,500 components to create its Puritan Bennett 980 and 840 high-performance ventilators, Jordan said, involving more than 100 suppliers from 14 countries.
As orders for ventilators pour in from around the world, Medtronic has been prioritizing the highest-risk, highest-need requests on a weekly basis.
Vyaire, which told the Globe it currently has no significant ventilator orders from the Boston area, anticipates peaks in demand starting in the summer. “We’re prioritizing based on the hot spots, and we’re going to fulfill customer orders in a way that reflects the humanitarian crisis,” Turbyfill said.
At a White House briefing Monday, Vice President Mike Pence cited new steps by the Food and Drug Administration to address the shortage. On Sunday, the FDA eased rules on the manufacture and use of ventilators, and it provided new guidelines for using devices originally designed for other purposes, such as ambulance-transport ventilators, anesthesia machines, and continuous positive airway pressure devices often used for treating sleep apnea.
Meanwhile, a high-powered group of senior Massachusetts physicians is spearheading an effort to use noninvasive consumer respiratory devices such as CPAP machines on an emergency “battlefield” basis, with additional components, to relieve the strain on ventilators, ICU beds, and staff and allow medical providers to care for other patients at home or in an alternate venue.
These devices are already in circulation and can be monitored remotely, they point out.
Under carefully controlled circumstances — especially with a modification that adds an N95 mask to reduce any exhaled viral spray — such devices could be repurposed on a wide scale to help patients with less severe symptoms.
“We have to be sure the patients who are going to intensive care units and ventilators are the patients who desperately need them," said Dr. David Margulies, cofounder and chairman of Q-State Biosciences and former vice president at Boston Children’s Hospital, who is part of the team leading this effort.