Projecting the demand for ventilators at the peak of the COVID-19 outbreak in the USA
2020; Elsevier BV; Volume: 20; Issue: 10 Linguagem: Inglês
10.1016/s1473-3099(20)30315-7
ISSN1474-4457
AutoresChad R. Wells, Meagan C. Fitzpatrick, Pratha Sah, Affan Shoukat, Abhishek Pandey, Abdulrahman M. El‐Sayed, Burton H. Singer, Seyed M. Moghadas, Alison P. Galvani,
Tópico(s)Respiratory Support and Mechanisms
ResumoThe coronavirus disease 2019 (COVID-19) pandemic has been straining health-care systems worldwide. For countries still in the early phase of an outbreak, there is concern regarding insufficient supply of intensive care unit (ICU) beds and ventilators to handle the impending surge in critically ill patients. To inform pandemic preparations, we projected the number of ventilators that will be required in the USA at the peak of the COVID-19 outbreak. Our estimates combine recent evaluations of COVID-19 hospitalisations1Moghadas SM Shoukat A Fitzpatrick MC et al.Projecting hospital utilization during the COVID-19 outbreaks in the United States.Proc Natl Acad Sci USA. 2020; (published online April 3.)DOI:10.1073/pnas.2004064117Crossref Scopus (320) Google Scholar and data on the proportion of patients with COVID-19 in the ICU requiring ventilation (appendix p 2). At a basic reproduction number of 2·5,1Moghadas SM Shoukat A Fitzpatrick MC et al.Projecting hospital utilization during the COVID-19 outbreaks in the United States.Proc Natl Acad Sci USA. 2020; (published online April 3.)DOI:10.1073/pnas.2004064117Crossref Scopus (320) Google Scholar 115 001 (IQR 101 006–131 770) invasive ventilators and 89 788 (78 861–102 880) non-invasive ventilators would be needed, on average, at outbreak peak (figure). Considering that 29·0% of the existing 97 776 ICU beds in the USA are routinely occupied by patients without COVID-19 requiring invasive mechanical ventilation,2Wunsch H Wagner J Herlim M Chong DH Kramer AA Halpern SD ICU occupancy and mechanical ventilator use in the United States.Crit Care Med. 2013; 41: 2712-2719Crossref PubMed Scopus (182) Google Scholar, 3American Hospital AssociationFast facts on US hospitals.https://www.aha.org/statistics/fast-facts-us-hospitalsDate: 2020Date accessed: March 13, 2020Google Scholar we calculated that 69 660 of the 98 015 invasive ventilators in the USA before outbreak start would be available for the COVID-19 response.4Society of Critical Care MedicineUnited States resource availability for COVID-19.https://sccm.org/Blog/March-2020/United-States-Resource-Availability-for-COVID-19Date accessed: March 23, 2020Google Scholar, 5Rubinson L Vaughn F Nelson S et al.Mechanical ventilators in US acute care hospitals.Disaster Med Public Health Prep. 2010; 4: 199-206Crossref PubMed Scopus (63) Google Scholar These available ventilators include additional units in stockpile or storage. Consequently, at least 45 341 (IQR 31 346–62 110) additional units would be needed for the surge at the peak. Of the 22 976 non-invasive ventilators,5Rubinson L Vaughn F Nelson S et al.Mechanical ventilators in US acute care hospitals.Disaster Med Public Health Prep. 2010; 4: 199-206Crossref PubMed Scopus (63) Google Scholar we estimated that 12 499 units would be available, assuming 54·4% availability as estimated for routinely used invasive ventilators (appendix p 1). For these non-invasive devices, a minimum of 77 289 (66 362–90 381) additional units would be needed at the peak. As a step towards filling this gap, 52 635 limited-featured devices exist.5Rubinson L Vaughn F Nelson S et al.Mechanical ventilators in US acute care hospitals.Disaster Med Public Health Prep. 2010; 4: 199-206Crossref PubMed Scopus (63) Google Scholar Although these could be deployed for treatment of moderate cases, they might not be an appropriate substitute for ventilators in the care of severely ill patients.5Rubinson L Vaughn F Nelson S et al.Mechanical ventilators in US acute care hospitals.Disaster Med Public Health Prep. 2010; 4: 199-206Crossref PubMed Scopus (63) Google Scholar These estimates should represent a lower bound for additional ventilator requirements. To avoid triage for use of ventilators,6Truog RD Mitchell C Daley GQ The toughest triage—allocating ventilators in a pandemic.N Engl J Med. 2020; (published online March 23.)DOI:10.1056/nejmp2005689Crossref PubMed Scopus (516) Google Scholar units would have to be perfectly distributed both geographically and temporally, which in turn relies on centralised coordination among states and more precise forecasting than is currently possible given the constraints on testing for severe acute respiratory syndrome coronavirus 2. Worryingly, areas such as New York city are experiencing the first surge of cases in the absence of national coordination, while facing competition with other regions simultaneously trying to secure these critically important resources.7Whalen J Romm T Gregg A Hamburger T Scramble for medical equipment descends into chaos as US states and hospitals compete for rare supplies.https://www.washingtonpost.com/business/2020/03/24/scramble-medical-equipment-descends-into-chaos-us-states-hospitals-compete-rare-suppliesDate: March 24, 2020Date accessed: March 25, 2020Google Scholar Also concerning is that the USA is already several weeks into its epidemic. With invasive ventilator needs exceeding availability at week 14 of our simulations, there are substantially fewer weeks to procure the requisite supply. We urge three complementary avenues of action to reduce the imbalance between supply and demand for ventilators. First, vigilant social distancing has potential to flatten the curve,1Moghadas SM Shoukat A Fitzpatrick MC et al.Projecting hospital utilization during the COVID-19 outbreaks in the United States.Proc Natl Acad Sci USA. 2020; (published online April 3.)DOI:10.1073/pnas.2004064117Crossref Scopus (320) Google Scholar which will both delay and suppress the outbreak peak. In addition to reducing the peak demand for ventilators, the delay would provide a window of opportunity to ramp up ventilator production. Second, it is plausible that the USA will experience several asynchronous local peaks rather than one apex. A nationalised allocation system that transfers ventilators based on state-level epidemiological projections would most efficiently capitalise on existing units. Third, the USA simply needs more ventilators. In that respect, the Defense Production Act has been invoked, compelling some automobile manufacturers to shift production to ventilators.8Vazquez M Collins K Sidner S Hoffman J Trump invokes Defense Production Act to require GM to make ventilators.https://www.cnn.com/2020/03/27/politics/general-motors-ventilators-defense-production-act/index.htmlDate: March 27, 2020Date accessed: April 7, 2020Google Scholar This Act also permits the Administration to coordinate distribution among states, thereby addressing our second recommendation. The Administration has refused to engage in coordination, suggesting that it is not yet needed. However, given the time required to refit manufacturers and begin producing ventilators, waiting until the national shortage is upon us would be disastrous. By contrast, these three steps will save lives and avoid the devastating rationing that would unfold in the absence of action. APG acknowledges funding from the National Institutes of Health (NIH; grants UO1-GM087719 and 1R01AI151176-01), the Burnett and Stender families' endowment, the Notsew Orm Sands Foundation, and a National Science Foundation grant for rapid response research (grant 2027755). MCF was supported by the NIH (grant K01 AI141576). SMM acknowledges support from the Canadian Institutes of Health Research (grant OV4-170643; Canadian 2019 Novel Coronavirus Rapid Research) and the Natural Sciences and Engineering Research Council of Canada. All other authors declare no competing interests. Download .pdf (.16 MB) Help with pdf files Supplementary appendix
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