Thread by @nickmmark

I’m excited to share a project I’ve been working on to facilitate #helmet interface non-invasive ventilation for people with respiratory failure due to #COVID19. This thread is a brief #tweetorial on helmet interface ventilation.
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Projections show that in a severe/continuing pandemic, the # of people requiring MV may exceed available vents. It’s not just the vents but a shortage of medications used to keep pts comfortable on the vent and personnel who know how to safely use them. thelancet.com/journals/lanin…
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So what can be done? One thought is to build more vents, but that’s easier said than done: vents are complex, highly regulated devices. Despite lots of enthusiasm it's not easy/quick to ramp up vent production. It also doesn't fix medication shortages.
npr.org/2020/03/31/824…
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Not only are ventilators resource intensive, but patients with #COVID19 who are sick enough to require invasive ventilation often do poorly. This is more a correlation w/ disease severity rather caused by IMV per se. That said, what if we could avoid intubating COVID pts?
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Several studies (and meta-analyses) have shown that in patients with hypoxemic respiratory failure we can avoid intubation by using non-invasive positive pressure ventilation (NIPPV). This can also potentially reduce ICU mortality. ➡️ncbi.nlm.nih.gov/pmc/articles/P…
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We also know NIPPV works for coronavirus: In the 2004 SARS outbreak, one group used NIPPV to avoid intubation in 70% of cases (n=14) and pts treated with NIPPV had shorter ICU LOS (3.1 vs 21.3 days). Importantly, none of the 105 HCWs exposed got SARS.➡️journal.chestnet.org/article/S0012-…
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Unfortunately, there are two big challenges to using #NIPPV in patients with ARDS due to #COVID.
1. Many patients don’t tolerate wearing a tight-fitting mask for days &
2. Air leak around the mask may aerosolize a significant amount of virus, potentially placing HCWs at risk
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This is where helmet ventilation comes in. Instead of a tight fitting face mask think Apollo astronaut. The helmet interface forms a transparent bubble around the patient’s head and forms a tight seal w/ valves around the collar. This is more comfortable and better tolerated.
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In a 2016 RCT of helmet vs “traditional” facemask NIPPV for n=83 ARDS pt, the helmet interface significantly reduced risk of intubation (18% vs. 62%), increased # of vent-free days (13 vs. 28), and (most importantly) decreased mortality (34% vs. 56%)!
➡️ncbi.nlm.nih.gov/pmc/articles/P…
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Another advantage of a helmet interface NIPPV is that it may more effectively contains aerosols. A 2015 study used intrapulmonary smoke particles w/ a manikin illuminated by laser to quantify particulate leakage. Compare B (helmet) with C (mask):
➡️journal.chestnet.org/article/S0012-…
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Let’s summarize what we’ve learned so far:
* we can save lives using NIPPV in ARDS
* we can avoid intubations in SARS using NIPPV
* helmet interface NIPPV works better than mask for ARDS
* helmets may better contain aerosolized particles
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There are some big unknowns:
* how many #COVID patients will tolerate #NIPPV?
* for most patients, will NIPPV w/ a helmet obviate the need for IMV or just delay it?
* will outcomes actually be better using NIPPV in COVID?

We need studies to answer these important questions.
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Hopefully I’ve convinced you that trying helmet interface NIPPV has merit in ARDS due to COVID19.

That’s why two months ago, some friends (@gregmckelvy) and I began working on a way to increase the production of these helmets and get them to the patients who need them.
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Turns out, there is only one US company that makes helmets for NIPPV - SeaLong Medical - which is a small family-owned small business in Texas. We talked to the owner - Chris - and found out what it would take for him to increase his helmet production from 50/week to 5000+.
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You can read more about SeaLong Medical here btw:
WSJ➡️ wsj.com/articles/lacki…
CBS➡️ dfw.cbslocal.com/video/4495556-…
NBC: nbcnews.com/news/us-news/t…
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Over the last few months, SeaLong has gotten a ton of orders, but they have had trouble meeting demands.
They needed a way to scale up production with a larger factory, more machines, and more staff. We helped them write grants/proposals to expand helmet production.
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Excited to announce that, just this week, SeaLong received a $325,000 grant from OpenPhilanthropy.org @open_phil and will be ramping up to 5000 units/week (and eventually more).

Hopefully these units will help some people with #COVID19 avoid needing ventilators.
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I'm hoping we can find more sources of funding to expand access to this potentially life-saving intervention. For those who want to give to this cause, you can donate to their GoFundMe campaign
➡️ gofundme.com/f/s22t4-o2-hoo…
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Disclaimer: I have no financial relationship to SeaLong. I do think they have a good product. I think Chris and his family are good people who have been working 7 days a week to produce helmets since this pandemic began and are selling these helmets essentially at cost.

fin/