State Sleep 0408-2020
April 22, 2020ID5090
To CiteDCA Citation Guide
- 00:00Goes into the patient with sleep apnea and we worried about bacteria.
- 00:06We worried about pollens and dust and we worried about humidity and all of to deal with all of those things.
- 00:15The machines have built-in filters that really filter the air going into the device.
- 00:23On the other hand, we have worried but way less about what leaves the patient.
- 00:30After all, what actually leaves the patient?
- 00:34What leaves the patient and goes into the environment is air,
- 00:39which contains carbon dioxide and water vapor,
- 00:42and that's really all we ever thought about.
- 00:47Well there are so. In order to deal with with the CO2,
- 00:51for example, there are two reasons why all conventionals C pap systems have leaks.
- 00:58They all have built-in leaks and this has been true from Day 1 from 1985 when commercial machines became available and they have a leaks.
- 01:09In order to wash away exhaled carbon dioxide to reduce the risk of carbon dioxide retention.
- 01:17And that was the real problem in the early days of of C Pap,
- 01:21we tried to use peep and other systems and what we did was we made the patient sick with ceiling to retention.
- 01:29And the other reason to have a built-in leak into the system is that if the Cpac Machine fails,
- 01:36let's save the electrical power goes off,
- 01:39or that gets unplugged, or the machine breaks or whatever.
- 01:43So if the machine fails,
- 01:45the patient can actually breathe and we really haven't thought much about this leak for 30 five years until now.
- 01:53With Isco VAT 19 infection.
- 01:55So I started to worry about this,
- 01:58so I started to worry about this.
- 02:00A March 10th, 2020 in it and I actually remember the exact date at that time there were zero cases at Yale,
- 02:07New Haven Hospital, and I'll talk more about that later,
- 02:11but I was not the only one who is concerned.
- 02:14Um, so this is now a from a website from the Kaiser Permanente.
- 02:23When used for pressure support or as a ventilator path,
- 02:27they were writing about this official.
- 02:30Since scientists have known for years that when used with a face mask,
- 02:35such alternative devices can possibly increase the spread of infectious disease that are by error sizing.
- 02:43The virus weather used in the hospital or at home.
- 02:48First responders called to the life care center of Kirkland.
- 02:52This is in the state of Washington starting February 24th.
- 02:57Initially used C pap machines to treat residents before it was known that they were infected with the virus.
- 03:06In other words, the first responders had been using C Pap to support patients and they were really infecting themselves and this is at the very beginning.
- 03:18Of the epidemic in United States.
- 03:22So, so here we're looking at Cove it 19 at my hospital.
- 03:26What happened to the data here?
- 03:29It sort of has vanished.
- 03:32So basically, uh, in the last month there have been 0 cases at the beginning of the month,
- 03:40and as of yesterday I don't know why this is not moving here.
- 03:46Let me just. So that's what you should be looking at right now.
- 03:52Can you see that?
- 03:54Yes, OK. For some reason the there we go,
- 03:58the graph just showed up.
- 04:00So about a month ago they were like 0 cases and there was not not a real issue and this is what has happened until yesterday.
- 04:12So by yesterday we went from zero to 328,
- 04:16admitted patients in our hospital and 58 patients were on ventilators yesterday and so this has been.
- 04:25Dramatic change and all of a sudden you know Cove.
- 04:29It has really overtaken all of us,
- 04:32so when we think about patients with an infection or any patient at all,
- 04:39patients produce two types of potential airborne.
- 04:43Um carriers virus carriers. One are droplets and the droplets are produced by coughing.
- 04:50Sneezing droplets are relatively large and they really dropped quickly and I'll give you some data on that later and they also produce what are called bio aerosols and the
- 05:03these aerosols are produced by breathing,
- 05:06for example, when you go out.
- 05:09An an in very cold weather and you see steam emanating from your body.
- 05:15Those are really aerosols and speaking,
- 05:18and these bio aerosols are much smaller and they can remain suspended for much longer periods of time.
- 05:26So looking at particle size is OK,
- 05:29so these are the kinds of particle size is that have to do with the respire Tori system in our discussion.
- 05:39So viruses that are really on the bottom left of this are quite small.
- 05:45Their extremely small and this slide here shows how long it takes for a particle of different sizes to settle to drop and.
- 05:56This is a study that looks at how quickly they will settled by 5 feet,
- 06:04so an extremely small particle of a hot half a micro meter.
- 06:10It can stay suspended for 41 hours.
- 06:14You know that's a long time and one micro Micron up to 12 hours to drop by 5 feet and this is data that comes from OSHA.
- 06:27And So what we're talking about are particles that can potentially hang around for a long period of time.
- 06:35So if you look at,
- 06:37for example, the droplets, which would be much bigger,
- 06:41they actually will hang around for somewhere between 5 and 10 seconds.
- 06:46So basically things coming from the patient,
- 06:50things coming out of the see pap machine are going to be in the air.
- 06:55Depending on their size. So here's what we're going to talk about in the next hour.
- 07:02I'm going to present a case of,
- 07:05uh, of a sleep apnea patients who was infected with COVID-19 and then Robert Thomas is going to present the problems of treating these patients and then at the end
- 07:19of this, I hope to have a wide open discussion and you'll be able to ask questions.
- 07:26Bye bye. At the bottom of your screen,
- 07:29it should be able. It should say chat and if you have a question the the chat will allow you to ask a question or if there aren't the Zillion
- 07:38people we can have, you actually speak your questions.
- 07:42So here are going to be the rules of engagement for this.
- 07:46Uh, no recording or photographing the interview.
- 07:50You will be shown I'm going to show you an interview of a patient and he has given both written and verbal permission.
- 07:58For us to be used in this session,
- 08:00and while we're, you know,
- 08:02during the session itself, I'd like you to mute your microphone and then identify yourself when you are speaking.
- 08:10So I bought a month ago.
- 08:12Um, I. I received notification from Yale that I was to work at home.
- 08:18And this is my new office for a variety of reasons I had to set up in the dining room because Yale wanted the background of my what the patient
- 08:29saw to look sort of normal.
- 08:31Where's my own office? Upstairs is a total disaster with books all over the place and so forth.
- 08:38So this is my office.
- 08:40So in order to have this office on my dining room table,
- 08:44I actually resurrected an 11 year old iMac,
- 08:47which to my great surprise.
- 08:49Actually still work, although I couldn't update a damn thing on it.
- 08:54And I also had an iPad running Kanton.
- 08:57Ocanto is the program that connects to epic in our system and this is where I see the patient and the patient sees me because all of our visitors have
- 09:10becomes telemedicine visits, and I'm guessing that's true for many of you here.
- 09:17So, so I've been doing telemedicine visits for several weeks and then.
- 09:24This patient shows up on my schedule and how did it come about so the patient was set up for a face to face visit?
- 09:33Because because he had not been compliant with Cpac.
- 09:37Now, for those of you who are not familiar with with insurance companies and see Ms if a patient does not compliant sometime between 31 and 90 days,
- 09:48there's a threat to take away the machine.
- 09:52But there's much more to the story.
- 09:55So this is our patient.
- 09:57He's a 40 year old that I saw.
- 10:00I saw him literally a bottle week ago today.
- 10:03Actually 6 days ago, a 40 year old male patient web designer who in November,
- 10:10November 20th presented with snoring,
- 10:13sleepiness and obesity. January the 13th.
- 10:16He had a home sleep test which showed he had moderate obstructive apnea with the respire Tori event index of 16.9.
- 10:26With an 8 year auction saturation of 81%
- 10:31and he was prescribed C Pap of between 5 and 15 on auto pap 5 to 50.
- 10:40So January the 30th, he phones up and leaves a message saying that he had been using the machine for six days and it feels like he's suffocating and just
- 10:50that he's not getting enough air.
- 10:53So we changed the pressure to 10 to 20 auto path,
- 10:5610 to 20 and then he had on March the second he had an acclimation,
- 11:01visited our clinic and finally they were able to get a pressure that he was comfortable with and the mask was comfortable.
- 11:09And here exactly a month later.
- 11:12He's on my video visit schedule because he has not been compliant.
- 11:18So here's the interview and I just wanted to let you know that I received permission from the patient to do this interview.
- 11:27How did I do this?
- 11:28So as I mentioned, I had my iPad.
- 11:31Can't on my iPad I could see the patient.
- 11:34I could speak to the patient and I just used my cell phone to actually take a picture of the patient while I was chatting with him and let's just
- 11:46see if this works. Afternoon Mr Hobart This is Doctor Krieger from the sleep disorder center and I just want to make sure that I have permission to use this
- 11:57interview for teaching purposes 'cause I think you have a story to tell that people would find very helpful in this crisis so I'm just going to begin to front
- 12:09end here. You were diagnosed with sleep apnea in December.
- 12:13We stop breathing 16 times an hour.
- 12:15We started you on C Pap and by the.
- 12:18And we end by the time you got a Mass that work.
- 12:22Shortly thereafter, you developed a pretty bad situation.
- 12:27Can you tell us about that?
- 12:29What happened November not November,
- 12:32March 12.
- 12:34Yeah, absolutely. March the 12th I believe was the day I contracted the Chrome virus.
- 12:41Um? I I don't know if that was the exact day,
- 12:46but I believe it was my friend who I had on my safe list basically of friends that I was at that time.
- 12:54They were telling us we could say for being groups of 10 I think it was as long as we were keeping group small and I was with a friend
- 13:04that was on my safe list who was later diagnosed.
- 13:08A few days after that with the virus.
- 13:12The day that he had called me with his results,
- 13:16I started feeling the first,
- 13:19the first symptoms of the provirus,
- 13:22and that was on that Sunday.
- 13:25Let me get that exact page for you here.
- 13:28That was Sunday. Uh the 15th.
- 13:33Send the first symptom was the shortest threat,
- 13:37so you became short of breath and did you continue to use the see pap at that time?
- 13:46I did not and why was that?
- 13:50Just just because I was scared and I just didn't know what to expect and I in that night on the 15th actually didn't sleep at all.
- 14:00Not even, not even a minute,
- 14:03because I I couldn't bring myself to fall asleep.
- 14:07So I felt as if I wasn't getting up there.
- 14:10So I just sat up and basically watch TV all night.
- 14:14And then what happened in with your symptoms?
- 14:19Well then they got worse.
- 14:21The cost started to develop the next day and receiver started develop the next night.
- 14:28I remember taking my temperature was already 2.7.
- 14:32And I didn't sleep that next night,
- 14:36but not with the see Pap Machine.
- 14:40And sleep is terrible at night too.
- 14:43But I did wake up,
- 14:44uh, probably two or three times.
- 14:47Very dehydrated. And uh, and the Fever remained for the next.
- 14:54Next, slide five or six days.
- 14:58He's very complicated. Did anybody else in your home develop?
- 15:05Um coronavirus infection. Yes, I believe everyone in the in my home.
- 15:13Just been through it now.
- 15:15The only other one, only one that has the actual test results.
- 15:20My wife. Uh, and push she was positive.
- 15:24Uh, but it took a long time to get the test.
- 15:28I think it was almost Seven days before she heard back from her doctor with the results.
- 15:35It actually told me as long as I was OK recovering at home to just remain at home and not to get tested.
- 15:44Actually you can. And why was your wife tested?
- 15:49She's just I guess you know,
- 15:51neurotic in a way, and in some ways with that.
- 15:56But she really had. No,
- 15:58she she called. Uh, I remember spending the better part of the day on the phone.
- 16:04Different doctors to try to.
- 16:08Try to get that text and she finally was able to get the test edit drive thru locations.
- 16:15I think in in Westport or go walk.
- 16:18Maybe it works and you have two kids and you think they have the infection as well.
- 16:26I'm leaving having as well yeah,
- 16:29they like I mentioned before,
- 16:31they they were both. Don't seem to recover quicker than immediate they had.
- 16:38Fever, cough, shortness of breath.
- 16:42Symptoms were not not as intense with them and only lasted for two or three days.
- 16:51And they have not been tested.
- 16:56There are no no. The situation now is that you are getting better and can you tell us how you know that you're getting better?
- 17:08Well. Here I mean. Like I said yesterday,
- 17:16there was there was a moment that it was almost a clearly defined moment when I felt the virus just gonna leave.
- 17:23My body was almost a.
- 17:25Spiritual experience, but if you will it was.
- 17:28It was really weird. It just left my body and I knew it was over a new at that moment.
- 17:35Then I was better and then like I said before,
- 17:38it was emotional too for me.
- 17:40But it was. I didn't need a test that you need any doctor,
- 17:46tell me I was better.
- 17:48I I knew I had that warm feeling back inside.
- 17:51I got hollow, empty, heavy,
- 17:54just sick feeling was gone.
- 17:56So in terms of of your sleep apnea,
- 17:59what I'm gonna recommend is for the time being.
- 18:03For you not to go back onto your cpac machine and the reason is we don't know whether your children actually,
- 18:12whether they had a cold or whether they had something else.
- 18:16And the problem with C Pap is that with the circuits it might actually spread the virus in your home.
- 18:25So for the time being,
- 18:27because you're asking is mile.
- 18:30Stay off of the see Pap Machine and hopefully everybody is going to recover a example here.
- 18:38Well on the road to recovery.
- 18:40So that's what we're going to recommend at this time,
- 18:45and if anything gets worse,
- 18:48make sure you instantly contact your doctors,
- 18:53OK? Alright, Yeah so so.
- 18:55Anyways, thank you for letting me a video tape this and your story.
- 19:02I think people will find very educational.
- 19:07So thanks. Thank you very much Mr.
- 19:11Hobart bye bye.
- 19:14Thank you so so I hope you can hear me now.
- 19:18So I spoke to the patient today.
- 19:21He's better. His wife isn't quite cured yet.
- 19:26The children are 100% back to normal and his wife is maybe 80%
- 19:32normal so that was the interview.
- 19:36Now. Now on April the 1st.
- 19:38So we're talking about roughly the date that I saw this patient.
- 19:45This came out from the National Academies of Sciences,
- 19:48engineering, and Madison. And this this national resort resource was asked to talk about whether or not patients are infectious.
- 20:00And so I've highlighted parts of the report.
- 20:04So this is a letter that went to the president.
- 20:08The task force currently available research suggests the possibility that the virus could be spread by bio aerosols generated directly by patients exhalation.
- 20:22And further on it goes and it gives some data.
- 20:26A recent study of the of the Kovid Air socialization at University of Nebraska Medical Center showed widespread presence of viral RNA in isolation rooms where patients with SARS.
- 20:42Over two were receiving care of note air collectors positioned more than six feet from each of the two patients,
- 20:51yielded samples positive for RNA.
- 20:54And it's also worth mentioning that they were positive,
- 20:58even though the patients were not coughing.
- 21:01So anecdotally, the highest airborne RNA concentrations were recorded by personal samplers,
- 21:09while a patient was receiving oxygen through a nasal cannula.
- 21:15In other words, the nasal cannulas seemed to be spreading the virus as well.
- 21:22So here's a chronology of how we got to finally talk about this and that takes us to the rest of the presentation.
- 21:32So on March the 11th I started to think about and inquire about pack circuits that could reduce shedding a virus,
- 21:42an amazingly it couldn't find anything.
- 21:46I contacted a bunch of of Artie's representatives.
- 21:50Several manufacturers I see all of a path company and this is something that everybody was concerned about.
- 21:58What they really weren't a whole bunch of answers.
- 22:02By March 24th eye contact,
- 22:04I contacted the doctor Robert Thomas and we discussed the issue and we decided to work on a document highlighting the issue and and a proposed solution.
- 22:15So this is a terrific picture of Doctor Thomas and and he's,
- 22:21uh, and I'm going to.
- 22:23I'm going to stop my share and hopefully doctor Thomas is gonna take over,
- 22:29and Doctor Thomas is an associate professor of Medicine,
- 22:34Harvard Medical School and. I'm going to pass the baton to him and I'm going to stop the share if I can get my mouse to go into that whole
- 22:46thing there, OK? So Robert,
- 22:49it's all yours.
- 22:58OK, you might have to unmute yourself.
- 23:02Robert, can you unmute yourself?
- 23:19Can you hear me now?
- 23:22Perfectly now yeah. OK. So you go ahead.
- 23:29OK. So. Oh I made the.
- 23:38I'm not sure I would call a mistake,
- 23:41but I took a chance and.
- 23:44Sent out a message on patient site,
- 23:46which is our patient gateway to about.
- 23:492000 patients of mine.
- 23:53Trying to give them some.
- 23:55I was only getting some emails about what to do if I get kernel iris and such.
- 24:01So I sent out an email with my thoughts of that time which roughly similar to what I will share with you now.
- 24:10And of course, I gotta avalanche of return emails.
- 24:14Um? Made me regret transiently,
- 24:17anyway, why did that, but ultimately it was useful in.
- 24:21Um, preventing further anxieties in the group,
- 24:25as well as giving some ideas as to what folks where.
- 24:30Concerned about and what what possibilities can be offered for such a patience?
- 24:37If I can do my slide right so the challenges I see are.
- 24:44Common symptom overlap. So we've been doing telemedicine setting up new patients,
- 24:51and of course they're going to have operated with symptoms,
- 24:56so no later mouth breathing,
- 24:58dry mouth, stuffy nose, it's allergy season.
- 25:02Behind why this is around.
- 25:05So and not everybody can just walk to some spot and get the rabbit test done.
- 25:12Not yet anyway. So we're going to have.
- 25:16C pap related or populated direct effects,
- 25:19which can overlap with kernel error symptoms.
- 25:24And the usual suspects of allergy and been on viruses.
- 25:28Yes, of course. Uh, the issue of dispersion of viral particles,
- 25:31which was only touched upon.
- 25:34Uh, I gave some thought about risk stratification because not all apnea patients are the same.
- 25:40And what are the optimal alternative therapies?
- 25:43And all the messages I got from my patients forced me to spend a bit of time thinking about it and then.
- 25:51A look in the one of my fellows,
- 25:53uh? Uh.
- 25:56You know, Austin? Possible idea of inserting a filter into the circuit an literally.
- 26:03When I was answering his email,
- 26:05I got a call from Doctor Krieger and.
- 26:09We kind of follow that down a bit.
- 26:12Settings for risk stratification I.
- 26:16Uh, suggest a four risk categories,
- 26:20low, intermediate, high and extreme.
- 26:25So extreme moriscos somewhat easier.
- 26:27Anyone on went later, or who is being treated for respiratory failure.
- 26:33And many of the you know,
- 26:34several of those who responded to my broadcast email,
- 26:38actually wear on trilogy's and that type of thing.
- 26:42And they clearly are it really high risk and there's not much room for error there.
- 26:48I would come to the low risk.
- 26:49A younger individuals you can decide for yourself what you would call young.
- 26:54But perhaps less than 40.
- 26:58And biologically milder summer pure sleep apnea,
- 27:02obstructive apnea ram. Dominant apnea.
- 27:05And not severe desaturations I would call it biologically miner.
- 27:10Well, Mila because they may have lots of symptoms for sleep quality and such.
- 27:16But would they be at risk off as long as they don't dry?
- 27:20Will they be at any?
- 27:22Terrible risk by not using path as an example.
- 27:26Intermediate risk as patients who have substantial apnea,
- 27:31those you don't want to.
- 27:34Without without any form of treatment and also have high low gain apia,
- 27:38various types, periodic breathing, complex apnea,
- 27:41central sleep apnea. Uh, but otherwise in decent medical shape,
- 27:46high risk would be heart failure.
- 27:48CEO, PD and oxygen. Maybe Theo paean.
- 27:51Oxygen could be an extreme risk situation.
- 27:54So we're asthma by history.
- 27:57So now is it really bad sleep apnea?
- 28:00I have triggered acatic a red meals from apnea.
- 28:03Pregnancy epilepsy. So those are going to really high risk individuals and I was thinking how can I charge my treatment options for such individuals?
- 28:14So it turns out that many of my patients home oximeters.
- 28:18I generally don't ask about that in clinic,
- 28:21but you know what time they have got home oximeters.
- 28:25So some of them will give you a whole night.
- 28:28Uh, information. Some of them I just spot checks.
- 28:32But that's a useful thing in this day and age,
- 28:36and I'll show you some examples from Amazon,
- 28:41which I snapped. Snapshots of today,
- 28:45so low risk. I would stop by non supine sleep if their problematic insomnia.
- 28:52Short-term consideration for. A sedative.
- 28:58No, it's all paid him or something of that kind.
- 29:00It's really just to help them over the period of infection and they get better.
- 29:05And then you know things are fine of course,
- 29:07and everyone gets worse and get short of breath and so on.
- 29:11And then they deserve to go to the ER.
- 29:13They would need to do so.
- 29:16The intermediate risk, and that's the majority of the patience I have.
- 29:22Uhm, you know I would probably ask him to stop the fat.
- 29:27Get them oxygen. No considers all of mine if they're high Lookin apnea and home oximetry,
- 29:34I would consider ideal if they had that option.
- 29:37They will also sleep in a different room.
- 29:40Ideally room with the window.
- 29:42Good aeration. Stay away from their families if they don't have families,
- 29:47even better.
- 29:49Uh, extreme risk would be a pretty low threshold for hospitalization.
- 29:55Yeah, and uh, you know,
- 29:57data tracking can be done online for at least the trilogy device.
- 30:01I think. Astral also you can do that.
- 30:03And of course. Buy Pepsi and such for the high risk.
- 30:08You know? If there was not such a hospital crunch,
- 30:13you could even make a case of having them admitted their substantial coronal virus related symptoms.
- 30:19Otherwise, the state or my would like them to continue past,
- 30:23probably given supplemental oxygen. Uh,
- 30:26probably convert to a non vented filter configuration,
- 30:29which I will show in a moment.
- 30:31At home off symmetry can't get it to the home care companies,
- 30:35at least not regional home care or reliable.
- 30:38Perhaps there is a home care company or two who may do so,
- 30:42but there's too much concern about how to disinfect the.
- 30:46Oximeter the you know. The packaging,
- 30:51you name it. And it'll be certain nice to track the respiratory rate.
- 30:57So this is a kind of configuration which.
- 31:01I got a cracker and I came up with.
- 31:04And it's based around the non vented mass configuration which will be using for well 15 plus years of the Beth Israel.
- 31:14For patients with high Logan apnea,
- 31:16which helps to stabilize CO2 by allowing a little bit every breathing so you have a well,
- 31:21this is a native non vented mass,
- 31:23but we will learn how to make a lot of mass non vented.
- 31:27Uh, then you have a little bit of connection to just for ergonomics and you have a safety valve anniversary well and then the see Pap Circuit.
- 31:37Uh, some configurations are less clunky because you have the integrated safety valve.
- 31:42Uh, in the mask itself.
- 31:45And it turns out there are a large number of.
- 31:49Filters are there. And all of them,
- 31:52almost of them. It's not all of them will actually fit quite nicely into the standard tubing.
- 31:57You may or may not either connector.
- 32:00But these kinds of tubings filters are available and.
- 32:06They are, uh, uh, if you cleared with fairly stringent requirements and demonstration of filtering,
- 32:15and. How do I look at some of the FDA approval letters?
- 32:18It goes into the site and K pathway,
- 32:20but if they approved, let us.
- 32:23They have a show that it blocks 99.999%
- 32:28dusty 9th of bacteria and virus.
- 32:33Uh, I couldn't, uh, find exactly how they determine that.
- 32:39But you know, I saw the FBI letters allowing them to make that claim,
- 32:44so I'm hoping that.
- 32:46You know there was actual data.
- 32:49And there are specifications of desirability specifications,
- 32:54so these filters for using ventilators as an example.
- 32:58What flow rate, what resistance to flow is permissible?
- 33:03As an example, if you have a leak of 60 meters a minute,
- 33:08it will bump up your.
- 33:11A pressure drop. The pressure drop is less than actually a centimeter,
- 33:14so it's not like when you apply such a filter,
- 33:17you will have 10 centimeters.
- 33:19People had dropped to 5 centimeters.
- 33:21See that it's not quite that way.
- 33:22There will be a small drop,
- 33:24but not quite that way.
- 33:26And, Uh, I don't have a patient who.
- 33:29I've done this too because amazingly now my patient so far have tested.
- 33:36False do were needed to be tested.
- 33:38The cause of the symptoms.
- 33:40I guess it'll it may just be a matter of time.
- 33:44But this configuration potentially useful for not just criminalize,
- 33:48but you know influenza. Now the infections of the upper airway.
- 33:53We generate elevation you don't keep using C Pap as best you can.
- 33:58Well, this is a simple way to.
- 34:00Uh, keep the system safer.
- 34:04The filters can quite cheap,
- 34:05is less than a Buck or not more than a dollar.
- 34:09Yeah, and uh, you know they can be changed more than once a day if it gets so goofy.
- 34:14It is true that when you inhale you will be inhaling through the filter,
- 34:18so you probably inhale some of your own particles.
- 34:22But there's probably no way to escape that.
- 34:27There's a non rebreathing well.
- 34:30Uh, which could be considered?
- 34:33Uh, where, uh, it's. It'll be in the same position,
- 34:37but there will be a large leak port,
- 34:39meaning the expiration because of the increased pressure inside the circuit will be constant.
- 34:45Expert Tori flow and you'll need to throttle that expert expert Tori flow in some way too.
- 34:51Uh, prevent. Too much liq say this is the configuration in terms of oximeters available.
- 34:58I just went this morning and took some snapshots all from.
- 35:04Amazon. A Lucky Health Ring Tracker.
- 35:08Bellevue oxygen ring. Tracker all night wrist oxygen monitor via Tom Variable you can see that these are not cheap.
- 35:18199 two 1921 nine, 159 uh,
- 35:20they're pretty. They're kind of serious devices.
- 35:25But they will give you a full oximeter.
- 35:30Well report in an app.
- 35:33Some of them animated buzz if it drops below a certain level.
- 35:37So it looks like the home oximetry situation may be getting more sophisticated than we actually think.
- 35:44No, no, so as examples of those.
- 35:48Download discuss 3 cases which icon for the last couple of weeks.
- 35:53So the first one is 50 audio gentleman with quite severe OSA.
- 35:58And Lo and behold, he develops fever,
- 36:01sore throat. And to make matters interesting,
- 36:05he also developed acute diverticulitis.
- 36:08But there's no lower respiratory symptoms at all.
- 36:12Are you starting on uh?
- 36:15Uh, augmentin by his PCP for the diverticulitis.
- 36:20And, uh, here, so home oximeter.
- 36:22So we track that he moved to an isolated room.
- 36:24Continue tracking. And, uh. You know it.
- 36:29He settled down fairly quickly,
- 36:31the fever, maybe? It was acute diverticulitis.
- 36:35Maybe it was coronavirus will never know.
- 36:38Uh, but uh, if not for the acute diverticulitis,
- 36:42I guess the case of carnivalist stronger.
- 36:46But we just don't know.
- 36:49Asking to keep using his see pap.
- 36:52The second patient has. And the more moderate sleep apnea.
- 36:58But get good clinical benefit from it.
- 37:00Anne has severe asthma. Every year hospitalization on Indian or late modulation therapy.
- 37:09And he was now starting to have,
- 37:11as usual, summer spring asthma.
- 37:14Flare was coming up.
- 37:16And he was. Really worried because his flair often there will be some fever and upper respiratory tract symptoms and.
- 37:27You know there was no simple way to know whether his.
- 37:31Lower etc sentence where he asked know whether it was the current virus.
- 37:36So I decided we decided that we will,
- 37:39of course, in all these instances I communicate with the primary care physician and we make a kind of conjoined decision.
- 37:46He also had an oximeter.
- 37:49Not surprising because of his asthma.
- 37:51So we settled on tracking and I nearly ended up adding oxygen.
- 37:56But then it's flair subsided,
- 37:59but he would be a person I would early.
- 38:02Not wanting to stop. Fat,
- 38:05but I would add oxygen.
- 38:07Uh, and uh?
- 38:09No, no, maybe I would use a non vented option transiently for filtering.
- 38:17And then I will patiently with a physician pediatrician.
- 38:21Uh, interesting story here. That MA.
- 38:25About 20 years ago, but he had substantial vegetables and lap near.
- 38:32Um? Non vented mass configuration actually work quite well,
- 38:37but it made him feel little odd.
- 38:39Uh, so he just using a rented mask at the low pressure side,
- 38:43sleeping. Here's some degree of residual apnea.
- 38:46We tried using low dose episode made in the past.
- 38:49He developed vasculitic computer skin vasculitis.
- 38:53But he but he, you know,
- 38:55specially called me up and said,
- 38:57what should I do if I get symptoms?
- 39:00Uh I said, well I would probably just use oxygen.
- 39:05Uh, with the filter configuration,
- 39:07and if he can't tolerate that,
- 39:09stop the path and just use oxygen.
- 39:12Now the patient with all appliance who said what should I do?
- 39:15I said well just use soap and water on your plants everyday.
- 39:19He also has some upper every sentence,
- 39:22but. Has not been tested and doesn't look like.
- 39:27Uh, once testing is more freely available,
- 39:30will probably have patience with my symptoms calling us up,
- 39:33but whether we will get to that?
- 39:36Quickly I just don't know.
- 39:38So these are my 3 cases and hopefully none of the patients on ventilator.
- 39:47Melanie has a bunch of patients on ventilator and hopefully none of them will develop compatible symptoms.
- 39:54And that was all I had to say.
- 40:02Myself here, can you hear me now?
- 40:06OK so I can you guys if you can hear me,
- 40:09so I'm so there's a bunch of questions in the chat and what will do is will go through the questions and those of you who want to pipe in
- 40:20pipe in but just identify yourself and so we will go through the questions.
- 40:27I have one question here.
- 40:29Should we move to a oral appliances more at this time the answer is maybe,
- 40:35but not really. And the reason is most dental offices are not going to be doing dental appliances during this pandemic.
- 40:45I've spoken to some dentists about this question.
- 40:49Might be what if a patient develops kovid and is already on an appliance an the appliances breaks?
- 40:58Of the dentist is not gonna bring him in because believe it or not,
- 41:03some of the dentist that I know can't get protection and so they would be in trouble.
- 41:10So what they did say,
- 41:12however, is that the mold the information may be at the fabricator and they may be able to make another appliance based on the model that they already have.
- 41:24Next question was, how old were the patients Sheldon?
- 41:28I think there were five and 10.
- 41:30Uh, and they are much better now.
- 41:33Uh, next question, is it?
- 41:34Uhm, can you just ask a patient to use C Pap and his or her own room and not allow family members into that bedroom?
- 41:43I don't think that would make a huge difference.
- 41:47I think it would be dangerous no matter Wat.
- 41:50Um, just because being in your own room,
- 41:53I know that some of the celebrities they've sort of put themselves into a hibernation type situation.
- 42:01At home, thinking that that's going to separate them,
- 42:05but in fact with common heating systems,
- 42:08God knows what we don't know what happens to to these viruses.
- 42:12So let's move down to more questions.
- 42:15No one question. This is a terrific one from.
- 42:19From one of the attendings Here at Yale,
- 42:22do you think C pap spread the influenza virus is badly in the past and the answer is probably that's true.
- 42:31We just didn't really think about it.
- 42:35Next question with the risk be the same for all interfaces.
- 42:41Robert, what do you think about that?
- 42:44So it probably varies by the amount of leak.
- 42:51So for the. The full face mask clearly have a higher leak,
- 42:56and the higher the pressure.
- 42:59The higher the you know.
- 43:03What do you call it?
- 43:04The? What League do they call it for getting the term right now?
- 43:09Uh, they see when a chart from Phillips,
- 43:12an rationally Robert. That's right,
- 43:15they their charts from Phillips and rest Med way to tell you how much leak is OK based on the mask and based on the pressure so.
- 43:25If you have, you know 30 versus 40 liters per minute across.
- 43:32A night that's a lot of leak.
- 43:34The difference would be quite a bit,
- 43:37so you probably will have a difference in.
- 43:41In what mask used the cuter nasal pillows have the least leak?
- 43:47And the classic full face mask has the biggest boots right now.
- 43:52OK, so let's see the next question.
- 43:54Could I just follow up on a question I asked earlier that you answered?
- 43:58Dentists offices are closed. You're correct about that,
- 44:02but 36% of dentists who practice dental sleep medison are open.
- 44:06Where is the average dentist who just does?
- 44:08Dentistry is closed, but there's only about maybe 4 or 5000 dental Sleep Medicine providers in the country,
- 44:15so 36% of them are open and companies like persona sleep technologies have a CAD Cam process do store the digital information of the files.
- 44:23And so they could, as you suggested,
- 44:25make another one. Just want to get that in there,
- 44:28for, you know, thank thank you very much.
- 44:30So uh, let's see, could I just go along the same line?
- 44:34I'm not, I'm not in our boil.
- 44:36There are boiling by temporary temporary appliances.
- 44:40It can also be utilized that are made by a number of different companies so they can actually be shipped to the patients home and the patient.
- 44:49There's instructions and with the assistance remotely.
- 44:53And this they can walk through the process of making the appliance the mic app,
- 45:01or zip, uh, there's store free their energy.
- 45:05Provide some level of intervention while waiting till all this passes.
- 45:12Yeah, OK, so now there was a question having to do with family members and this question came up a couple of times.
- 45:23So one of the things that I think would be helpful to add a notation's room if they can get it is is a really good HEPA filtering system and
- 45:32their portable ones that are out there that aren't bad,
- 45:36and I think that would help.
- 45:37It wouldn't solve the problem,
- 45:39but it would help.
- 45:42Uh, let's see what we have here.
- 45:45Let's you underestimate or his friend,
- 45:48you have to change your settings.
- 45:50Yeah, so um, that is true.
- 45:52So a doctor pelayo mentioned that on a rest Med system,
- 45:57there's actually a setting in the machine itself where you can tell the see Pap machine that I'm adding a filter to your machine and it compensates for it and
- 46:09related to that I actually spoke to a couple of.
- 46:13Of Res Med Engineers in Australia last night and they have been testing this kind of a configuration similar to what we have been using.
- 46:26That that doctor Thomas showed,
- 46:29and they and basically the they were testing pressures at different pressures and with different configurations.
- 46:38And the there was very little degradation of the either a see pap or a Bipap machine with added filters and it worked fairly well.
- 46:48The other thing I want to mention is that you can add oxygen into the system as as Doctor Thomas mentioned.
- 46:57And there are different kinds of ways you can add oxygen.
- 47:02You can also also add a an adapter that allows you to connect a metered dose inhaler if the patient,
- 47:10for example, ends up on a BI level in an intensive care like unit,
- 47:15you can actually add, for example,
- 47:18albuterol from metered dose inhaler,
- 47:21or you can actually possibly even be able to add a nebuliser into the system.
- 47:27So one of the things that that the engineers from rest man told me it was in Wukan very often and this is not for sleep apnea patients.
- 47:38This was with patients just in general when they ran out of ICU beds,
- 47:43they would do noninvasive ventilation using.
- 47:47C pap machines, Bipap Machines,
- 47:50whatever machines they kind of had and just added viral filters if they could find them wherever an and whether or not that worked or didn't work.
- 48:00We don't really know, but this is something that actually did happen.
- 48:06So then we have another question of a patient lives alone,
- 48:10so I think if the patient lived alone,
- 48:13it's probably OK for them to use the pack.
- 48:16My experience with this one patient and other people that I know.
- 48:21Uh. Personally, who have chronic virus infection take off like crazy and when you're coughing like crazy trying to stay on a see Pap Machine is really really difficult so
- 48:37let's see. So that was another question.
- 48:42All right?
- 48:45So another question, can this be used in an ICU?
- 48:50The answer is probably yes and No.
- 48:55Which isn't a direct answer to the question.
- 48:58I think if you're gonna be using non invasive ventilation using uh,
- 49:02uh for example a bilevel machine,
- 49:05you actually have to know what you're doing in the use,
- 49:09and you need to have a response.
- 49:11Tory therapist that understands what's going into the patient,
- 49:15what's coming out of the patient,
- 49:17the hospital by level machines,
- 49:20you know. They usually have two limbs,
- 49:22they have an in, and they have an out.
- 49:25So there you can add filters an and you'll increase safety for the staff.
- 49:31With a regular BI level machine that's normally used at home,
- 49:35you would actually need to make sure that everything is working properly.
- 49:41You have filters in the right place,
- 49:44otherwise you're going to leave the the nurses and the staff in trouble.
- 49:51So do you wanna answer some of the next few questions?
- 49:57Um, Robert.
- 49:59So let's talk about the interface.
- 50:02Oh yeah, so there's one question about uh,
- 50:05HM ES. Um, so it says there are some studies and I see you,
- 50:10but H me. So what are your thoughts about the HM S?
- 50:14So that the Hitcher Maine,
- 50:16as long as it has been rated for a filter function,
- 50:20is fine. So there hicham ease which have a filtering rating.
- 50:24And the histamines which do not have a filtering rating.
- 50:27So if it's rated to be a filter also it should be fine.
- 50:32OK. So let's see here.
- 50:36Let's see what are your thoughts.
- 50:38I'm using a filtered H me three.
- 50:40OK, so that question we've answered.
- 50:42Then we have. From UK.
- 50:48How does how does humidification effect?
- 50:53The filters life, these are all these filters really gotta change them once a day at least if not.
- 51:00More frequently if it looks.
- 51:03Gunky, it would have to be changed.
- 51:06Uh, that space, uh in the specifications examples I saw I saw things like 20 eight 3335ML.
- 51:15So it's a pretty small amounts of added Dead Space within the filter.
- 51:23Hum.
- 51:24Yep, there's a leak around the mass,
- 51:27so these are definitely not a full proof.
- 51:30You can't. Having zero leak is almost impossible.
- 51:34This is more a mitigation strategy if I may use the term used frequently these days,
- 51:41it's not a perfect strategy,
- 51:43and I'd like to say something about that that the hospital grade masks are not as good as the masks that are used for for patients homes.
- 51:54So the hospital masks are much cheaper.
- 51:57Uh, and they simply do not work as well and and so even in the hospital setting,
- 52:03if you can get one of them asks that works one of the non vented masks for example of a quadrel air or something like that that's non vented.
- 52:14You're better off than the traditional hospital mask.
- 52:19Go ahead, Robert. Ideally, of course we should use a order nasal mask.
- 52:24If you use a nasal mask,
- 52:26anytime the patient opens amount talks out it's going to come,
- 52:30so that's definitely so. Uh,
- 52:33so go says that data suggests that UV light kills covered.
- 52:39Although FDA warning on so clean which comes ozone?
- 52:45So it turns out that the UV you need to.
- 52:51Truly kill viruses and sterilizes pretty a pretty powerful stuff like you can have it.
- 52:57You know bounds on to humans.
- 53:00And it is very effective.
- 53:02Um? Whether they would be a UV system good enough to kill viruses,
- 53:07I know there is a so clean accommodative which uses UV.
- 53:12But there is not good data available on,
- 53:15uh, you know what controls are used.
- 53:17They really check whether it killed viruses or not.
- 53:22Uh, it would be certainly theoretically possible to.
- 53:26Uh. For like some kind of UV light mechanism to even the filter area,
- 53:33but will just make the whole thing so complex in any League of UV light at that intensity you know will cause skin burns as an example,
- 53:43so. Oh, you mean like uh?
- 53:47You know? Would be needed to handle with care,
- 53:51and of course the cleaning up after its use is nice,
- 53:54but soap and water would work.
- 53:56Definitely an while. You're actually using it.
- 54:00It was still spew out.
- 54:02Hey so I just wanna answer rithwik.
- 54:07Question in Connecticut there so far behind in testing that it's it's less than academic.
- 54:16Unfortunately, the patients who the only people that seem to be getting quick test results around here are our medical personnel.
- 54:29Patience sometimes have to wait for like a week or two to get results.
- 54:36Rafael Esquer. Uh, please follow up about the mask in can I please go ahead and rock go ahead like Oh my God read background you got there and your
- 54:50honor. Factor cricket doctor Thomas to quick thing I understand intentional leak issue with the nasal pillows is less than with the full face.
- 54:57However, patients in practice, if you open your mouth wouldn't full face mask serve some form of barrier and switch as a mitigation strategy.
- 55:05Switchmode full face because at least they want to have their mouth dropping open during the night periodically.
- 55:11I mean definitely voting full face mask is best absolutely because yeah well fitting full face mask.
- 55:19Automation mask is definitely better than the nasal because with a nasal across the whole night,
- 55:25I'm absolutely sure people open the mouse intermittently.
- 55:29Uh, and uh, they will be,
- 55:30you know you want a few minutes of that will be enough to God knows billions of viral particles,
- 55:36I mean. And in those little inline photos,
- 55:39Hudson inline filters, I've noticed it prices jacked up on the Internet.
- 55:42You think we should be changed every day?
- 55:45Not once a week. That's the formula recommended.
- 55:48Well, that's a written recommendation without any reference or data.
- 55:54Unfortunately, uh, anything in half demand is going to go up today I I bought.
- 56:03About a week and a half,
- 56:05but almost two weeks ago I I purchased some of these mass.
- 56:10Sorry these filters of them and they were still at basic price.
- 56:15They hadn't gone up yet,
- 56:17but now I suppose it's up.
- 56:20I'd go ahead.
- 56:22Our antiviral filters helpful at all with standard vented mass.
- 56:26Probably not, because the pixelation would go out through the pores into the atmosphere.
- 56:32There won't be enough of a.
- 56:34Uh, back slow to make much of a difference.
- 56:38Coughing will make a oral appliance therapy impossible.
- 56:42Difficult, but not impossible, I suppose.
- 56:46Hum. The old appliances today,
- 56:48uh, you know, they do allow you to open him out.
- 56:52It's not like you're. You know?
- 56:55Trap shut. Would be good to open the nasal airway with a nasal dilator in conjunction with all appliance of a mild sleep apnea.
- 57:05I think so. Reasonable mitigation strategy by putting a fan near window to make a somewhat negative pressure room.
- 57:16Play. It's keep the window open is probably good enough.
- 57:22I'm guessing no. He put a sign near the window creating almost an exhaust like situation.
- 57:28In theory, that could be beneficial.
- 57:31But a good open window,
- 57:33and today at this temperature you can keep it open,
- 57:36at least in much of the US.
- 57:38Although it will get hot down South and you might in fact your entire neighborhood.
- 57:44That's possible, I suppose. A good idea too,
- 57:48sorry, increase risk of pneumonia with C Pap and cover patients with only mild upper area symptoms.
- 57:58We, I'm sure all of us get asked that by patients who have sinusitis or any upper airway.
- 58:04Do we force bugs down into the lungs with C pap?
- 58:08I'm sure we actually do force bugs down,
- 58:11but the lungs normally.
- 58:13You know cleric. Um, there isn't like an epidemic of.
- 58:20Bacterial pneumonia is infections in patients using C Pap at least.
- 58:26Nothing published as far as I know.
- 58:27If it's occurring, it certainly occurring in a more subtle way.
- 58:31But it, but almost certainly there will be some sitting in the airway.
- 58:37If you have free floating particles in the upper airway,
- 58:41and you of course have this air coming in.
- 58:45So I think their plan.
- 58:50Is there a plan to obtain an objective analysis of air solution mitigation by the mask filter configuration you showed us today?
- 58:59It would be nice if we can do that.
- 59:03A corner versus, Uh, I mean,
- 59:05you have to do something like that in a biohazard for facility.
- 59:10Yeah.
- 59:13Because you can't just do it in A.
- 59:17In a lab, you would need to.
- 59:19Have a model respiratory model and then actually have corner virus.
- 59:26A real Colonel iris. And then have.
- 59:31You know, capture the air coming out and run it through while media.
- 59:35If you're talking about some pretty heavy duty stuff to do it safely.
- 59:40Hum. It would need a high level bio safety environment to do so.
- 59:45So so, um, Robert, I actually spoke to,
- 59:49UM, one of our faculty members here at the ale.
- 59:53And what he stressed it is to put in a second viral filter.
- 59:59In the in a strategic place in the circuit and measure the viruses on the second filter and he said he's he can probably do that.
- 01:00:09He does that kind of stuff and and the only problem is we would need IRB and stuff like that,
- 01:00:16and so we kind of.
- 01:00:18You know, I don't even know if RIRB is functioning these days.
- 01:00:24So there's a better Israel,
- 01:00:25their functioning essentially for covered.
- 01:00:28Related stuff only. Yeah yeah.
- 01:00:31Anyway. So we did think about it.
- 01:00:35Alright, so uh, let's see any other questions here.
- 01:00:42Any chance of a fact sheet summarizing these options?
- 01:00:47Maybe through a TSO ASM?
- 01:00:49So we have sent a letter to the JCSM.
- 01:00:53Uh, and hopefully it will be published quickly.
- 01:00:58Uh, with the basic issues involved,
- 01:01:00yeah, the the letter has been accepted and it shows it.
- 01:01:05It's really describes much of what we talked about today.
- 01:01:10And it should be available on their website.
- 01:01:14I think in a matter of days.
- 01:01:16Stop, but to me also,
- 01:01:18a larger question is you know away from Kuwait,
- 01:01:21no influenza and such, should we?
- 01:01:25You know constantly change the configuration while a person has a substantial library or lower airway infection.
- 01:01:35You know, I was only perfectly aware of.
- 01:01:38The droplet. Uh, issues it really.
- 01:01:42Medical school information based learning a bootable closest.
- 01:01:46No, I didn't, uh, give it too much thought.
- 01:01:49Since then. But now it's tempting to want to do that.
- 01:01:55Uh.
- 01:01:57Hopefully you can convince the home care companies or demanded from them.
- 01:02:01If someone has a diagnose influencer.
- 01:02:04To just use for every call will be a bit much,
- 01:02:07but someone who is diagnosed influence I think will be a reasonable thing.
- 01:02:12Alright, any other questions? Uh,
- 01:02:15we're a few minutes over.
- 01:02:16Will be happy to take a couple more questions if anybody has them.
- 01:02:22OK, so there's another one here from the UK.
- 01:02:25Oh essays or risk factor?
- 01:02:27Random insurance. We just response team's eyes.
- 01:02:30Asian conoce a be a risk factor for a new Monia the there's some data that suggests that they haven't looked at OSA specifically,
- 01:02:40that I know of. But obesity,
- 01:02:42I believe has been shown to be a risk factor for Cove it infection,
- 01:02:47and certainly if a patient has diabeetus alot of our patients have metabolic issues diabeetus.
- 01:02:53Obesity, so my guess is it probably is a risk factor for the patients that they get it and probably then go on to be to really have a severe
- 01:03:06problem. Alright, so if there are no other questions here,
- 01:03:11I think, uh, I think we can call it an afternoon and an I hope all of you are safe,
- 01:03:18uh, and I'm really happy that we have got to talk to each other,
- 01:03:23at least for a few minutes an and one more question.
- 01:03:27Possibly it has to do with an elect assists and the issue of the pap therapy actually help decrease the development of atelectasis.
- 01:03:38And so if you've got to sleep apnea patients through your,
- 01:03:42if the recommendation is to not use C Pap that maybe we're enhancing the likelihood of them developing a worsening new monia,
- 01:03:51whereas if they were to use a see pap that actually may prevent preventive role in the worsening of the code 19 itself,
- 01:03:59yeah? Yeah, so that's that's sort of a controversial thing.
- 01:04:03In other words, the patient is sick enough that they require opening up of lungs that might collapse.
- 01:04:10They should really be in a hospital.
- 01:04:12Ann, not you know, not on a on a home see Pap Machine.
- 01:04:16They need to be monitored,
- 01:04:18in my opinion, much more carefully.
- 01:04:20As long as you know,
- 01:04:22as long as facilities allow that.
- 01:04:24But what would we decrease?
- 01:04:26The likelihood of them getting to that point?
- 01:04:29By helping to you know the peep.
- 01:04:32The positive airway pressure you're getting,
- 01:04:36but actually will help prevent the atelectasis so.
- 01:04:40Such a double edged sword?
- 01:04:41Yeah, it's a double edge sword.
- 01:04:43It it is. It's a double edge sword in one of the things we have to always bear in mind is we need to do whatever we can to predict
- 01:04:51the nurses they respond. Tory therapist and the doctors you know the medical students were walking and taking care of these patients now.
- 01:05:01Alright, so there's boy these questions keep on coming here.
- 01:05:07Uh, uh, let's see alright,
- 01:05:09lot of thank you's here and,
- 01:05:12uh. Yeah, so um, this is good.
- 01:05:15I think we need to do another session in a few weeks.
- 01:05:19Once we have a little bit more experience which Wich St Nyack who used to be here.
- 01:05:26And she was, uh, you know she was in in Boston for awhile so let's see an I think that's a great idea.
- 01:05:35Sry an everybody keep healthy and I'm going to sign off now.
- 01:05:40Thank you very much. Thank you.
- 01:05:43Bye bye.