State Sleep 0408-2020

April 22, 2020

ID5090

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.