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Thursday, June 17, 2021

To breathe easy, use NIV instead of HFNO to conserve Oxygen stock, Karnataka Govt urges hospitals

The move to reduce usage of high flow oxygen machines to support the breathing of patients is a shift from a policy that was followed in the first wave of the Covid 19 crisis in the country where ventilator usage was advised only as an ultimate resort on account of poor outcomes.

Written by Johnson T A | Bengaluru |
Updated: May 17, 2021 7:26:24 am
Karnataka congress, Karnataka congress vaccine plan, Karnataka covid situation, Karnataka government, Karnataka vaccination, Karnataka news, Indian expressAn official demonstrates on wearing oxygen mask during the launch of 'Oxygen on Wheels', an initiative to provide oxygen to COVID-19 patients inside the local transport buses, in Bengaluru, Wednesday. (PTI)

WITH oxygen supply shortages causing deaths of Covid-19 patients in hospitals around the country, including 33 in two districts of Karnataka in recent weeks, oxygen supply concerns are giving doctors in charge of hospitals and ICUs sleepless nights during the second wave of the pandemic.

One of the things that the Karnataka government has now advised hospitals to do in order to conserve oxygen supplies is to use ventilators to provide oxygen to ICU patients in a more efficient manner instead of high flow nasal oxygen (HFNO) systems that was the norm in the first wave of the pandemic last year.

Following a meeting with district health officers, directors of medical colleges and super specialty hospitals across Karnataka this week, the state health minister Dr K Sudhakar said that all hospitals had been advised to use non invasive ventilators instead of high flow nasal oxygen systems to help Covid 19 patients breathe – in order to conserve oxygen supplies.

“Patients with moderate symptoms need about 20-60 litres of oxygen per minute. So we have to find ways to reduce dependence on oxygen and hence we are trying to utilize non invasive ventilators (NIV) as an alternative. This will reduce oxygen demand by 80 percent. All patients on HFNO will be shifted to ventilator beds,” the health minister said.

Policy change

The move to reduce usage of high flow oxygen machines to support the breathing of patients is a shift from a policy that was followed in the first wave of the Covid 19 crisis in the country where ventilator usage was advised only as an ultimate resort on account of poor outcomes. Ventilators were also in short supply during the first wave but numbers have now increased in parts of Karnataka following central supplies last year.

“In the first wave HFNO usage was advised because oxygen consumption and supply was not an issue. Now the oxygen demand is so high that inefficient usage through HFNO must be restricted and so they have decided that non invasive ventilation is better,” said Dr C Nagaraja, a pulmonologist and director of the Rajiv Gandhi Institute of Chest Diseases, a state run hospital which treats Covid 19 patients.

“There has been a three-fold increase in infections and severity in the second wave. If you use HFNO then oxygen supplies will be sucked out. The non invasive ventilator will use only 50 percent of oxygen compared to the 20 to 60 litres used up through HFNO. In this crisis we have to save oxygen and lives by using NIV,” the RGICD director said.

In the first wave of the Covid 19 crisis there was a conscious effort among ICU doctors to avoid putting patients on ventilators unless absolutely necessary on account of a high percentage of deaths among patients who were intubated and put on ventilators for breathing support.

“In the first wave when we were treating patients there was thinking that once you intubate they do not come out of the ventilator and we were delaying this till the end. The guidelines were also to delay intubation. The advice was to use oxygen, HFNO or Bipap and to delay intubation but now the same thing is not being followed and non-invasive ventilation is being used early for treating,” said Dr Vijay Kumar, the ICU head at the Vikram Hospital.

“We never realized in the first wave that HFNO systems will suck so much oxygen. They consume 60 to 80 litres per minute. Our 6000 litre oxygen tank which needed refilling every 10 days is getting depleted in a day,” said the head of a 150-bedded government Covid-19 treatment hospital where ventilators were not actively deployed on account of HFNO usage.

10-fold increase in oxygen consumption  

“The oxygen issue gives me sleepless nights. We have stopped using HFNO systems to conserve the oxygen in our 6000 litre oxygen storage tank,” said the superintendent of another 150 bed government Covid 19 treatment facility in Bengaluru.

Hospitals are incidentally reporting a nearly 10-fold increase in oxygen consumption in the second wave of the Covid 19 crisis.

“I am living hand-to-mouth when it comes to oxygen. In non-Covid times, I was using 1,400 litres of oxygen per day. My consumption yesterday was 10,000 litres. It also reflects that I did not have patients who needed oxygen in the first wave but in the second wave the patients need it at higher levels,” said Dr Sanjiv Lewin, the head of medical services at the St John’s Medical College Hospital where over 1,000 beds are occupied by Covid-19 patients.

“I should ideally have three days of stock to be on the safe side with the patients. This is 30,000 litres of oxygen. I have never gone above 15,878 litres in the storage which is the stock for just 1.4 days,” Dr Lewin said last week.

“The oxygen supply quantities have not increased but the hospitals in the districts and Bengaluru are increasing their consumption beyond supplies by increasing oxygenated beds. This is the core reason for hospitals running out of oxygen. This is unsustainable. The consumption has to remain within the available supplies,” Karnataka chief secretary P Ravikumar said in a May 9 order calling for rational usage of oxygen across districts. The state has said that no hospitals can increase oxygenated beds without notifying authorities.

IT-based O2 management system being developed

“Oxygen is one of the most valuable resources that is used in the management of Covid-19. Hence, monitoring of oxygen logistics and supply chain is crucial in the fight against Covid-19,” says the May 9 government order.

Apart from advising hospitals to conserve oxygen supplies by using non invasive ventilation rather than high flow oxygen systems that were preferred in the first wave the Karnataka government has started putting in place automated oxygen consumption monitoring and alert systems for preventing incidents like the 24 deaths at the Chamarajanagar district hospital on May 2 due to oxygen shortage and nine deaths at a Kalaburagi hospital.

“An end to end IT-based oxygen management system is being developed. It should be operational in a few days,” said Munish Moudgil who is the state nodal officer for oxygen distribution.  “There is daily monitoring of oxygen consumption in each district, BBMP zone and hospitals. Buffer oxygen stocks are being built at each district to handle any unforeseen shortages,” Moudgil said.

The Karnataka government has projected a requirement of 1471 metric tonnes of oxygen in the state per day as of April 30 but has an availability of only 842 metric tonnes per day through domestic production.  The high court on April 27 directed the centre to take steps for making more allocations to Karnataka as per the projected requirement.

“If the allocation is not made as on April 30, 2021, going by the projected figures of the state government, the shortfall of oxygen in the state will be more than 600 metric tonnes per day,” the HC pointed out in its April 27 order. On Friday the state saw a consumption of 828 metric tonnes (725 kilo litres) of oxygen across 30 districts.

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