For respiratory therapists, a shortage of a simple tube brings a new coronavirus risk

This is one in a series of reports from hospitals responding to the Covid-19 pandemic.

They had bolstered their ranks with everyone available. They’d hired traveling respiratory therapists, to stop in at Massachusetts General Hospital before moving on, riding the tides of coronavirus from one packed ICU to the next. They’d borrowed others from the smoking cessation program, which had itself largely ceased. They’d brought in students with limited state licenses, to pick up whatever tasks their training had covered so far.

Even Carolyn LaVita found herself pulled back to the bedside constantly these days, to help figure out how to mechanically coax breath into lungs swollen with Covid-19. She was one of the hospital’s two assistant directors for respiratory care. Her job was to make schedules and onboard new staffers, to deal with whatever problems came up — and she’d found herself dealing with more and more of them as the number of patients on ventilators had swelled from 40 or 50 pre-pandemic to around 175 now.

The trouble was, problems could be contagious. What had started, on the second weekend in April, as a low rumble of secretions in an intubated patient’s lungs — just the routine accumulation of mucus inside someone too sick and sedated to cough it up — seeded a different problem when the respiratory therapist on duty checked the supply closet. Normally, you’d fish out a specific sort of catheter, hook it up to the breathing tube, lower it down the person’s throat, and vacuum out the gunk, with a particular sucking sound, like sipping at the foamy dregs of a drink through a straw.

But that sort of catheter was running out. When it comes to pandemic-time shortages, we tend to focus on the most visible: nurses reduced to wearing garbage bags instead of protective gowns, the possibility that ventilators themselves might have to be rationed. This instance was less stark. There were alternatives to this tubing with its crinkly plastic sheath: The ICU has nothing if not a plethora of tubes. Yet the simple act of swapping out one for another didn’t just give respiratory therapists a little more work; it could also put them at a little more risk.

“Our goal is for them not to feel it,” said Paul Biddinger, the emergency physician and disaster preparedness specialist who was now helping to guide Mass. General through the crisis. It was Thursday, April 16, and he was hoping that the purchasing team would manage to secure more of these inline suction catheters within days, so there would be as little change for the respiratory therapists as possible.

In the meantime, Mass. General could borrow a handful from sister hospitals around Boston where the ICUs still had a little more leeway. Soon, though, respiratory therapists would have to switch to the less efficient catheters entirely. Not suctioning a Covid-19 patient — or any intubated patient — wasn’t an option. “This kind of secretion plugs up someone’s breathing,” Biddinger said.

For those working under LaVita, that was just one responsibility among many. Pushing air into the tiny sacs of someone’s lungs can be a dangerous proposition. Provide too much pressure, and the tissue can distend, like a balloon pocketing outwards, its surface growing frighteningly thin. Provide too little, and that lung-sac can deflate, making it hard to bring the next breath in. “There’s a real sweet spot,” LaVita explained.

A respiratory therapist’s job is to maintain that kind of balance, watching levels of oxygen and carbon dioxide in the blood, controlling the size and frequency of mechanical breaths. It’s a task of constant tinkering. The unconscious actions our body normally takes, the unnoticed adjustments that keep our blood and organs aerated, are now in that person’s hands.

The newness of Covid-19 was stressful. At first, doctors had put patients on ventilators when blood oxygen levels dropped, even though the person still seemed strangely able to talk and breathe, because that was what helped with other, more familiar kinds of pneumonia. Now, who would actually benefit from ventilation was a matter of research and debate.

Once a patient was on a ventilator, LaVita helped guide her staff through any uncertainties that arose. If she was on, she was the person they called when a machine started making a weird noise. She was the person who pitched in if there weren’t enough respiratory therapists to intubate everyone in the emergency room who needed intubation. She was the person shuffling the week’s shifts when one of her workers developed coronavirus symptoms and had to be replaced.

Underlying all of that was a greater uncertainty, and a gnawing sense of dread. “We don’t know — no one knows — when our max number of patients is going to be. … People are waiting, waiting, waiting to see, ‘Is this the max that we’re going to get, or should I continue to expect more?’” LaVita said. “However, the folks that we see — the patients who are intubated — their hospital course is incredibly long. They’re not just here for two days. They’re here for three or four weeks. So as soon as we hit the peak, we know we still have three weeks after that — of this — to sustain.”

This past weekend, as she headed into work to unpack ventilators the hospital had received from the strategic national stockpile, her son Mikey had looked up from the living room floor, where he was building pillow ramps for his matchbox cars, and asked her why she had to leave again. “He’s only 4, so he doesn’t really understand what’s going on,” she said. She wished then that she could be in both places at once.

The lack of inline suction catheters generated a kind of worry that expanded outward and worsened other worries. What was most useful about this particular piece of plumbing was that you could hook it up to the Rube Goldberg of breathing tubes and let it live there for days. Every few hours, when alerted by the numbers on the ventilator or lung sounds through a stethoscope, you could lower it down into the endotracheal tube — one tube inside another — and vacuum out the phlegm, then raise it up and leave it in place, ready to be lowered again. “It’s all contained,” LaVita said. “There’s no disconnecting of the ventilator tubing, it’s all part of one system.”

The replacement, if you run out of the inline version, is a single-use suction catheter. “You actually have to open the ventilator circuit and insert it every single time,” LaVita went on. That means opening up a port in the breathing tube, and every time you do that, you potentially divert the rush of the infected person’s breath, spewing droplets and particles into the room. Such procedures are known as aerosolizing or aerosol generating — “a term,” LaVita said, “I use too frequently these days.”

Respiratory therapists wear gear to protect themselves — gloves and gowns, face shields or goggles, N95 respiratory masks that create a seal around your mouth and nose — but still, you didn’t want to expose yourself any more than you had to. With the stay-in-place catheters gone, those risky moments added up fast. LaVita estimates going through about eight to 10 single-use suction catheters per patient every 24 hours.

The change might seem almost unnoticeable to anyone who didn’t actually have to do the extra work. For those who did, it heightened concerns about their own safety and added a few more steps to their 12-hour days. Already, LaVita needed to check to make sure staff members were eating lunch.

It was dire enough that Ed Raeke, the hospital’s director for materials management, subverted his usual protocol, as he’d been doing more and more these days. The distributor he usually worked with couldn’t do much for him, so he’d gone straight to the source, asking the manufacturer about sending a shipment direct. It looked like he’d managed to score the 350 or so inline catheters he was looking for. “But then they came back and told us it’s back-ordered until mid-May,” he said.

“We’re basically out,” he said. He was disappointed but not surprised. He imagined national ventilator use was the highest it had ever been, creating a rush for all the accompanying odds and ends. It was like a game of whack-a-mole, trying to source new streams of different products all the time, from N95 masks to ICU feeding pumps, arterial blood gas syringes, and sanitizing wipes. He’d taken to prowling through his stock rooms in the basement more often than usual, hoping that he’d stumble on a stash he’d somehow missed. Sometimes — very occasionally — he was pleasantly surprised.

In the floors above him, infected lungs kept oozing secretions. LaVita’s respiratory therapists kept suiting up and going in to suction with the single-use catheters they had, keeping damaged airways clear enough to breathe. At least they had equipment enough for that.