ASAA Webcast: COVID-19 w/ Dr. Craig Feied, Dr. Peter Stein, Adam Amdur & Gilles Frydman

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Webcast: Sleep Apnea and Covid-19 Transcript:

Adam Amdur: Welcome, it’s March 25th, 2020, and we’re in the middle of the COVID-19 crisis. Today, we’re honored to have Dr. Craig Feied, did I pronounce that right, doctor?

Dr. Craig Feied: Well, we say Feied but that’s … go by Craig, that’ll, that’ll do it for us.

Adam Amdur: Dr. Craig, I’m, I’m classically known for putting foot in mouth as we know so I’m sure this won’t be the first or last time that I do that. We’re also welcome to have Dr. Peter Stein and Gilles Frydman, and myself. And what we would like to do with you today is basically ask one very simple question, and that is: what is going on and how can our patients survive this crisis that’s a little bit beyond the imagination of even Hollywood at this point? And we have a lot of patients who are auto-immune compromised. We have a lot of patients that are sleep-deprived already, who have respiratory issues, that have mental health issues, that are taking drugs that might be counterintuitive to what we should be doing in a, in a situation like that.

There’s a lot of misinformation on the internet. We want to talk to the best. We are by no means experts, but we feel like if we could start to gather and learn from each other and be able to disseminate what makes the most sense to give people practical help and knowledge in what they should do next. And then the next step, I think we will have some sort of impact on this crisis as, as big and as, as large of a global pandemic issue this is. So with that being said, Gilles, you have something you want to sort of throw out here with, with your history as the founder of ACOR of bringing hundreds of cancer communities online and the co-founder of Smart Patients, as far as patient-led and patient-hosted, sort of, discussion with

Gilles Frydman: Yes, but, but before I do this, I want to follow up on what you are saying. Anything we can do to help people deal with the massive uncertainty that they are facing every day is going to be, is going to have a real impact. So, whatever we can do in the next 30 minutes to help those, those, all those uncertainties will be welcome.

Adam Amdur: Let me introduce… Go ahead.

Gilles Frydman: No, no, go ahead.

Adam Amdur: I was going to introduce… I’d like to ask Dr., Dr. Craig and Dr. Peter to sort of give a background on, on their expertise and why we brought them to this call because I think I’ll butcher more of their background and translating it into layman’s terms than, than the other way around. So, if you don’t mind, Dr. Craig, we’ll let you go first.

Dr. Craig Feied: Okay, thank you so much, Adam. Well, let’s see. I am a physician, board-certified in initially emergency medicine, and then worked for many years in vascular medicine, also in preventative medicine, particularly in clinical informatics. And for a number of years, I’ve been with WhisperSom Corporation, which is developing less-invasive ways of managing sleep apnea, ways that might be effective for people who cannot tolerate CPAP or for whom CPAP is, is not a, not the best option, not a good option. And I also spent many years as head of the Institute for Innovation in Washington DC. We had quite a, quite a large group of people working on innovation in every area of medicine, from nursing, to critical care, to out-patient, to pre-patient, pre-hospital, and emergency.

Part of our – that system we had a large project, multi-year project, federally funded to develop new hospital designs that would be all-risks ready, that would scale-up ten-fold or twenty-fold in the event of a disaster, precisely like the disaster we’re facing now. We worked extensively in bioterrorism. And bioterrorism is something that occurs very rarely, we hope never. And as a result, and we’ve only had a few incidents of bioterrorism in the world since we started working in this more than twenty years ago. But the model that occurs every year that behaves just like bioterrorism is emerging disease because every year we have these diseases emerging, mostly in the area of Wuhan, and, and a few other hotspots. And then, most years they piddle out on their own, they get shut down; they’re well contained. We get a small cluster of cases. Every so often we end up with effective human-to-human transmission, and it takes more public health effort to control it. We’ve seen those. But most people are aware of those larger events. And then, of course, our greatest fear is that one of these will escape and be the – the mixture of transmissivity and, and lethality that creates the kind of the perfect storm we’re seeing now.

Of course, the one we’re seeing now isn’t as bad as it could get. But it is absolutely bad enough, and so, I’m happy to be able to help in any way I can and bring any of the perspective that I have to this conversation.

Adam Amdur: Well, thank you so much because I’m sure everybody on this call already just learned more in, in five minutes than we probably learned in the last three weeks. Peter, Gilles, please – jump in and ask the questions you guys want to ask as it relates to our patients’ concerns directly in regards to sleep apnea, CPAP machines, and this virus, and what we should be doing at home, and what we should be doing, whether we have to go to a temporary MASH-type unit or hospital. Are these machines aerosoling the virus? Is it exacerbating the lungs? Is it helping prevent potential respiration issues or failures? Those we’re hearing online.

Gilles Frydman: I think it would be good to start with the basics. Everybody is hearing about ventilators, that we are going to have a big problem with not enough ventilators. And I’m not sure that most people know what a ventilator is, and how the ventilator is connected in any way, how they are related to CPAP machines. So, talking about what is a ventilator and explaining the differences between positive air pressure and negative air pressure would be, I think, useful.

Dr. Craig Feied: Well, I’d be happy to speak about that if you’d like unless somebody else wishes to do so.

Dr. Peter Stein: I should give a… Okay… Let me just pause and give a bit of background on myself. I’m a scientist, engineer of the MIT ilk. And I have a brother, a sister, a daughter, and a son and they’re all MDs. And I’m constantly reminded that I’m not a real doctor.

However, however, in, in, in this potential, in, in this particular instance, I’m data-weenie , and I’m watching, and I’m looking at everything. And I’m looking at how things go, and I’m also a sleep apnea patient who ran into trouble and had a CPAP machine. And yes, I have a lot of questions about what happens if I get it? And also, what it means to, all of my comrades in arms here on this, on this issue. And so, some of my questions are yes, what are the basic differences between a ventilator and a CPAP machine? And I believe I can answer that because I believe a ventilator also has a pull to it, where a CPAP machine is just positive pressure. But also, I hear rumors that it’s not it’s good for you. I hear rumors coming out of China that there are a lot of autopsies. And clearly, what’s going on is there’s a, there’s a serious lung obstruction happening here where, where mucus is being calcified. And so, yeah, what does this all mean for us that have a, that have a… where, where do, where do patients with a, with a, with, with problems that are at risk? So yeah, definitely want to hear from you.

Dr. Craig Feied: Well, Adam, you’re… The, the first question there was about ventilation, what is ventilation versus airway support. So, let me, let me just start with this. When we breathe in, normally our lungs have negative pressure. We, our diaphragms descend and then creates a vacuum, a slight vacuum, and air is pulled in. That’s the physiologic way that breathing occurs, negative intrathoracic pressure. If we take a patient who has very poor musculature; can’t make their respiratory muscles work, or nerve damage, the most physiologic way to treat them would be in the irons lungs that were heavily used during the era of polio. I believe there is one patient in the world today still living in an iron lung. Maybe, maybe there are more – there’s one of whom I am aware.

The, the advent of intubation tubes that go down the throat, though, through the vocal cords, into the trachea, where a little balloon blows up right at this level – that allowed us to control breathing very quickly and easily without putting people in this massive, room-sized iron lung. We don’t really have iron lungs anymore. So, when we do that, we blow air in to inflate your lungs. And then we stop blowing air in and your lungs’ natural elasticity blows the air back out. And that is a perfectly normal and healthy way to breathe, except for one thing. It’s positive pressure during, blowing the air in as opposed to negative pressure blowing the air in. That has a lot of effects on the heart, the refilling of the heart, the blood flowing back into the thorax from your periphery, from your arms and legs, getting into the heart. Sometimes that’s a positive effect, it can help to unload the heart in a patient with congestive heart failure. If you have less blood flowing in, your heart is less overstretched. Your blood, your heart may be able to push blood out into, into your chest more easily because it’s not already full of blood.

And so it, that kind of thing, positive pressure ventilation can be lifesaving for those people where negative pressure ventilation really didn’t help them that much. But for most people, there is a slight risk that over time we overinflate the lungs. We may injure the lungs in this way. Particularly, if one part of the lung is collapsed and the other part is open, the air may not go to the collapsed part. It may go, preferentially, to the open part. Just like when you blow into a balloon, you know those, those long thin balloons that they make at fairs that no normal human being can blow up. You try to blow into there, blow as hard as you can, you cannot get it to start stretching. But once you get it popped open, now you can blow pretty easily because the pre-stretched part expands much more readily, much less tensile strength holding it together.

That can happen in the lung. So, the closed part doesn’t get the air, the open part gets overinflated, and you can end up with alveolar injury, lung injury. That is one of the mechanisms by which ventilators, respirators that push air into your lungs can cause harm in patients with those COVID-19 because they do have many areas of the lung that are collapsed. And not just collapsed like in ordinary pneumonia where maybe it’s collapsed and you might like to pop it open, splint it open and then it would be fine. Maybe it was collapsed because it had a little fluid in it, or white blood cells in there, not like that. In this case, we’re talking about interstitial, meaning between the cells, thickening. The entire walls of the thing are becoming extremely thick, and it’s not, they’re just, they inherently don’t have the flexibility at that point that they should have. They may be, now it’s possible, they may be gummed down by thick, interstated mucus that’s dried up. I have not seen those autopsy reports. I’ve heard many reports of that kind. At this moment, in my community, there are regarded as rumors.

The only autopsies that I’ve seen have not shown interstated mucus, and there are things, special things we can do to treat that mucus. But if it’s not there it won’t help us to treat them. So, I hope I’ve answered at least one question, perhaps I’ll stop at this point and, and let us refocus.

Adam Amdur: I think we could ask a thousand follow-ups. I’d go to Peter first as far as the first one that you had on your mind. I know, I know that, that, that I had is, and I’ve already considered is, am I, is, is this the time where – do I go get a tracheotomy? Is that the best preventative mechanism because of potentially what happens in the, in the, in the world and loss of power. If I get an upper respiratory issue, upper airway issue, is that a crazy maneuver? Is that a… you don’t do that unless, it’s, it’s, it’s last resort? That’s, that’s the first thing that came into my mind. I see you shaking your head.

Dr. Peter Stein: I’m going to try to explain things but, so the simple question is, is, you get sick, you get it, you’re not too bad, you’re told to stay at home. Do you stay on your CPAP machine? Or do you wrestle with a way of not being on the CPAP machine? Do you just drink tons of caffeine and stay up all the time, do something that makes sure you’re not on that . You can’t, it’s like the electricity on it .

Dr. Craig Feied: I would, I would… I’ve heard that kind of thinking battered around. I would disagree with that because here’s what’s happening. Let’s suppose you’re a person who does not normally use or need CPAP. You have normal lungs and you may be thinking you’re fine and you’re going to get away with this. Maybe you’re out partying on the beach in Florida a week ago or two weeks ago. And now all of a sudden, you’re feeling worse than you’ve ever felt in your life. And you start having trouble breathing. And maybe the second or third day you get a lot worse, you go to the hospital. And you’re judged to be sick enough to need to be admitted, so let’s first ask on what basis do we make that decision. Well, generally it’s, if you cannot oxygenate adequately at home. So, that means if we put a finger pulse oximeter on you and you are desaturating at rest then you need supplemental oxygen, at least.

And we know that once you need supplemental oxygen, many people progress to needing more, and more, and more, and ultimately, cannot oxygenate with, either with nasal cannulas or even with as mask of, of oxygen. So, at that point, we have to choose how do we improve oxygen getting into the blood? There’s something called the P to F ratio. It’s how much inspired oxygen we’re giving you versus how much is in your blood. When that ratio gets to be higher, only intubation will work. But there’s this grey zone in-between where non-invasive ventilation has been to the go-to therapy, in the emergency department, in the ICU, for many, many years for patients with many problems including pneumonia. And, so non-invasive ventilation in the hospital means a mask like a CPAP mask, but typically we are working more with full facemask. Now, this is a CPAP mask, but it’s a total facemask. This one is, I think this is the Life Fit or the FitLife. This is the closest thing that is available to consumers that matches what we do in the hospital, which is to put something over like this that people who aren’t used to a mask can, can tolerate because they don’t have the acclimatization time, they’re already sick, they’re fighting to breathe.

Better than this is, perhaps, even the whole hood ones. You’ve probably seen these on television, and they’re common in China and in Italy, in which this large, plastic bulb is put over your entire head and inflated. There are some places where they’ve fabricated those out of old water bottles. I’ve seen a, an ICU intensivist who taught us how to fabricate them out of a plastic bag, a Ziploc bag. We put an oxygen tubing into one corner of the bag and turned up the oxygen flow, and put a valve, an exit valve, on the other corner of the bag, and then they put over the head and tape it down. And you turn the oxygen flow up high enough. Oxygen flows in, you can inhale it. They flow it in enough that it blows up the bag and creates a little bit of pressure, they control the pressure by putting what is called a PEEP-valve on the end of the outflow portion.  The PEEP-valve, you just tighten it down until the backpressure is what you want it to be. If you don’t have a PEEP-valve, you take the end of a tubing and you put it in a, in a vessel of water, a bottle of water. And you tape it so it’s down as many centimeters of water as you want the back pressure to be. So, five centimeters of water, you’ve got five centimeters of PEEP. Bubble call it bubble-pap.

When, when these things are done, what’s happening is that we’re inflating any unused alveoli, any that were closed down, and briefly, we expect to get better oxygenation, better ventilation. People will look better, they’ll feel better, their oxygen levels will come up. That’s exactly the same thing as putting on your CPAP mask with the exception of the fact that we’re supplying supplemental oxygen. So, I don’t think – given that our therapy, our initial therapy is non-invasive ventilation which starts with CPAP – I don’t think there is any reason not to use your CPAP at home. The thing that we do differently with non-invasive ventilation that goes beyond CPAP is, if that alone is not good enough then we move the people to BiPAP. Effectively, we’re doing the exact same thing, and Adam, you are muted, so, although you’re moving your mouth, I’m not actually hearing you say yes.

But BiPAP, a lot of people have BiPAP machines at home. That’s basically what we would put you on in the hospital. We talk about having ventilator shortages. For many, many people, if you’re going into the hospital you’ve got a BiPAP machine, bring it with you because that may be, we may be tweaking the settings, but that may be exactly what would be wishing we had to put you on or to put people on. We may spare somebody else the need for a machine.

Adam Amdur: It’s, it’s like the American Express commercial – don’t leave home without it. You got it – you got it, bring it with you.

Dr. Craig Feied: And, of course, with BiPAP we’re giving a little extra pressure during inhalation, less pressure during exhalation. Now, the problem with CPAP is, of course, it raises the work of breathing. We actually have to work a little bit more to get the air out. BiPAP takes that away by, takes a lot of work of your inhalation, so net, net you come out positive. With that said, most people who are put on non-invasive ventilation, and if they don’t get better right away, they tend to progress to need to be intubated anyway. To need to be intubated because we need higher pressures, we need more control, we need to be able to control the absolute volume that gets given as well as the pressures that are given. Some BiPAP machines have mandatory assist and we can have all those controls on them. Most, most really don’t. The amount of volume that you get depends on the pressures or on how long you try to inhale.

Adam Amdur: Let me ask you a simple question that I’ve always wondered, and, and I know we’ve taken apart machines before. But it’s always nice to hear this from experts. Are the guts and the parts primarily the same for CPAPs, BiPAPS, and ASVs, auto servo ventilators? That it’s just a matter of the algorithms in there that control how the valves flow? Is that a fair assessment to say?

Dr. Craig Feied: Okay, okay. The space bar stopped working for me.

The first thing that’s different is between the high-end, very complex CPAP machines and a common ventilator, the first thing that’s different is, primarily, just the industrial nature of a commercial machine intended to be used in a hospital. Modern CPAP machines can have a long MTBF, meaning time between failures. They can really run a long time without breaking down. And, so, there’s no, no real practical difference between a CPAP machine and a hospital ventilator on that, sort of, axis anymore – there used to be. But, I think, we’re talking about the ability to be sterilized, to be moved between patients, to treat some of the edge cases, settings that would allow you to treat edge cases, patients who require ventilatory speeds that you’d never do with a CPAP machine, people who might have 100 breaths per minute, so high-speed oscillatory ventilation, those kind of things. Other than that, I think it’s really just a matter of the intended purpose – the functions, the valves are the same.

Adam Amdur: So, that would lead me to my next question, and, and there are a lot of rumors and stuff on the internet, and, and so-called hacks, of people, taking old CPAPs. We have our CPAP assistance program. Unfortunately, we don’t even have any more machines. But we do have our inventory of factory-sealed CPAP masks that will probably wind up going to one of these states to supplement the inventory shortages that are going on right now. So, we’ve been in discussion with a couple of the states. But, it’s, it’s, it was funny. I was going through my garage a couple of weeks ago and I found one of my old Respironics bricks. And I was literally about to throw it away and I was like, you know what let’s just leave this here.

Somebody might need this, and I, and I know that whether it’s my neighbor or somebody else, this thing is going to, is going to save somebody’s life, and, it’s just, I, I, I know the surpluses are sitting out there. I know there’s, there are discussions over purchasing them. But we know the inventories are in the warehouses. We don’t know what the quantities are. But it’s time that we go and get those, and then it’s time as a country we come together to start making enough so we that have enough beds, we have enough respirators and ventilators, so that we can learn about this virus, spread out the window , and basically not kill our healthcare system. Because right now, we’re going to kill the system and our frontline workers. Cause they’re going to be sleep-deprived, they’re going to be autoimmune compromised from this virus, and we already know that what scares me, and what Peter I keep discussing is the growth rate for the closed cases that we’re seeing with some of the data coming out from the, the coalesced stuff all over the world.

And if, if that growth rate really is, is, is accurate, that’s, that’s, it, that’s whether it’s not Wuhan – it’s multiple Wuhans. It’s New York, it’s Florida, it’s Louisiana, it’s Texas, it’s California. This doesn’t discriminate. So, I’m not trying to be a whistleblower, but I want to know what we can do as a sleep field, as a sleep patient community, to get the word out there, the right information out there because there’s a lot of misinformation out there.

Dr. Craig Feied: One, one question that you had raised in writing that I would like to make sure we do address here is the questions of increased risk to those around you when you are using your CPAP. So, to address that I would point out that most ventilators that are used in a hospital today are so-called, dual-circuit, or closed-circuit ventilators. That is the patient is on one end and then there are two tubes that go back to a ventilator. The inhaled air goes in one and the exhaled air goes out the other and gets captured, filtered and usually goes through a CO2 absorber that’s used in the operating room or that sort of thing. Whereas most CPAP is singled in , the air comes into the patient and then from there, there has to be a leak. When you exhale, you exhale into the mask. In the older style, the air goes down, the exhaled air goes down the tubing and then the forward flow pushes it back out through a leak that’s put in somewhere into the tubing.

With more modern masks, the leak is built into the mask very often. In this particular model, the leak is built into a valve. There’s a valve here that is going into the mask that has the leak built into it. The mask is airtight. This leak, this little leak that’s right here, everything you breathe out goes out that leak, plus all the extra air that’s blowing to wash the carbon dioxide out of your mask because you don’t want to rebreathe your own carbon dioxide. So, this becomes a forceful jet of air that is absolutely packed with infected particles. Where we talk about a three-foot or a six-foot radius, a patient wearing one of these probably has a 30-foot jet. Of course, a sneeze or a cough can cause air to travel that far. You can see it easily with an infrared camera.

But this is what’s freaking out the nurses, when patients come in and they’re sick but they’re not yet requiring ventilation. And it’s night and they want to put their CPAP on. And the nurses don’t want that because they feel now this stuff is blowing right at my face, it’s going to get in the little cracks behind my mask, and, or you may be at home and being told to quarantine. Maybe you’re the only one whose been told to quarantine. What do you do about your family? If you’re, are you going to wear this thing or not? So, these are questions we don’t good answers to. I do think that if you put some sort of fabric collector around this, two layers of pillowcases or something, the particles will be trapped in, in there. The air will come out and will be no worse than your normal exhalations.

Adam Amdur: So would you be worried about still trapping the CO2 in that extra bag or that extra layer?

Dr. Craig Feied: No. These vents are one-way. They only allow… unless you overpower it, you cannot breathe in through this. You can, there’s a built-in… let’s say it got blocked down here, then you would breathe in hard enough, you could pull air in through there. But, generally speaking that’s not going to happen.

Adam Amdur: Great. Peter, Gilles, please. I’m, I’m a little bit, trying to absorb it all. So, when I talk to Dr. Craig, it… he has a way of, he’s been teaching a long time, and he has a way of, what do they say? Brainwashing? A little voice technique? So, I’m a little bit…

Gilles Frydman: I was reading numbers from the FDA on March 22 about the number of existing ventilators in hospitals, and what may be the need if the crisis really evolves the way they think. So, there are 162,000 existing ventilators across hospitals in the US. They might be an additional 15,000 available from the Federal Strategic National Stockpile, and perhaps another 2,000 at the Defense Department. But since the estimates are that some 900,000 may be needed at the time of peak demand by COVID-19 patients unable to breathe for themselves, the outlook for hospitals and individual healthcare providers appear challenging, which is why they’ve changed the directive and are now allowing the use of BiPAPs and CPAP machines from what I understand. The new guidance said that examples of alternative use of respiratory devices used to address shortages might include CPAP, auto-CPAP, and bi-level positive airway pressure machines typically used for the treatment of sleep apnea. this is a guidance issued three days ago, which I was unaware of until this morning.

Dr. Peter Stein: So just to be clear, ventilators do not pull at all, they, they don’t go to negative pressure? They just decrease positive pressure like a BiPAP machine, correct? Is that, is that correct, Dr. Feied?

Dr. Craig Feied: That’s a fairly correct statement. There are ventilators that can be set to negative end-expiratory pressure. We’ve been saying PEEP, PEEP, PEEP, PEEP means positive end-expiratory pressure. That means the final resting pressure when you’re done exhaling all the way, that’s the resting pressure that would hold your alveoli open. The single-limb machines cannot function without some amount of positive end-expiratory pressure because they must be pushing oxygen forward all the time to wash out the carbon dioxide from your mask. If they didn’t blow then the carbon dioxide would be sitting there, and you would re-inhale it. So, PEEP is a requirement for those systems. It can be fairly low PEEP. If your leak is really large, then the air just blows out. But typically, most of these machines won’t go below one or two centimeters of water of PEEP, and only non-invasive ventilators that we, of which there are quite a few in the, still in the pipeline, obsolete, they wouldn’t go before, maybe, four centimeters of PEEP because the way the ventilator leak part of the circuit was constructed. They needed that amount of flow in order to blow it out.

The more modern ventilators that are closed-circuit machines, can have a negative phase to the respiration. They can have negative end-expiratory pressure. And that’s principally used for people who have hyperinflation syndromes, severe end-stage COPD where all their alveoli are sort of chewed up. And they have these large, instead of small sacs in their lungs they have large ones, and they get air trapping. And so, you may actually like to help them breathe out a little bit. So, those are very rarely used and, I think, many ventilators don’t have it.

Dr. Peter Stein: You know, what, what I hear, what I want to reiterate is something that Adam and I have looked at. It’s a, it’s a, it’s a world health site that would seemingly indicate that if you become severe… What it does is it, it says worldwide the percentage of patients that have recovered is about 14, 13 percent that have died, actually. That they can say have gotten sick and then recovered. So, it’s clear that it’s a very progressive disease. It gets worse, and worse, and worse, and worse. So, this obviously is pretty dang serious in terms of the number that have potentially died. But that other, that, that indication is that that is being driven by Italy, and Spain, and places where it’s gotten out of control. And by gotten out of control, it just means that people are getting the proper medical attention. Adam, there should be a statewide emergency call for anybody with old respirators, old, old CPAP machines. They can be used, especially, if they have more of the masks for the ventilators. They could clearly be used as a substitute. So, as they are, certainly a BiPAP machine and even some of the… maybe they can, they can help control some of the valves or something or create valves. I think there should be a recall, an outpouring of support for people coming up with old machines, and anything they can.

Adam Amdur: Dr. Craig, I’d love to ask you one final call to action you’d want to leave our audience with, and our community with. This has been amazing; I can’t thank you and Dr. Stein enough. We’re going to be doing a lot more. This is We invite people to come to our sites no matter which way they enter, whether it’s on the web, or via the Facebook channels, or our forums, or Instagram, or Twitter, or in the professional LinkedIn groups. We definitely want to get the best, most accurate, up to date information. And I think this has been a great start to helping educate and I think we all got a lot smarter. And it’s, once again I’m dumbest person in the room but I enjoy, and I love every second of it. And I want to give you the last word in the call to action. Take it away.

Dr. Craig Feied: Well, thank you, Adam. I really would like to echo what Dr. Stein said. There is a secret, hidden reserve of ventilatory capacity in the country at this time. And that is all the machines that have gone into the hands of CPAP users that are not currently being used. They may be backup machines. They may be extra or travel machines. They may be obsolete or duplicate machines. They may be machines that have some small problem with them that could be readily fixed, accessories missing, or something of that kind. I do think there would be value in attempting to collect all of that material and create it as a supplementary stockpile for those hospitals that potentially may need it. I think it’s absolutely correct what we heard about the, the need for ventilators. Remember, the best estimates we have are that a minimum of perhaps 250,000 Americans will die from this disease with quality treatment. That’s looking sort of at the best outcomes that have been achieved in the areas that were not overstressed. And the worst, if we get good medical care, roughly 1,500,000, maybe 1.7 million people.

With poor medical care, by poor medical healthcare, I really mean no medical care for those need a ventilator and can’t get one. With the absence of ventilatory support, the death rate will at least double. Everything we see shows that. That is the message that comes out of Italy and Spain and other places where we see patients lying on the floors. Only social isolation can prevent us from having that experience in every city in the United States. It is social isolation that allows us to keep those peaks somewhere near the number of ventilators that we really have. And in fact, because the United States is quite large in geographically diverse, it is totally possible that we could take a place like New York, get it completely under control, and be able to move doctors and material, ventilators and other material, out of New York and off to San Francisco or Los Angeles or wherever the next big peak is because New York would have successfully brought their volumes down.

Now that doesn’t mean people won’t get it, it may circulate two or three years. But you certainly, if you’re going to get it, you certainly want to get it at a time when there’s a bed for you and a ventilator for you, and your doctor’s not in quarantine. So, I think we, we should call on everybody to honor the quarantines, to honor their social separation, to honor the lockdowns. That it is the thing that can make a huge, massive difference. Cut death rates in half. And then let’s see if we can’t collect some of these old, unused CPAP machines and allow them to be repurposed where they are going to be desperately needed.

Adam Amdur: That’s an amazing call to action, and I think that’s a challenge for everyone in our community and for all our overlapping communities. I like to always say that everyone sleeps. There are eight billion of us in this world. The one thing we all have in common, chronic to rare, cradle to grave, and the only one extra caveat is I like the idea of the call to action for supplies, and obsoletes, and what’s sitting in the garage or in the closet. Is there a possibility that we could get people with 3-D printers and jamming these parts out for people? We’ve seen stuff like that. These are, these are vacuum blowers, right, at the end of the day?

Dr. Craig Feied: There are a number of efforts underway to make homebrew ventilators, to make parts for ventilators where the parts are obsolete, and the parts have gone missing, and nobody has them. I think that effort is pretty seriously underway. If, upon collecting a lot of almost working devices or working devices, if upon doing so we could identify certain parts that needed to be printed, there’s a massive community that’s prepared to print them, and can do so very quickly. So, I think that’s a great addition to this kind of a thought.

Adam Amdur: Yeah, I think these are the kind of parallel efforts we’re going to need to do whether we get this under control, and, if obviously, if New York is under control or not, if the next one is Florida, Louisiana, Texas. Or if it’s going east or west, I mean, maybe California is going to look amazing because they were so early to quarantine, and you have to give props to Governor Newsom for that. It’s the people who hesitate and the paralysis is what’s not going to get us anywhere right now. Gilles, I didn’t give you sort of a chance to jump in with your, sort of, last call to action. But if you would love to give it, I’d open to you considering your experience with the cancer community and compromised immune systems over all these years. I’m sure those people would love to hear from you.

Gilles Frydman: No, the only thing I have to say is that it’s really… we all have to work really hard to help people find the right information. There is so much disinformation that multiply the feeling of unease that people have. They hear, they hear information and five minutes later they hear the opposite. And I think what we’re doing right is just one little example. I hope we’re going to have many more of these webcasts where we can help people find the right information coming straight from real experts. Thank you, Dr. Feied, for doing this.

Dr. Craig Feied: Thank you for being here.

Dr. Peter Stein: I just want to chime in, thank you very much. I’ve learned a lot, and it’s also making me think of what the, the small business innovators might do. I’m not sure you can’t make a CPAP machine out of a vacuum cleaner, and a hose, and a bag as you start to describe it to me. And there are some things that we may want to start thinking about getting out there to the media, and to the governments and the media about this.

Adam Amdur: So Peter, I’d say let’s leave that as our cliffhanger, invite everyone to visit us at Register with us, stay tuned for more newsletters, blogs, podcasts, and Facebook Lives, and webcasts. We will have our summit May 15th, it will be our, once again, our national annual summit. And I’m sure a lot of this conversation will dictate the agenda for that. And may we all be here in May. Hopefully, we’ve stopped this peak and flattened this curve to buy us some time because right now time is, is, is the asset that we need. For all of us to make it through this because where we go one, we go all. Thank you so much, everybody. Thank you, Dr. Craig. Thank you, Gilles. Thank you, Dr. Peter. My cousin. Good night, good luck, and may the Force be with all of us.

End of tape.

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