Can I Just Vent for a Minute?

Hello to everyone and thank you again for following along with this blog! 

It’s been a couple of weeks since my last blog and while I do have plenty of time to write, recently I haven’t had the words. Emotions have been particularly high and frankly, downright all over the place. Trying to complete normal life functions, like finding an apartment for residency in the current public health emergency means that “normal” is out the window. I’m working on putting this down into words, but it is tough to qualify the last few weeks of cancelled celebrations, rescheduled (with hope and luck) trips to friends, and inability to see the people you love most in the world. When I figure it out (soon), I’ll let you know. 

In the meantime, I’m thankful for the fact that medicine is a team sport and I’ve had the pleasure to learn with some amazing team members. For assistance with this one, I’ve enlisted my classmate with a particular interest and experience in critical care medicine. 

In the news cycle, you’ve heard plenty about how the availability of mechanical ventilation is necessary to combat the toll this virus is taking on the lungs and our population. It’s a lot of terminology and vocabulary thrown out at once and it can be difficult to truly understand what it means to be admitted to an intensive care unit and recover from a prolonged illness that potentially requires a machine to breathe for you.

To help in talking through and explaining how an intensive care unit (ICU) works, I chatted (remotely of course) with my friend and classmate Laura Di Taranti. Laura has recently matched into emergency medicine in New Jersey and trust me, she’s the kind of person you want to first see when you enter an ER. She’s spent some time prior to medical school interviewing people who were patients in the ICU. As with everything that appears on this blog, we’re still students and not experts in the things we discuss, but share a desire to give you the knowledge and tools to understand your health care. Laura uses quite a bit of technical language in the ensuing explanations, but she does her best to italicize and define words as soon as they appear. She has also included a glossary at the end of this post for you to reference while reading, if you would find that helpful. 

What is critical care medicine? 

Critical care medicine is the practice of medicine in the intensive care unit (ICU). An ICU bed is a little different than a regular hospital bed, and patients who get them are sicker than patients who require regular hospital beds. ICU beds are also less numerous than regular hospital beds. According to data on the NJ Department of Health website, there are 70 acute care hospitals in the state of NJ with a total of 15,268 regular beds and 1,853 ICU beds.*¹ Admission criteria will differ from ICU to ICU, but generally, people who go into ICUs require mechanical ventilation, certain medications called vasopressors which support blood pressure, and/or continuous renal replacement therapy for kidney failure. 

Almost every physician undergoes some ICU training in residency, but physicians can obtain further training in critical care medicine to serve as attending physicians (aka the boss) on the ICU. The attending critical care physician (or intensivist) can be an emergency doc, an anesthesiologist, a surgeon, or an internal medicine doc. Neurologists may also serve as intensivists on special ICUs for patients with brain and spine diseases. These physicians may be augmented by advanced practice providers like physician assistants (PAs) or nurse practitioners (NPs), who completed graduate-level education and received on-the-job training in their respective units. 

What really makes an ICU, though, is the nurses. Because patients in an ICU typically have some form of organ failure, they require intensive and frequent monitoring. The patient-to-nurse ratio on an ICU does not exceed 2:1 – meaning, at most, a single nurse has two patients at a time. In contrast, a “step-down” bed (a bridge between the ICU and a regular hospital bed) might come with a 4:1 nursing ratio, and regular floor beds might have 6:1 or even 8:1 nursing ratios. 

What are intubation and mechanical ventilation? Are they the same thing?

Intubation and mechanical ventilation are similar but not technically the same thing. In intubation, an endotracheal tube is inserted into a patient’s windpipe (aka the trachea). In mechanical ventilation, a machine called a ventilator is connected to that tube to breathe for the patient. A ventilator cannot be used without a tube, and a tube cannot be used long-term without a ventilator. 

Figure 1: an endotracheal tube. Image from Smith’s Medical

Figure 2: a ventilator. Image from Pipeline Medical

Intubation can be a routine procedure when it is planned, as is often the case when a patient has surgery. However, none of the intubations for COVID-19 are planned, and the decision to proceed with an unplanned intubation is not taken lightly. In an unplanned intubation, the patient is sedated (put to sleep) and paralyzed so that s/he does not move. A tube is then inserted through the mouth and into the windpipe, and this tube is connected to the ventilator. The paralytic drugs will then wear off, and the patient will then be maintained on a sedative medication so that s/he does not feel pain while intubated and mechanically ventilated. 

Intubations can occur in the operating room, in the emergency department, or on a hospital floor. If a patient is extremely sick, paramedics may perform intubation before the patient reaches the hospital. Anesthesiologists, emergency docs, and critical care docs all have extensive training in intubation. Docs get a lot of help with ventilator management from respiratory therapists, who have completed at least an associate’s degree and specialized on-the-job training. 

When someone is on life support, what does that mean?

In my opinion, it doesn’t really have a meaning. I dislike the term “life support,” because the ICU is rife with different life-sustaining interventions, and it’s better to be specific. What is the problem, and what can be done to support the person with that problem? If a person needs help to breathe, “life support” could be intubation, mechanical ventilation, or something called ECMO (ECK-mo, or extracorporeal membrane oxygenation). If a person’s heart is not beating, “life support” could be CPR. If a person’s kidneys are not working, “life support” could be continuous renal replacement therapy. If a person’s blood pressure is too low, “life support” could mean inserting a large IV in one of the veins of the neck or groin and administering medications, blood, and/or fluids. 

What I’m hearing in the lay press, though, is that “life support” is meant to mean mechanical ventilation. The term “medically induced coma” is similarly nebulous, but my interpretation of that is that the patient is mechanically ventilated and in order to keep him/her comfortable during that, s/he has been put on sedative medications. 

Why does someone need intubation or mechanical ventilation?

There are a few reasons to intubate someone. The first is that a patient is confused and cannot maintain consciousness to a degree that s/he would be able to breathe independently. Examples of this scenario include traumatic brain injuries, overdoses or poisoning, or severe bleeding or non-pulmonary infection. Patients in this category generally have a completely normal respiratory system, and patients with COVID-19 will generally not be intubated for this reason. 

A patient with COVID-19 might be intubated because s/he can’t ventilate and/or s/he can’t oxygenate. Ventilation is the process of actually taking a breath, allowing oxygen to get into the lungs and carbon dioxide to get out of the lungs. Oxygenation refers to the actual microscopic process at the level of the air sacs in the lungs (called alveoli) in which oxygen is exchanged from air to blood and carbon dioxide is exchanged from blood to air. After all, the whole purpose of breathing is to get oxygen to the blood to distribute to the rest of the body. A patient who can’t ventilate often has a problem with the passages that lead from the nose and mouth to the lungs; examples include asthma and anaphylaxis, a severe type of allergic reaction. A patient who can’t oxygenate often has a problem with the lungs themselves. If a patient with COVID-19 needs to be intubated, it is more likely that s/he can’t oxygenate because of the effects that COVID-19 has on the lungs; however, people with other respiratory conditions like asthma are at higher risk of complications from COVID-19, so it is possible that a patient with COVID-19 is also unable to ventilate. 

In COVID-19, a common reason that patients are intubated and mechanically ventilated is for something called acute respiratory distress syndrome (ARDS). Something always predisposes a patient to ARDS; in this case, it’s COVID-19. ARDS is a type of diffuse lung injury that occurs within 1 week of a new insult to the lungs. The result is diffuse inflammatory damage to the alveoli, causing them to fill with fluid. This fluid prevents oxygen from transferring from the air into the blood. This is a can’t oxygenate problem. ARDS is diagnosed based on low oxygen levels in the blood and imaging, usually a chest X-ray or a chest CT.² Below, I’ve included an image of a normal chest X-ray and a chest X-ray of a patient with ARDS. Notice how on the normal chest X-ray, the lungs (circled) are black and clear. On the chest X-ray of the patient with ARDS, the lungs are filled with this whitish gunk, which represents the fluid filling the alveoli. The gist is that ARDS = bad. 

Figure 3: normal chest X-ray. Radiopaedia rID: 31525. 

Figure 4: chest X-ray of a patient with ARDS. Radiopaedia rID: 66478.

What are the pros and cons to mechanical ventilation?

Before we talk about pros and cons, it’s a good idea to talk about alternatives to mechanical ventilation. Mechanical ventilation is not often the first intervention that is performed for patients who can’t oxygenate. 

The first step is usually a nasal cannula, which is a plastic tube that hangs out in the nose and delivers oxygen at a rate of 2-6 L/min. 

Figure 5: nasal cannula. Image from Wikimedia Commons

The next step might be a nonrebreather mask, which is a plastic mask that covers the nose and mouth and delivers oxygen at a rate of 10-15 L/min. 

Figure 6: nonrebreather mask. Image from Wikipedia

The next step might be a hi-flow nasal cannula, which is a thicker version of the standard nasal cannula hooked up to an air humidifier that can deliver oxygen at a rate of 20-60 L/min. 

Figure 7: hi-flow nasal cannula. Image from Hamilton Medical

In some patients who can’t oxygenate well, another step might be to use BiPAP or CPAP. These are other, noninvasive forms of breathing support in which pressure is applied to the airways to keep them open. However, previous experience with both ARDS and MERS (a different type of coronavirus) suggests that these noninvasive forms of breathing support are not effective to avoid intubation.^3,4 Another intervention that may actually help to prevent intubation is something called awake proning, in which a patient lies on his/her stomach. Through some cool physiology, this can help recruit different parts of the lung to oxygenate a little better. There’s not a lot of data on it yet, but it’s been well-established that lying intubated ARDS patients on their stomachs improves mortality.⁵ There are some recommendations out of China to try awake proning to prevent intubation.⁶

Intubation and mechanical ventilation can be offered to patients who have not done well with any of the above interventions. Which brings us to our most important pro of mechanical ventilation: it can keep ventilation and oxygenation happening when the lungs and other interventions can’t. A patient can’t survive if s/he can’t ventilate or oxygenate, and intubation and mechanical ventilation can buy a patient with COVID-19 time to heal while the lungs can’t perform their essential functions. 

There are cons of intubation and mechanical ventilation. First, the intubation procedure itself could go poorly. Sometimes the tube is put in the wrong place, often the esophagus; this is easily rectified if the problem is recognized early and the tube is replaced correctly. Sometimes, the oxygen levels in a person’s blood drop during the procedure. Teeth and vocal cords can be damaged as the tube passes through them. The intubation itself may fail, and the patient may need to be taken to the operating room to have a surgical procedure or have an incision made in the neck outside the operating room; neither is a great outcome.  

Once the endotracheal tube is in place and the patient is connected to the ventilator, there are a bunch of potential complications. These include ventilator-associated pneumonia (a nasty lung infection), lung injury due to pressurized air flowing from the ventilator into the lungs, and vocal cord injuries. There can also be complications with the tube itself; for example, it can become displaced from its assigned location if not secured correctly, and this can require a re-intubation with a different tube, which has carries the same risks as the initial intubation. 

If an endotracheal tube has been in place for a prolonged period of time, the discussion will move towards a tracheostomy. A tracheostomy is a surgical procedure in which a hole created in the windpipe through the neck. A tube is then passed through this hole and connected to a ventilator. Patients with tracheostomies are generally more comfortable and require less sedative medication than patients with endotracheal tubes.⁷ The point at which a tracheostomy is considered is usually around 10 days.⁸

Figure 8: tracheostomy. Image from Mount Sinai Health System

Do I need to be in an ICU to use a ventilator?

Yes. Patients who are on ventilators require close monitoring that can only be done with those low nursing ratios that are only seen in the ICU. The ventilator should be adjusted to meet the patient’s needs, which can change often. 

What does it feel like? Would the person be awake during it?

An endotracheal tube is much narrower than the windpipe itself, since the tube must fit within the windpipe. As basic physics (ugh) would have it, a smaller tube diameter means more resistance to airflow, which makes it more uncomfortable to breathe. In addition, the ventilator itself pushes air through that tube to overcome the resistance, which increases discomfort. One patient described the experience: “‘…it’s kinda like, did you ever get hit in the stomach, and air gets forced out of your lungs, all of a sudden? That’s the feeling you get – that’s what it was like going in.’”⁹ For that reason, patients who are intubated and mechanically ventilated receive high doses of sedative and pain-killing medications to increase comfort and prevent a patient from fighting against the ventilator. These medications have side effects, however, and one of the most important is delirium, which I discuss below. Therefore, the lowest effective dosages of these medications are used, which may contribute to a feeling of moving in and out of unconsciousness. 

These medications also can suppress the patient’s drive to breathe, so when it is time for a patient to come off the ventilator, these medications have to be decreased or stopped. The patient will undergo a spontaneous breathing trial, in which parameters on the ventilator are adjusted to see if the patient can breathe without support of the ventilator. Patients often report anxiety and fear during this process “‘because this was keeping me alive and then they’re just taking it away. It’s kinda scary, you got to do this stuff on your own.’”⁹ If the patient has a successful spontaneous breathing trial, s/he may be disconnected from the ventilator and have the endotracheal tube removed from the windpipe in a process called extubation. This is what ICU clinicians hope for when a patient is initially connected to a ventilator. However, some patients who are extubated will need to be re-intubated if clinical status warrants. 10-20% of patients who are extubated in the ICU will be re-intubated.¹⁰ 

What do patients in the ICU experience? How about their families?

I have never been a patient in an ICU, so I will rely on the expertise and experiences of people who have been. Experiences vary from person to person, but I’ll include some quotes from some research studies that interviewed people who were patients in the ICU. 

When patients are intubated or mechanically ventilated, they can’t communicate by speaking, which may contribute to a feeling of helplessness. One patient in a Dutch study from 2008 noted, “‘…and what was very annoying of course was that you couldn’t talk. You just let things wash over you sort of. But I have to say that it makes you feel kind of scared, I mean, trying to talk and not being able to…You can’t say what’s bothering you or anything, and you can’t ask for anything.” ¹¹ 

Patients in the ICU often experience something called delirium, which is an altered sense of consciousness due to an illness. ICU delirium can manifest as a patient not knowing where s/he is, not knowing who else is in the room, not knowing what day it is, or even experiencing hallucinations and nightmares. This can cause the patient to sometimes act in frightening ways – for example, trying to pull out his/her own endotracheal tube and disconnecting from the ventilator. One patient in a British study from 2015 described his experience of delirium: “‘I was hallucinating a lot and I had this feeling that I was being abducted by aliens and I was taken in a spacecraft to another planet. And all the time I was thinking now that I’ve been taken to a different planet, I have to find a way to escape from there, so, I was plotting ways to get out of the planet.’” ¹²

While all of that seems really awful, it is important to note that patients in these studies generally expressed a thankfulness that they were alive. One patient expressed, “‘I have got such a different outlook on life…I’ll have the odd day where I will dwell a bit…but everyday is a new day and it’s a beautiful day…I’m a different person.’” ¹³

Families are an extremely important part of ICU care, especially since the patient often cannot talk to his/her care team. Families are often a lifeline for patients in the ICU as they represent a familiar, comforting presence in a world of frightening experiences. One patient noted that family contributed significantly to recovery: “‘I recovered so fast, contributed to my family’s support. I felt their love when they visited me.” ¹⁴ It is important to note that family visits may be tiring for the patient but can serve other purposes, such as information gathering and interface with the ICU clinicians.¹⁵ This is particularly concerning in the time of COVID-19, when families are unable to visit their critically ill loved ones due to concerns about viral infectivity. 

Unfortunately, families experience a lot of stress when a loved one is in the ICU. One patient with ARDS noticed how his hospitalization affected his wife: “‘I would have to say it was pretty taxing on my wife. She was going to the hospital at five o’clock in the morning and getting home at two o’clock in the afternoon, probably five out of seven days. Then she picked the kids up and went to work. You know, she’s a no-quit kind of person, but I could tell it was hard on her.’” Family members in the same interview study echoed that loved ones’ hospitalizations were difficult: “‘I feel like I need to be there for him, but he is difficult. I know he is scared, but he doesn’t seem to realize how hard on me this is…how hard it is for our kids. I am a nurse and see this every day, but I cannot believe this is happening to me. It is just too much sometimes, overwhelming. What will I do if he gets worse? We are sinking.’”¹⁶ Just as patients require emotional support while in the ICU, so too do families. 

What’s it like to be discharged from the ICU? People in films and on TV seem to bounce back right away.

That is…not correct. Getting discharged from the ICU is a process. Depending on the hospital and the patient, a patient may go to a step-down bed or straight to a regular floor bed. Patients and families tend to notice a drop-off in attention at this point, which makes sense because the nursing ratios increase.^17,18 Depending on how weak a patient is, s/he might not be able to go home after being discharged from the hospital and may instead need to go to an inpatient rehabilitation facility to work with occupational therapists and physical therapists. Occupational therapists help patients regain functionalities such as feeding themselves and using the bathroom independently. Physical therapists help patients to increase their strength and move around more easily. Their work helps patients regain at least some functional capacity. Some patients will return to baseline with their help, but this is not the case for everyone. 

Even after a hospital stay and a possible inpatient rehabilitation stay, patients who have been in the ICU often need close outpatient follow-up with both a primary care doc and some specialists. Physical and occupational therapy will likely continue inside the home. Modifications to the home may need to be made – e.g., using a mobility aid such as a walker to get around, moving a bed to the first floor of a home because stairs are too tiring, or requiring in-home nursing care to monitor a patient’s status. The time to return to “normal” varies greatly from patient to patient, and “normal” may never be achieved for some patients. 

There is a poorly understood syndrome called post-intensive care syndrome (PICS) that some patients experience after having been in the ICU. This syndrome describes the physical, emotional, and cognitive deficits that a patient experiences post-ICU. While in the ICU, patients can lose a lot of muscle mass because they’re not moving around and because their bodies break down muscle to extract energy when critically ill; this results in physical weakness after the ICU. After experiencing ICU delirium, patients may not be able to process information like they used to, which results in cognitive deficits. Being in the ICU is also scary, so some patients come away with psychiatric illness that resembles post-traumatic stress disorder, which results in emotional deficits. It is unclear whether PICS occurs just because a patient is in the ICU or because of the underlying pathology that put the patient in the ICU.¹⁹ It’s hard to know exactly how many people experience PICS after having been in the ICU. 

Loved ones who have supported a patient through an ICU stay may also experience PICS-Family (PICS-F). Loved ones may experience similar emotional and psychological deficits, including anxiety, depression, and PTSD. Loved ones of formerly critically ill patients also may face a high informal caregiving burden, which increases workload at home and stress. ¹⁹ 

This is a long way of saying that critically ill patients and their loved ones continue to require support after discharge from the ICU and after discharge from the hospital. There’s a lot of research that should be performed to identify how exactly we as healthcare professionals should do that.

What if I don’t want to be intubated or on a ventilator?

That is okay. You don’t have to be intubated or put on a ventilator unless you want to be. One of the primary ethical principles of medicine is patient autonomy – i.e., the patient gets to make decisions about his or her own medical care. And if you’re thinking about this – congratulations, you’ve taken the first step in the incredibly important process of planning end-of-life care. 

If a patient is sick enough to need intubation or mechanical ventilation, it is possible that the patient will not be able to communicate with healthcare providers that s/he does not want those interventions. It is therefore really, really important to tell someone about your wishes not to be intubated or mechanically ventilated. Healthcare providers will always err on the side of life – meaning, if you need to be intubated, the doc doesn’t know whether you’d like to be intubated, and there’s no one around to communicate that you don’t want to be intubated, the doc will intubate. Because of visitor restrictions in hospitals due to COVID-19, it is possible that a patient may be alone when a decision about intubation is needed, although efforts are often made to contact a patient’s family or friends. 

If it is your decision that you don’t want to be intubated or mechanically ventilated, the first thing you should do is tell someone. This person should be someone that you would trust to make decisions on your behalf in the event that you cannot. This is called a healthcare proxy. If you do not designate a healthcare proxy, the healthcare team will attempt to locate the next of kin (e.g., spouse, child, parent). You should also tell your primary care physician or another physician that you see on a regular basis. 

The next thing that you should do is write down your wishes. A few different options exist, and it depends on the state in which you live. In NJ, our department of health has an excellent website to help you complete paperwork identifying a healthcare proxy and outlining your wishes in a document called an advanced directive. It’s important to know that an advanced directive can be overturned by your healthcare proxy, which allows for flexibility if wishes change based on the situation. 

NJ has a more durable document called a POLST; this document cannot be overturned by a healthcare proxy because it is a physician order. Therefore, it’s more inflexible than an advanced directive. Even if you decide that you’d rather have an advanced directive than a POLST, I think the POLST is a great starting point to talk about life-sustaining interventions. In addition to documenting whether you’d want intubation and mechanical ventilation, the POLST documents whether you’d want CPR or artificial nutrition (which is food through a tube). It also gives you space to talk about overall goals of care – for example, would you like to try to get better at any cost, or would you prefer that your comfort be maintained even if that means foregoing life-sustaining interventions? What do you fundamentally value about life? More information about the POLST, including copies of non-English versions, can be found here.

Once you’ve talked about and documented your wishes, it is important to make sure that at least three copies of your wishes exist. One should be with you, one should be with your healthcare proxy, and one should be with your primary care physician. If you need to go to the hospital, make sure that you bring this document with you. 

Make no mistake – these conversations are hard. It’s difficult to think about your own mortality and the mortality of your loved ones. It is normal to not want to discuss wishes at the end of life. Take small steps to start the conversation; you don’t have to walk away with documentation in hand immediately, and it’s totally okay to pose questions and come back to the discussion later. Even though these conversations are hard, it’s incredibly important that you have them with the people you love. It is extremely stressful for patients and their loved ones when the first person asking these questions is the emergency doc in a life-threatening situation; please don’t put yourself in that position. One of the most gratifying things that we can do as healthcare providers is to take care of someone the way s/he would have wanted, and the best way to make sure that happens is for that to be documented. 

More resources for starting the conversation about end-of-life care planning can be found on the Conversation of Your Life website, which is run by the New Jersey Healthcare Quality Institute. Even more resources, including books to read and films to watch that might help start the conversation with your loved ones, can be found on their brochure. 

Glossary

• Acute respiratory distress syndrome – (ARDS) diffuse lung injury occurring within 1 week of a different respiratory insult, resulting in low blood oxygen levels and fluid in the lungs; important complication of COVID-19 infection that requires intubation and mechanical ventilation 
• Advanced directive – document that identifies a person’s healthcare proxy and a person’s wishes for healthcare in a time in which s/he cannot express them; not a legally binding document and may be overturned by a healthcare proxy 
• Artificial nutrition – liquid food delivered through a tube for a critically ill patient who cannot eat solid food through his/her mouth
• Alveoli – sacs in the lungs in which oxygen is exchanged from air to blood and carbon dioxide is exchanged from blood to air 
• Awake proning – intervention in which a non-intubated patient lies on his/her stomach in order to recruit different parts of the lung to oxygenate better; used in conjunction with other interventions such as hi-flow nasal cannula 
• BiPAP or CPAP – non-invasive breathing support that generates pressure to keep airways open
• Delirium – altered sense of consciousness that occurs due to illness 
• ECMO – (extracorporeal membrane oxygenation) a machine similar to the heart-lung bypass machine in which blood is removed from the patient’s body, oxygenated externally, and then returned to the patient’s body; may be used if intubation and mechanical ventilation fail, but not everyone who is a candidate for mechanical ventilation is a candidate for ECMO 
• Endotracheal tube – plastic tube inserted into a person’s windpipe to connect to a ventilator 
• Extubation – the process of removing an endotracheal tube from a person’s windpipe and disconnecting from the ventilator 
• Healthcare proxy – a person who is appointed to make healthcare decisions on a patient’s behalf when the patient is unable to express his/her wishes; may be identified on a POLST or other advanced directive 
• Hi-flow nasal cannula – plastic tubing inserted into the nose of a patient that can deliver humidified oxygen at a rate of 20-60 L/min 
• Intensive care unit – (ICU) special unit in the hospital for critically ill patients who require interventions such as mechanical ventilation, vasopressors, or continuous renal replacement therapy; staffed by a multidisciplinary team including physicians, NPs, PAs, and nurses; has at maximum a 2:1 patient:nurse ratio 
• Intensivist – physician who has undergone additional training and board certification after residency in order to take care of patients in an intensive care unit; may be trained in emergency medicine, surgery, anesthesiology, internal medicine, or neurology 
• Intubation – the process of inserting a tube into a patient’s airway in order to support his/her breathing; requires mechanical ventilation long-term 
• Mechanical ventilation – the process of artificially breathing for a patient with a machine; requires intubation first 
• Nasal cannula – plastic tubing inserted into the nose of a patient that can deliver oxygen at a rate of 2-6 L/min
• Nonrebreather mask – plastic mask that covers a patient’s mouth and nose and can deliver oxygen at a rate of 10-15 L/min 
• Nurse practitioner – (NP) healthcare provider who initially trained as a nurse and then underwent additional, graduate-level training to increase his/her scope of practice; may prescribe medications, perform assessments, and order tests; generally works under the supervision of a physician 
• Occupational therapist – healthcare provider who has undergone specialized, often graduate-level training to help patients perform their normal activities of daily living, such as feeding themselves and going to the bathroom independently 
• Oxygenation – the microscopic process that occurs in the alveoli in the lungs in which oxygen is transferred from the air to the bloodstream 
• Physical therapist – healthcare provider who has undergone specialized, often graduate-level training to help patients increase mobility and develop strength 
• Physician assistant – (PA) healthcare provider who underwent additional, graduate-level training to prescribe medications, perform assessments, and order tests; generally works under the supervision of a physician 
• POLST – (physician order for life-sustaining treatment) specific type of advanced directive in some states that identifies a person’s healthcare proxy and a person’s wishes for healthcare in a time in which s/he cannot express them; differs from other advanced directives in that it cannot be overturned by a healthcare proxy because it is a physician’s order 
• Post-intensive care syndrome – (PICS) describes the physical, emotional, and cognitive deficits that a patient experiences after having been in the ICU 
• Post-intensive care syndrome – family – (PICS-F) describes the emotional deficits that a patient’s loved one experiences after supporting that patient in the ICU 
• Respiratory therapist – healthcare provider who has at least an associate’s degree and is an expert in managing patients who are intubated and mechanically ventilated 
• Spontaneous breathing trial – (SBT) test in which the parameters on the ventilator are adjusted to determine whether a patient can breathe without the assistance of the ventilator 
• Step-down – describes a bed or unit in which the nurse:patient ratio is slightly higher than in the intensive care unit but slightly lower than on a regular medical/surgical floor; generally used as a bridge between the ICU and the medical/surgical floor 
• Trachea – the windpipe into which a tube is introduced in intubation 
• Tracheostomy – surgical procedure in which a hole is created in the trachea through the neck; a tube is then passed and connected to a ventilator 
• Ventilation – the process of breathing 
• Vasopressor – (pressor) a medication given to increase blood pressure when it is low

Footnotes

* This data was generated from adding up the number of hospital and ICU beds reported from each acute care hospital on the NJ Department of Health website. (Yes, I did this manually.) This is data reported by each acute care hospital and may not be completely accurate, as some data sets did not report ICU beds or general hospital beds. This also does not represent the number of beds that are available at any given time, and not all beds will be available for COVID-19 patients. Bed management is fluid, especially in this situation, with capacities changed frequently based on need. 

References

1. Health Facilities. NJ Department of Health. https://www.nj.gov/cgi-bin/dhss/healthfacilities/hospitalsearch.pl. Accessed April 7, 2020. 
2. Ferguson ND, Fan E, Camporota L et al. The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Medicine 38, 1573-1582 (2012). doi:10.1007/s00134-012-2682-1. 
3. Alraddadi BM, Qushmaq I, Al-Hameed FM et al. Noninvasive ventilation in critically ill patients with Middle East respiratory syndrome. Influenza and Other Respiratory Viruses 13, 382-390 (2019). doi: 10.1111/irv.12635. 
4. Frat J, Thille AW, Mercat A et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. New England Journal of Medicine 372, 2185-2196 (2015). doi: 10.1056/NEJMoa1503326.  
5. Guérin P, Reignier J, Richard J et al. Prone positioning in severe acute respiratory distress syndrome. New England Journal of Medicine 368, 2159-2168 (2013). doi: 10.1056/NEJMoa1214103.
6. Sun Q, Qiu H, Huang M, Yang Y. Lower mortality of COVID-19 by early recognition and intervention: experience from Jiangsu Province. Annals of Intensive Care 10, 33 (2020). doi: 10.1186/s13613-020-00650-2. 
7. Nieszkowska A, Combes A, Luyt C et al. Impact of tracheotomy on sedative administration, sedation level, and comfort of mechanically ventilated intensive care unit patients. Critical Care Medicine 33, 2527-2533 (2005). doi: 10.1097/01.CCM.0000186898.58709.AA. 
8. Andriolo BNG, Andriolo RB, Saconato H, Atallah ÁN, Valente O. Early versus late tracheostomy for critically ill patients. Cochrane Database of Systematic Reviews, CD007271. doi: 10.1002/14651858.CD007271.pub3.
9. Jablonski, RS. The experience of being mechanically ventilated. Qualitative Health Research 4, 186-207 (1994). doi: 10.1177/104973239400400204. 
10. Thille AW, Richard JM, Brochard L. The decision to extubate in the intensive care unit. American Journal of Respiratory Critical Care Medicine 187, 1294-1302 (2013). doi: 10.1164/rccm.201208-1523CI.
11. Hofhuis JGM, Spronk PE, van Stel HF et al. Experiences of critically ill patients in the ICU. Intensive and Critical Care Nursing 24, 300-313 (2008). doi: 10.1016/j.iccn.2008.03.004.
12. Gallop KH, Kerr CEP, Nixon A et al. A qualitative investigation of patients’ and caregivers’ experiences of severe sepsis. Critical Care Medicine 43, 296-307 (2015). doi: 10.1097/CCM.0000000000000613.
13. Maddox M, Dunn SV, Pretty LE. Psychosocial recovery following ICU: experiences and influences upon discharge to the community. Intensive and Critical Care Nursing 17, 6-15 (2001). doi: 10.1054/iccn.2000.1536. 
14. Wang K, Zhang B, Li C, Wang C. Qualitative analysis of patients’ intensive care experience during mechanical ventilation. Journal of Clinical Nursing 18, 183-190 (2008). doi: 10.1111/j.136S-2702.2008.02518.x.
15. Olsen KD, Dysvik E, Hansen BS. The meaning of family members’ presence during intensive care stay: a qualitative study. Intensive and Critical Care Nursing 25, 190-198 (2009). doi: 10.1016/j.iccn.2009.04.004.
16. Cox CE, Docherty SL, Brandon DH et al. Surviving critical illness: acute respiratory distress syndrome as experienced by patients and their caregivers. Critical Care Medicine 37, 2702-2708 (2009). doi: 10.1097/CCM.0b013e3181b6f64a.
17. McKinney AA, Deeny P. Leaving the intensive care unit: a phenomenological study of patients’ experience. Intensive and Critical Care Nursing 18, 320-331 (2002). doi: 10.1016/S0964-3397(02)00069-1.
18. Chaboyer W, Kendall E, Kendall M, Foster M. Transfer out of intensive care: a qualitative exploration of patient and family perceptions. Australian Critical Care 18, 138-145 (2005). Doi: 10.1016/s1036-7314(05)80026-8. 
19. Needham D, Davidson J, Cohen H et al. Improving long-term outcomes after discharge from an intensive care unit: report from a stakeholders’ conference. Critical Care Medicine 40, 502-509 (2012). doi: 10.1097/CCM.0b013e318232da75.