Elon Musk's BiPAP Machines May Be Better Than Nothing, at Least

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Photo: Brendan Smialowski (Getty Images)

Tesla and SpaceX CEO Elon Musk said he’d be sending desperately needed “FDA-approved ventilators” to hard-hit hospitals across the nation dealing with the coronavirus crisis—but they haven’t been the high-grade kind needed to keep intensive care patients alive. Instead, those sent off so far appear to be Bilevel Positive Airway Pressure (BiPAP) machines of the kind used to treat sleep apnea, according to a Thursday report by the Financial Times’ Alphaville.


BiPAP machines are similar to CPAP machines but have two pressure settings instead of just one. They cost around $800, according to Alphaville, while ICU-grade ventilators useful for severe cases generally retail for up to $50,000 on the open market. Musk has said he secured around “1,255 FDA-approved ResMed, Philips & Medtronic ventilators” from suppliers in China for distribution, but Tesla-branded boxes in a photo tweeted by NYC Hospitals appear to show at least 40 of them are ResMed S9 Elite BiPAP machines, which appear to be discontinued. (It’s not clear how many of the 1,255 respirators touted by Musk are these BiPAP machines.)

Image for article titled Elon Musk's BiPAP Machines May Be Better Than Nothing, at Least
Screenshot: NYC Hospitals (Twitter)

It’s tempting to view this as déjà vu of that time Musk promised to save a Thai soccer team trapped in a cave with a useless “submarine,” and it’s not exactly a great look for a billionaire to promise “FDA-approved ventilators” and then delivering cheap devices that aren’t really ventilators, aren’t in short supply, and are far from desirable alternatives to ICU-grade gear. But that does not mean BiPAP machines are totally useless given the crisis situation the U.S. is now in.

The FDA has indeed released guidance indicating that non-invasive respiratory devices can be used to treat covid-19 patients—though they are unlikely to provide sufficient oxygen to patients doing poorly enough to end up in the ICU. Their use has also been questioned by the American Society of Anesthesiologists, which has noted that the BiPAP and CPAP machines “may increase the risk of infectious transmission.” The issue is that high-grade ventilators are closed systems that use breathing tubes to deliver oxygen to the lungs and filter the air supply, whereas the sleep apnea machines generally use face masks that can leak air and help aerosolize the virus.


According to Kaiser Health News, CPAP machines are suspected of contributing to the major outbreak at Life Care Center of Kirkland in Washington state, one of the early U.S. epicenters of coronavirus infection. There, 129 residents, staff, and visitors were infected with the virus, with at least 40 associated deaths.

However, UCHealth critical care specialist Dr. Jeff Sippel told Kaiser that BiPAPs could be jury-rigged to work with breathing tubes, as “the hardware actually fits.” They wouldn’t necessarily make a lifesaving difference in truly at-risk patients, but could be used to aid breathing in less intense cases or for patients low on the list for ventilators (such as in anticipated triage situations as covid-19 patients flood hospitals). North Shore University Hospital medical director for respiratory therapy services Dr. Hugh Cassiere told Gothamist that medical personnel at his hospital have been doing just that: attaching breathing tubes and a filter to BiPAP machines. They’ve also been 3D printing connectors to make the conversions, which are reportedly running low.


“We’ve started using them in emergency cases,” Cassiere said. “We’re not recommending ventilating the world with it. We’re saying you have two choices, no ventilator and the patient dies, or use this method, and that’s the approach we’re taking.”

It’s not clear whether all the ResMed S9 machines in question are ones that could be effectively modified to support patients. According to a working protocol published by Dr. David Reich and other Mt. Sinai Health Systems doctors, they were able to convert ResMed S9 VPAP ST devices delivered by Musk to critical care capable systems. But the protocol notes that “the repurposed non-invasive ventilators should be discontinued as soon as a sufficient supply of ventilators becomes available.”


Similarly, some medical personnel have weighed modifications to ICU-grade ventilators so that they can be used to support multiple patients—although some experts are concerned that doing so could further endanger patients already at low odds of survival. Studies have shown that few covid-19 patients on ventilators survive, and those that do often have to remain on the machines for weeks, raising the risks of fatal complications.

“We think it’s great that Tesla purchased bilevel non-invasive ventilators from a platform of ours that we developed five years ago in Asia and sent them to New York,” the CEO of ResMed, Mick Farrell, told Alphaville. “... The bilevels featured in Tesla’s tweet are built on the same platform as our S9 CPAP machines for sleep apnea but deliver non-invasive ventilation that can be beneficial to many COVID-19 patients struggling to breathe while trying to fight off this virus.”


Farrell told CNBC that similar devices have seen extensive use in Europe and China, but conceded that Musk’s efforts might be better directed towards building batteries for use with invasive respirators.

Kaiser noted that some doctors are skeptical, especially about the use of the CPAP and BiPAP machines in the field.


“In general, we’re just telling them not to use it,” University of Colorado School of Medicine associate professor of clinical medicine Comilla Sasson told the site. “Because we are concerned about community spread, and we have to assume that anybody with respiratory distress is a COVID patient.”


In tweets on Thursday, Musk defended the donations and said that hospitals selected to receive the devices were given “exact specifications,” with all confirming they would be of “critical” help. Musk also said that Tesla was in possession of Medtronic intratracheal ventilators, which can be used in critical cases, and would begin delivering them to healthcare providers in New York City on Thursday night.



I’m normally loath to even think of defending Musk, but given what Dr. Reich is putting out as Mount Sinai’s protocol for the donated machines, both you and the FT article at best have an incomplete idea of what’s going on and more than likely have the story outright wrong here.

This is the important part of the tweet from Dr. Patel, who is pulmonary boarded and thus actually has some idea about the capability of the equipment:

“but some models (e.g., VPAP ST, VPAP ST-A) could do the job”

While CPAP and Bilevel (BiPAP is trademarked by ResMed’s blood enemy, Respironics) do precisely nothing besides splinting open someone’s airway - hence the comment about them being unsuited for respiratory support is correct - what’s completely missing in this article is the third category of machines out there: xPAPs that are non-invasive ventilators.

Those are not $800 machines but rather $6000 ones that are prescribed to those with central or complex apneas, usually for a patient with a comorbid diagnosis of something like multiple sclerosis. For those individuals, they desat PO2 (their blood oxygen levels) not because their airway is occluded but because their medulla oblongatas have something wrong with them. Their brains are thus not reacting properly to CO2 levels in the blood and prompting a breath.

Prior to the mid 2000s, there was almost nothing that could be done to help someone like that outside of hooking them up to a traditional ventilator, but with some creativity ResMed started testing a fairly complex programmed machine with both hardware and software not in their other models - you can’t really ‘modify’ a basic CPAP or Bilevel to do what they do since there are electronic components missing - and came up with the ST, which had genuinely miraculous results for those with central and complex apnea. Respironics soon followed with their own adaptive servoventilators (ASVs).

Both models do two very, very important things that CPAP and Bilevel don’t: they can prompt breaths with backup rates and they can control tidal volume, which is how much air actually gets into the lung. The latter is critically important for treating someone with ARDS (which is largely how COVID kills) since in the 2000s crit care people figured out that (in very simple terms) less can often be more.

Outside of sleep medicine and a few neurologists and pulmonary types, you’re almost never going to run across someone who is familiar with this subclass since it’s a tiny, tiny category - something like 1-2% of the machines sold - and that’s one major reason why you’re seeing this response from those in other specialties who are decrying their use: they genuinely haven’t ever seen them before and don’t actually know what they’re capable of.

And yes, there are drawbacks; supplemental oxygen support has to be put in on a T valve (which fortunately the ST/ASVs are already designed to work with) and this is certainly a second choice compared to traditional invasive ventilation (especially if someone requires paralytics, now also part of best practice for ARDS) and to the best of my knowledge they’ve even been tested for this use before, let alone used in a clinical setting. But the protocol established by Mount Sinai clearly indicates what they have is the STs where tidal volume and backup rates are being programmed, and if Musk indeed sent them a shipment then Dr. Patel’s next tweet is more appropriate:

So, no. There aren’t a ton of ST/ASVs out there, but if Musk actually did buy what he could find and send them onwards he’s almost certainly done a good thing. My fingers are crossed that this is the case.