A LEADING Bradford doctor says there is a "sense of dread" that decisions taken in Italy - where medics were unable to provide intensive care for all patients because of shortages of kit or staff - could potentially have to be replicated here.

As the estimated peak of the coronavirus crisis nears, the Bradford Royal Infirmary (BRI) is faced with two issues - ventilators and oxygen. 

Professor John Wright, a medical doctor and epidemiologist, is head of the Bradford Institute for Health Research at the BRI and has shared his frontline insight as the hospital copes with the challenges of the virus. 

In the latest instalment of his diary for the BBC, he discusses how there are worries that ventilators the hospital has ordered won't arrive in time to meet the peak.

But, he says there is "growing evidence" that a machine used by patients with sleep apnoea in their own bedrooms can be used as an alternative. 

Oxygen is the other priority.

Prof Wright says hospitals are not built to provide the flow of oxygen needed to keep so many patients on ventilators.

"We're finding that our infectious 'red zone' wards can only take a maximum of 10 ventilated patients before the oxygen flow drops, triggering an alarm," he says.

"When we ordered extra equipment to deal with coronavirus cases, we were expecting the surge to come in May, but Covid-19 has turned out to be more transmissible than predicted and the peak is coming much sooner. So the extra ventilators aren't going to be here in time."

He says Continuous Positive Airway Pressure (CPAP) is the form of non-invasive ventilation which appears to work best for patients who have the virus. 

Some of the hospital's CPAP machines use 50 litres of oxygen per minute for a single patient - that's not usually a problem, because oxygen is not usually in short supply.

It became a problem in Italy, because of the number of patients needing ventilation.

"One of the issues is that while beds have oxygen next to them, we've never needed such a large flow of oxygen on the ward," explains intensive care consultant Dr Tom Lawton.

"We have something like 250 litres per minute available for each ward, and about 3,000 available for the hospital - which again, has never been an issue before. But if you're using 50 litres per minute for each patient, then that's suddenly only five on a ward and 60 in a hospital - and we need more than that.

"It's not just us, it's also hospitals around the country - they weren't designed for this level of oxygen use."

Watford General Hospital declared a critical incident on Saturday as it neared the point when it would have been unable to provide oxygen to patients who needed it.

Dr Lawton has been coming up with ingenious ways to get around the problem, including working with Leeds University on a 3D-printed valve that could be attached to ventilators to reduce the amount of oxygen they use.

He's also been looking at CPAP machines used to treat sleep apnoea at home. These maintain air at a continuous pressure, inside a mask, to keep the user's airways open - they have to be repurposed to provide oxygen for use in the hospital, but they use much less of it than standard hospital ventilators.

Dr Lawton called a local company to check availability, who said they had 2,000. 

The plan is to start with 100 to see whether, if used early enough, medics can prevent people deteriorating and needing to go on the more complex ventilators and on to the intensive care unit.

"We've been testing them over the weekend, and there's evidence from China and from the US that they seem effective. They just help inflate your lungs and that seems to be beneficial," says Prof Wright.

"They are also very simple, which means that there's no need for a huge amount of training."

Debbie Horner, the consultant in charge of Covid-19 intensive care planning, who has now returned to work after contracting the virus herself, explains the complexities surrounding supplying oxygen.

She says: "One of the issues that originally we didn't realise we were going to have is actually the diameter of the pipes coming into the hospital.

"So it's not just the total amount of oxygen that the hospital has, it's also how much can you get to the bedside? Or how many bedsides can you get oxygen to at any one time?

"We've had to consider how to distribute patients around the hospital "based on the size of the pipes."

The hospital wants to avoid the situation faced in Italy where medics were unable to provide intensive care for all patients because of shortages of kit or staff.

Planning is underway into how the BRI will deal with that situation of it arises.

That means putting a support network in place for clinicians.

There's also discussions about regional and national ethics committees, to support hospitals with the decision-making process, so everybody is making decisions using the same framework. 

"This is uncharted territory for us. There is a sense of dread about potentially having to replicate some of the decisions that have been taken in Italy," says Prof Wright.

"Hopefully it won't reach that point."