Nasal cannula crisis now proving fatal

The deaths of at least 16 Covid-19 patients at hospitals across the country last week, reportedly due to a shortage of oxygen, shone a light on the extent of the oxygen crisis.

Doctors say there is a very simple explanation for major district hospitals like Khulna Medical College Hospital or Rajshahi Medical College Hospital always being so overwhelmed -- the other hospitals in such districts are totally ill-equipped to deal with critical coronavirus patients who need high-flow oxygen.

At the moment, all districts except Panchagarh and Faridpur have central oxygen plants, but those are massively underutilised as most hospitals do not have life-saving high-flow nasal cannulas.

"Patients, who need more than 15 litres of oxygen per minute and have a stressed respiratory system, require supply from high-flow nasal cannulas," said Muhammad Asaduzzaman, head of the Department of Critical Care at Kuwait Bangladesh Friendship Hospital in Dhaka.

It is a known fact that the health facilities in Dhaka division are the country's best when it comes to treating critical patients, but what does the disparity look like?

Data from the Directorate General of Health Services (DGHS) shows that 1,714 high-flow nasal cannulas were being used at health facilities across the country yesterday.

Of the cannulas, 1,059 were being used by facilities in Dhaka division alone, leaving 655 cannulas for the other seven divisions.

Dhaka division's lion's share of high-flow nasal cannulas are being used by 72 hospitals, while the runt's share is distributed among 83 health facilities in the country.

This leaves districts which do not have a medical college hospital with meagre crumbs.

At least 56 hospitals across the country have less than five high-flow nasal cannulas and 15 hospitals have zero high-flow nasal cannulas, as per the DGHS data. This is the situation even though almost all hospitals have supply from central oxygen plants.

On July 2, six Covid patients died at Bogura's Mohammad Ali District Hospital. The hospital had only two high-flow nasal cannulas against its eight Intensive Care Unit (ICU) beds.

On that day, the hospital's superintendent told our correspondent in the district that there were many patients requiring high-flow oxygen support. "We are using over a hundred non-rebreather masks. But elderly patients are suffering due to the shortage of high-flow oxygen support," the superintendent, Nuruzzaman, said.

After the news of the deaths spread, the hospital received 17 new high-flow cannulas from private donations.

Munshiganj General Hospital has zero high-flow nasal cannulas, meaning it cannot take care of critical Covid-19 patients. It has a central oxygen plant which can carry up to 5,600 litres, but no way the hospital can deliver it to critical patients.

The hospital's Covid-19 unit's coordinator Md Jobayer Islam told our district correspondent that last week they had to refer four patients to Dhaka as they needed high-flow nasal cannulas, even though they had the oxygen.

"We also know that many patients come to the hospital and then choose to go to Dhaka themselves, but we do not know what that number is," said Jobayer Islam. "But only providing us with high-flow nasal cannulas will not be enough, we also need an ICU and physicians who can give critical care."

Nilpahamari District Hospital has one nasal cannula and 181 patients were admitted to the hospital, reported our correspondent yesterday.

The hospital has a newly-minted central oxygen plant with a capacity of up to 5,600 litres of oxygen that can be catered to up to 200 patients.

Our correspondent reported that on July 5, 171 people were tested, and 68 were found positive, putting the positivity rate of the district at 39 percent -- much higher than the national rate.

The three CHT hospitals of Bandarban, Khagrachhari and Rangamati have a total of five high-flow nasal cannulas.

"Even though we installed an oxygen plant in January, there is only one high-flow nasal cannula in Khagrachhari Sadar Hospital," said its Resident Medical Officer Ripon Bappi.

Similarly, Bandarban Civil Surgeon Dr Aung Swi Prue Marma said although there is a central oxygen system installed in the district, there are only three high-flow nasal cannulas.

Dr Rokibul Alam, resident medical officer of Thakurgaon District Hospital, for example, said in the hospital patients were having to take turns in using six hi-flow nasal cannulas.

"Out of 200 beds, 145 beds are currently filled. Critical patients are being sent to Dinajpur and Rangpur. We can be in trouble any moment," he told our correspondent in the district.

Since Khulna's surrounding districts do not have adequate critical care services, Khulna Medical College Hospital has to bear the brunt.

Before the Covid-19, we had to refill our oxygen plant once every 15-20 days. Now we have to refill it after two days. Even after that we find that the oxygen pressure drops around dawn," said KMCH's RMO Shubhash Ranjan Halder.

Meanwhile, with growing the consumption of oxygen in the hospitals emerged a pressure in the supply chain.

During the past several days, the daily demand for medical oxygen has increased to 210 tonnes from the normal-time demand of 100 tonnes, according to the DGHS.

Linde Bangladesh Ltd, a private oxygen producer which supplies around 90 percent of the usual national demand, has two liquid oxygen production plants—one in Narayanganj's Roopganj and the other in Chattogram's Sitolpur.

These two plants can produce around 90 tonnes of liquid oxygen daily.

Saiqa Mazed, spokesperson for Linde Bangladesh, told The Daily Star yesterday, "Earlier, we used to send our oxygen tanker to Rajshahi Medical College Hospital once a week. We are doing it twice a week now as the demand has gone up."

"Although we have kept backups to meet more demand, it will be tough if the demand grows even further. Because, transportation with safety is always an important issue," she added.

Prof Dr Mohammed Atiqur Rahman, chairman, Respiratory Medicine Department and Treasurer of Bangabandhu Sheikh Mujib Medical University said, "More high-flow nasal cannulas are needed but oxygen plants also need to have the capacity to cater to them. Private companies should come forward to resolve the crisis."

As the hospitals were running out of medical oxygen during March and April, the health officials said they would buy 40 mobile oxygen generators to meet the rising demand during the crisis.

Later on May 19, the Cabinet Committee on Economic Affairs okayed a proposal from the Central Medicine Store Depot (CMSD) to buy those generators in a direct procurement method to collect those immediately.

Yet when the country continues to reel from another surge of Covid-19 and patients are dying due to the shortage of oxygen, the CMSD officials said they have ordered three generators from Europe which will reach the country by the first half of August.

Meanwhile, the health ministry has formed a technical committee to decide the procurement protocols on the price and other issues on the remaining 37 generators.

"We expect to get three generators by the first week of August. To decide about the other 37 generators, the technical committee will sit in a meeting soon," Abu Hena Morshed Zaman, director of the CMSD, told The Daily Star on Saturday.

He also said, "We have been getting many requests from hospitals for high-flow nasal cannulas and we try our best to help them. But the thing is that unless they have ICUs, they should not need these cannulas."

[Our Bogura, Munshiganj, Nilphamari, Bandarban and Khulna correspondents contributed to this report]