Hospitals facing an expected shortage of ventilators are considering unusual workarounds for critically ill patients in a sign of how scarce the breathing machines have become.

The primary fallback plan is to substitute anesthesia gas machines, thousands of which are unused as hospitals are forced to cancel nonurgent procedures. Other more desperate plans include substituting less sophisticated machines for the breathing devices or splitting ventilators among multiple patients.

“We’re creative and we’re working and figuring it out,” Democratic Gov. Andrew M. Cuomo of New York, the epicenter of the coronavirus pandemic, said Tuesday.

The conversion of anesthesia machines would inject tens of thousands of new machines into the national supply as the U.S. health system confronts a shortfall that could potentially run into the hundreds of thousands, according to one recent estimate from the Society of Critical Care Medicine.

Cuomo estimates the state is still far short of the projected 30,000 ventilators it will need to meet expected demand when the peak hits in the next couple of weeks. The state ordered 17,000 from China, but only expects to receive around 2,500 in the next two weeks because of competition from the Federal Emergency Management Agency and other states.

There are between 160,000 and 200,000 ventilators in the U.S., according to the Society of Critical Care Medicine, whose members include medical professionals. But the U.S. could need as many as 960,000 if a worst-case scenario of infections plays out at once. The doomsday picture is unlikely, but hospitals are already struggling to care for the growing number of critical patients who need the breathing machines.

Weighing different approaches

Cuomo also said he again spoke to President Donald Trump Monday about the practice of using a ventilator for multiple patients, and has consulted with Vice President Mike Pence and White House adviser Jared Kushner. Cuomo indicated he would work with federal officials to better understand and possibly expand training on the practice.

“We have to get the federal agencies on the ground to understand how this operates, especially FEMA, because we have to be coordinated and people have to know what they’re doing,” Cuomo said Tuesday. “This is no time for anyone to be learning on the job and we’re going to be working through that today.”

Columbia University Irving Medical Center, a part of NewYork-Presbyterian Health System, is already placing multiple patients on a single ventilator. A team of doctors there developed a detailed protocol published by the Department of Health and Human Services Wednesday.

“The aim of developing and openly sharing this information is to help hospitals address a critical shortage of these life-saving machines by increasing the number of patients who can be supported with existing supply,” NewYork-Presbyterian Hospital said in a statement.

The hospital did not respond to questions about whether the facility was short on ventilators.

Cuomo has said the state already distributed 1,000 machines from its stockpile as needs arose.

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Six specialty care groups released a statement last week warning about the dangers of using a ventilator for multiple patients, saying that should only be used in the most dire of circumstances.

The state is also working to adapt other breathing apparatuses, like anesthesia machines, for use as ventilators. An anesthesia machine is already a ventilator with additional components that control gases like nitrous oxide. Repurposing an anesthesia machine is much safer than splitting a ventilator among multiple patients, experts say.

“We believe this is a viable resource,” American Society of Anesthesiologists President Mary Dale Peterson told CQ Roll Call. “It should be fully utilized before we’re even thinking about hooking more than one patient up to a single vent.”

Peterson said numbers from the Food and Drug Administration indicate there are 70,000 anesthesia machines in the U.S., the majority of which are sitting idle due to a roughly 70 percent drop in surgeries.

NYU Langone Health had 18 patients on converted anesthesia machines last week, Peterson said, but the health system declined to confirm the number. Richard Branson, a respiratory therapist and University of Cincinnati College of Medicine professor of surgery, said hospitals throughout New York and New Jersey are developing similar plans.

Branson has studied the issue for years. And while both he and Peterson acknowledge that extreme circumstances on the outbreak’s front lines could indeed call for extreme measures like sharing ventilators, it should be a last resort.

The strategy of using ventilators for multiple patients was used during the Las Vegas shooting, and video tutorials appear online. But even when a ventilator tube is split, the machine can only be adjusted to suit a single setting. Pumping too much air into a patient’s lungs could damage them, and patients are at risk of cross-contamination.

“This is not a plumbing issue. This is a physiology issue,” Branson said.

Another less favorable alternative to an anesthesia machine is a bilevel positive airway pressure, or BiPAP, machine, which exerts two levels of pressure through a mask to help a patient inhale and exhale. But it lacks alarms and other features a ventilator has, Branson said, making it only slightly better than a continuous positive airway pressure, or CPAP, machine, which is typically used for sleep apnea. CPAP machines have one level of pressure that forces air into a patient’s lungs, but doesn’t help the person exhale.

New York has ordered 2,700 additional BiPAP machines, Cuomo said Tuesday. The FDA issued an emergency use authorization in March allowing anesthesia machines and others to stand in for ventilators if necessary.

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A survey of mayors released Friday found that 85 percent are short on ventilators. Prices are also climbing as demand surges and supply lines fall behind. Cuomo said Monday that the price of the machine more than doubled from under $20,000 to more than $50,000 “if you can find them.”

“The price is up literally because we are driving the prices up,” he said at a press conference.

Cuomo likened the situation on Tuesday to an eBay auction between the federal government and states, saying that states are struggling to purchase more ventilators because FEMA has “bigfooted” the supply.

Trump officially invoked the Defense Production Act last week after weeks of confusion on whether he would actually use the law’s power to force private companies to manufacture crucial supplies like ventilators.

Trump directed HHS to force the vehicle manufacturer General Motors Co. to make ventilators after more than a week of discussions, a move that news reports say took the company by surprise. The first ventilators would be ready to ship sometime before May, while the federal government is expecting an additional 20,000 to be ready for the Strategic National Stockpile in mid-May.

But the immediate opportunity presented by anesthesia machines and other alternatives prompted some optimism from Cuomo, one of the most vocal critics of the Trump administration’s response.

“I still am hopeful that at the end of the day we have what we need,” said the governor.