CroResp Makeshift Respirator Mask for COVID-19 Pandemic: Interview with Ivor Kovic, MD

The COVID-19 pandemic has resulted in significant shortages of PPE for medical staff. This is extremely concerning, as it means that clinicians can’t adequately protect themselves, and infections among medical staff will lead to staff shortages at a time when every member of staff is needed. Similarly, infections among clinicians could promote the spread of the virus between patients.

In such a situation, medical staff need to find new and imaginative ways to protect themselves and their patients. A group of doctors in Croatia has developed a makeshift protective respirator mask called the CroResp that relies on a scuba mask, 3D printed parts, and an air filter. The device allows clinicians to minimize the chance of exposure to the virus while tending their patients. The device is open source, and is conceived to be made and used by whoever needs it.

The respirator covers the mouth and nose and delivers clean air to the user. However, it is inexpensive and easy to make, provided one has access to a 3D printer. The group behind the device is eager to hear from people who are interested in collaborating on similar projects and for sharing information that is useful for front-line staff fighting the virus.

See
a video about the CroResp below

Medgadget had the opportunity to talk to Dr. Ivor Kovic, one of the doctors behind the device, and a former Medgadget editor.

Conn Hastings, Medgadget: Please give us an overview of the current shortage of PPE during the COVID-19 endemic, and the potential consequences of this.

Ivor Kovic: I think it is fair to say that most of the
world was not ready for this pandemic and all the pressures it has put on our
healthcare services. As the situation evolved, starting from the outbreak in
China into a global issue affecting almost every country, so did our
understanding of just how severe the threat is. As we can see from the media,
but also direct testimonies of frontline healthcare workers on social media,
there is a severe global shortage and issues with distribution impacting even
the wealthiest nations. At the same time, the number of patients is growing
exponentially, and the situation has the potential to get even worse if we
don’t deploy alternative solutions promptly. Locally, in Croatia where I am
now, this is undoubtedly an issue. We still observe that our most exposed
colleagues are, for example, intubating COVID patients with inadequate
protective equipment, putting themselves at risk, but also risking a sharp
decline of those fit to continue working. Finally, infected healthcare workers
are also ideally placed to become super spreaders of the disease, a scenario
which is further fueled by the issues with broader availability of rapid
testing.

Medgadget: Tell us a bit more about yourself, and how you got involved in helping front-line healthcare workers.

Ivor Kovic: I am a Croatian medical doctor, an emergency
medicine specialist. For the last 6 years, I have been working in the United
Kingdom in various NHS Accident & Emergency departments across the country.
Prior to a significant outbreak of the disease in the UK, I travelled to
Croatia with my family for a vacation. Landing in Zagreb, the capital of
Croatia, made us immediately aware that the approach of the Croatian
authorities was almost the opposite of the one practiced at the time in the UK.
On arrival, we were ordered into mandatory self-isolation for 14 days, with
frequent checks by family doctors and even the police. I felt helpless sitting
at home until I quickly realized that there are other ways that I can help my
colleagues on the frontline. With a group of peers, who all shared great
motivation and a selfless attitude, I started an online educational portal in
the Croatian language for medical professionals in the region. We quickly
discovered, analyzed, translated and disseminated the latest guidelines,
scientific papers, expert opinions and other educational materials. This side
of the project is steadily growing, and we now have over 20 contributors,
continuously publishing new and very much needed information.

Medgadget: How did you get the idea to create this device?

Ivor Kovic: Working on the pandemija.info portal made us aware of efforts from various
groups across the world trying to create improvised equipment, from NiV masks
to ventilators. One such idea came from an Italian company called Isinnova.
Italy was the first country in Europe with a significant outbreak, so many
issues were first exposed there. One is the lack of NiV masks, needed for
non-invasive ventilation, a strategy which Italian doctors have embraced in the
treatment of COVID patients. They turned to Isinnova with an idea to transform
a full-face scuba mask made by a company called Decathlon, into improvised Niv
masks. So, they came up with a 3D printed adapter which replaces the snorkel
and allows the scuba mask to be connected to the ventilator. When I saw that
idea, it immediately made me realize that such a mask could also be transformed
into a personal protective respirator for medical staff. Respirators were
something that was at the time a much higher priority in Croatia, than NiV
masks. So after 3 days of non-stop work, we made the prototype and published
our findings online under the creative commons/open source licence. We designed
new adapters to connect bacterial/viral filters to different models of scuba
masks we found in stock in Croatia. Simultaneously we started conducting both
laboratory and user testing. Now, after two weeks, we can say with a higher
degree of confidence that this solution is readily available, easy to make and
far superior to loose-fitting masks. Once we were able to catch our breath and
look around, we discovered several groups around the world developing the same
idea. Most of them are open like us and don’t see a business opportunity in all
of this, so we regularly exchange information which is making the process much
faster.

Medgadget: How might the device be used by medical staff? Is it possible to reuse the device?

Ivor Kovic: Our version of the respirator, which we named
CroResp, is intended to protect the airways and eyes of medical personnel,
especially those who carry out procedures which generate aerosols. It is,
however, not yet officially approved. At the moment, it can be used only in the
case where the recommended equipment is not readily available, and at the
discretion of medical professionals. The device is used just like any other
type of respirator, with the same precautions and following official guidelines
for donning, doffing and reuse. Its advantages include the fact that it
protects the whole face, but also that it can be reused multiple times. The
scuba masks themselves are very robust and can tolerate abuse. We tested
several methods of cleaning and disinfecting, some of them quite aggressive.
Scuba masks remain functional with a good fit even after such procedures, while
bacterial/viral filters are easily replaced, just like the 3D printed adapters.
It is essential to select a filter device or medium that is available locally
because this concept and design can be easily adjusted to accommodate various
filtration solutions. We chose the bacterial/viral filters which are well known
and commonly used in intensive care units, for example, to protect patients and
ventilators from the spread of pathogens. There are various types of such
filters, and we selected the ones with the lowest flow resistance and the
highest filtration levels. A literature review and study of the technical
documents from various manufacturers make us confident that some of these
filters achieve the levels of filtration as high as those required for N99/N100
respirators.

Medgadget: Who is collaborating on this project?

Ivor Kovic: Our team is growing every day. However, the
core team members, who started the project also include Mr. Ivan and Marko
Gustin, who are responsible for designing and printing the adapters, and Mr.
Hrvoje Vukelic, who is responsible for communication with healthcare workers
and philanthropists. Furthermore, I have to mention Mr. Igor Habljak and Mr.
Kruno Golubic, who are giving all their time to the project. Furthermore, we
now have over 200 medical doctors in closed groups testing the equipment and
giving feedback. Some, like Dr. Mario Franolic also independently conducted
beneficial tests, for example, to test potential accumulation of CO2 inside the
mask. Finally, as I mentioned before, we are sharing knowledge with various
other groups, and have also started a simple web page to list all of them. Such
a list we think is crucial because it can help to spread the idea. I want to
invite your readers to get involved in spreading the message, and also those
working on similar solutions to get in touch so that we can include them in
this open database.

Medgadget: Please describe the components of the device and how it works.

Ivor Kovic: There are three main components of the
respirator. The essential component is the full-face scuba mask. Such masks are
available on the market under many different brand names. However, most of
these are OEM products from China and usually vary by smaller details, but also
more importantly by the design of the snorkel connector. These masks are used
for scuba diving and have passed fit tests to stop the penetration of water. To
create a respirator, the snorkel is removed and a custom-designed and 3D
printed adapter is put in its place. Finally, a bacterial/viral filter is
connected to the top. As with any respirator, a seal check is mandatory before
every use.

Medgadget: How easy is it to make the device? Do you envisage that you will help to create and distribute a significant number of the units, or do you hope that different research groups/hospitals will make their own?

Ivor Kovic: The device is easy to make if you have scuba
masks and bacterial/viral filters readily available. Of course, you also need a
3D printer to make the adapters from our open-source 3D models. Adapters can
also be produced faster using methods that create a mold for plastic injection.
Our group has two primary goals when it comes to the CroResp device. The first
is to continue with R&D efforts and improvement of the device, all of which
we will continue to share freely with the world. Everyone can make a device
following the detailed instructions on our website, both research/non-profit
groups or hospitals themselves.

Our second goal is to help the frontline healthcare workers in Croatia by making sure they get free respirators when they need them. The speed of this task will partially depend on the support we receive from the local authorities. However, even if such support does not come, we will still help our colleagues in any way that we can.