In late February, Alex Hornstein ’03 watched on TV from his home in Rhode Island as New York Gov. Andrew Cuomo painted a dire picture of his state’s immediate need for ventilators to treat an anticipated surge of COVID-19 patients. Unless the state could acquire tens of thousands of machines, New York might have to resort to an army of individuals standing over the sick and dying, manually squeezing rudimentary bag valve ventilators in a desperate attempt to keep people alive. 

The scenario baffled Hornstein. “That was the moment when it clicked [that] nobody has a plan,” he says.

Prior to helping found Looking Glass Factory, Inc., a Brooklyn-based holographic display company where he is chief technology officer, Hornstein worked internationally for nearly a decade using his background in electrical engineering to help developing countries set up rural infrastructure where infrastructure was lacking or nonexistent. That a state like New York, in a country like the United States could be brought to its knees by a supply issue seemed unreal to him.

“That sounds like a failing part of infrastructure if I’ve ever heard one,” he says. So, Hornstein started a volunteer-run group called Ventilator Project to do whatever possible to address the ventilator shortage crisis.

From his decade of experience in infrastructure development, Hornstein recognized immediately that the challenge lay in quickly solving a logistics and supply line crisis. “If you don’t have a ventilator at the hospital in time, what can you do that’s at the scale and the speed of the problem that can match?” he asked. “That’s where I got very interested in home-use sleep apnea machines.”

Commonly called CPAPs and BiPAPs, these sleep apnea machines have at their heart the same general mechanisms for moving air as do many hospital-grade ventilators. And while such ventilators were in critically short supply, not only in New York but throughout the country, including in Hornstein’s home state of Rhode Island, CPAPs and BiPAPs were plentiful, both on the shelf and sitting unused in the recesses of closets all over the country. The trick was in figuring out how to acquire those machines, then repurpose them as potential life savers.

Hornstein immediately began reaching out to as many pulmonologists as he could physically talk to. Sleep medicine pulmonologists were especially helpful, as they understood the physiology related to COVID but weren’t working in critical care and had some free time. For two weeks, Hornstein stayed on the phone all day, learning as much as he could about how ventilators worked and what a CPAP would have to do to be passably equivalent. It was a crash course in virology and medical device engineering, both of which Hornstein knew nothing about. 

A consensus began to develop. The idea of a machine designed for sleep apnea reinventing itself as a ventilator seemed doable. 

But there was another challenge to consider, a challenge that in ordinary times would not have been an issue. In 2020, information flows more rapidly than it ever has. But with cities and states shutting down and government and medical personnel in each state necessarily developing a hyper focus on their own state’s response, that exchange of ideas slowed dramatically, even between hospitals within the same state. 

Hornstein knew that overcoming that hurdle would be the next step in pushing his idea forward. “I’m like a tourist in this space,” he says. “I don’t have an official role like the doctors or state board of health officials, so I ended up working with ventilator shortage groups across three different states. I’m kind of just floating around, but I can understand what machines do, I can understand what doctors say, and I can take something that one doctor said and know what one hospital is doing, and I can go to another doctor and say, ‘This hospital is doing this, maybe you would like to do this.’” That simple transfer of information, Hornstein says, eventually helped close a ventilator gap in Rhode Island.

In the world of sleep apnea machines, there are two major types of machines — CPAPs, which deliver a constant pressure to the lungs, and BiPAPs, which sense a patient’s breathing and provide support to amplify their breaths. BiPAPs are rarer and more expensive, but they are the more versatile, useful machines. Ventilator Project’s early efforts focused on the revelation that CPAP and BiPAP machines used the exact same hardware, the only difference being a simple software switch, put in by the manufacturer, that either hid or displayed a ‘BiPAP’ menu with the higher-level features. Ventilator Project spun off an independent group of firmware engineers called Airbreak that developed a ‘jailbreak’ technique that would show that hidden BiPAP menu. 

As the project moved on, the challenge of presenting a technical concept like a jailbreak to hospitals and health care organizations proved slow and challenging. But further research coming from Italy and the University of Chicago soon revealed that a stock CPAP — new or used — could be safely employed as-is to help a person breathe simply by installing a few pieces of readily available equipment between the machine and the patient. 

The repurposed machine wouldn’t be helpful to the most critical of patients, and it wouldn’t replace the overall efficiency of a high-end ventilator, but it would be incredibly helpful to a large number of people in a pinch. And it could be done at a fraction of the cost of a new ventilator. 

Ventilator Project proposed a state-wide donation drive to collect unused CPAP and BiPAP machines from users around Rhode Island, and the RI Commerce Corporation, the University of Rhode Island, and 27 fire stations around the state agreed to help support the drive. Within two weeks of putting out the call for unused sleep apnea machines, approximately 850 units came in from donors. 

To say things moved quickly would be the most understated of understatements. Hornstein took a leave of absence from Looking Glass to focus exclusively on creating a pipeline for the machines. A supply chain of corporate vendors and private individuals who owned unused CPAPs and BiPAPs was established. Volunteers were recruited to sterilize incoming equipment. Doctors and hospitals from Rhode Island to Nigeria were contacted regarding their interest in acquiring the machines. Coordinating it all was VentilatorProject.org.

Working with a team of 100 volunteers from the University of Rhode Island and local durable medical equipment companies that professionally refurbish these machines, Ventilator Project was able to sterilize, test, and inventory the donated machines at a total cost of less than half that of a single, brand-new hospital-grade ventilator.

Just over one month after the sobering press conference that spurred Hornstein to action, the very first improvised ventilators were delivered to the Rhode Island Board of Health. It could not have been done, Hornstein says, without engaged partners, the generous heart of volunteers at the University of Rhode Island who helped recondition the sleep apnea machines, and the willingness of state and federal agencies to lay low mountains of regulation in an emergency situation.

Perhaps the greatest achievement is that, to this point, the repurposed machines, like the army of volunteers that Cuomo hypothesized, have not been needed. Shutdowns and social distancing measures blunted the worst-case scenarios. But there’s a chance COVID could reemerge bigger and badder in the fall. 

Hornstein says Ventilator Project will be there, ready to respond. The wheels are already turning on grant submissions that, if awarded, would keep the nonprofit going with a small paid staff. And while the organization can still move physical machines, the plan is to move information. “‘Ventilation consultants’ is what we call ourselves,” Hornstein says, and they are now consulting with doctors in 10 countries, and preparing pallets of donated units to ship to ministries of health in five countries who have reviewed sample units and would like to use them widely in their hospitals.

But for now, as the day-to-day work subsides, Hornstein is slowly transitioning back to his day job. “It was an extraordinary experience,” he says of the project, but not one he’s anxious to replicate anytime soon. Spinning up a new organization is by default a stressful engagement under the most ideal conditions. Doing it in an incredibly compressed time frame, completely from scratch, with actual lives on the line, is the most intense experience of Hornstein’s life. “When this is all over, I hope to never again work in the medical field,” he says. “Until it’s done, though, I’ll be here, with sanitizer spray in one hand and CPAP filters in the other.”