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Evolution continues with enhanced patient ventilator interactions

The latest advances in ventilators provide flexibility, information, and wonderful ways to measure very complex levels of patient–ventilator interaction moment by moment.

In recent years, the ventilators market has evolved significantly due to technological advancements, such as the development of advanced portable ventilators and improvements in sensor technologies used in ventilators. Technology is evolving, protocols are becoming more stringent, and technicians are becoming more educated on how to utilize and care for the equipment. Since their initial appearance, mechanical ventilators have become more sophisticated, and have expanded their application from the intensive care unit (ICU) to the respiratory medicine ward, and even to patients’ homes for long-term treatments. This was the result of combining the advances in understanding of respiratory physiology, pathophysiology, and clinical management of patients, together with technological progress in mechanical, electronic, and biomedical engineering. The global ventilator market in terms of revenue was estimated to be worth USD 3.9 billion in 2022 and is poised to reach USD 5.4 billion by 2027, growing at a CAGR of 6.3 percent from 2022 to 2027. The increasing number of preterm births, rapid growth in the geriatric population, rising prevalence of respiratory diseases, growing preference for home-based oxygen therapy, and the outbreak of infectious diseases affecting the respiratory system are expected to drive market growth. The emergence of home healthcare has expanded growth opportunities for the ventilators market. However, shortage of skilled medical workers and the excessive purchase of ventilators are factors expected to restrain the market growth to a certain extent in the coming years.

Technology trends
To improve outcomes, patient–ventilator interactions, and patient care, new devices and a greater variety of ventilation modes and strategies are being introduced today, continuing the rapid evolution that began decades ago. Engineering has played, and continues to play, a significant role in this process. In addition to helping to improve the technical performance of the ventilators, engineering is also helping to improve our understanding of respiratory physiology, pathophysiology, and the interactions between various ventilation strategies and the respiratory system.

The trend and anticipated weaning time will be projected by intelligent algorithms in future ventilators, based on patient history. The alarm-management system, which not only ensures safety but can also issue warnings about potential dangers, will be given more intelligence. Doctors’ and service personnel’s work will be made easier by remote monitoring of crucial parameters. Ventilators’ environmental impact will be reduced as a result of technological advancements, which will also improve their features with more sophisticated blowers and intelligent batteries that can function for extended periods of time without a pneumatic or electrical source.

There have been several advancements in mechanical ventilator technology in recent years, including:

NAVA. Neurally adjusted ventilatory assist (NAVA) is a mode of mechanical ventilation delivering pressure in response to the patient’s respiratory drive, measured by the electrical activity of the diaphragm (EAdi). NAVA introduced a new dimension to mechanical ventilation, in which the patient’s respiratory center can assume full control of the magnitude and timing of the mechanical support provided, regardless of changes in respiratory drive. This technology helps to decrease the risk of hyperinflation, respiratory alkalosis, and hemodynamic impairment. NAVA captures EAdi, and uses it to assist the patient’s breathing in synchrony with, and in proportion to, respiratory drive. Normal EAdi generally ranges between a few and 10 µV, µ while patients with chronic respiratory insufficiency may demonstrate signals 5–7 times stronger. Although there is no cutoff for weaning outcome, EAdi above 26 µV can be related to failure. Like proportional assist ventilation (PAV), there are no target tidal volume, mandatory rate, and airway pressure preset. Ventilator support is proportional to a combination of EAdi, and NAVA level, which defines the magnitude of pressure delivered for a given EAdi. NAVA depends on the captured signal of EAdi via sensing electrodes on a nasogastric tube so, in case of damage on phrenic nerve or alterations on its activity, NAVA cannot be used.

Therefore, NAVA, like PAV, is also designated for patients with stable respiratory drive, and can be used in patients who are ventilated on PSV (as long as EAdi is detected), or during weaning from mechanical ventilation. NAVA is also designated to improve synchronism, while generating proportional assistance to EAdi.

Non-invasive ventilation. Non-invasive ventilation (NIV) has become increasingly popular as it reduces the risk of complications associated with invasive ventilation and improves patient comfort. The non-invasive ventilation mode emerged as the largest segment and accounted for over 58-percent share in 2022. The usage of non-invasive mechanical ventilation in a wide range of applications and its ability to offer precise and higher concentrations of oxygen are key factors contributing to the segment growth. The non-invasive ventilation can be delivered using advanced intensive care ventilators that can offer various respiratory support modes.

High-flow nasal cannula. High-flow nasal cannula (HFNC) systems deliver heated and humidified oxygen at high flow rates to patients, providing improved respiratory support and reducing the risk of complications. High-flow therapy is useful in patients that are spontaneously breathing, but have an increased work of breathing. Conditions, such as general respiratory failure, asthma exacerbation, COPD exacerbation, bronchiolitis, pneumonia, and congestive heart failure, are all possible situations where high-flow therapy may be indicated. High-flow therapy has shown to be useful in neonatal intensive-care settings for premature infants, with infant respiratory distress syndrome, as it prevents many infants from needing artificial ventilation via intubation, and allows safe respiratory management at lower FiO2 levels, and thus reduces the risk of retinopathy of prematurity and oxygen toxicity. Due to the decreased stress of effort needed to breathe, the neonatal body is able to spend more time utilizing metabolic efforts elsewhere, which causes decreased days on a mechanical ventilator, faster weight gain, and overall decreased hospital stay entirely. High-flow therapy has been successfully implemented in infants and older children. The cannula improves the respiratory distress, oxygen saturation, and the patient’s comfort. Its mechanism of action is the application of mild positive airway pressure and lung-volume recruitment. Numerous factors are driving growth in the global high-flow nasal cannula market. At the forefront is the ever-increasing number of respiratory disorders. Besides, soaring popularity and uptake of heated humidified high-flow nasal cannulas and increasing investments in research and development programs by companies to come up with better products leveraging more sophisticated technologies is also positively impacting sales.

Portable ventilators. Portable ventilators have become smaller and more advanced, making it easier for patients to be mobile while receiving respiratory support. The advanced ventilation technology combines responsive leak and circuit compensation and precision flow trigger controls to enable comfortable breathing and accurate therapy. In recent times, manufacturers have been developing wirelessly connected portable ventilators to have a meaningful impact on patient outcomes. By connecting to a cloud-based patient-management application, the current Bluetooth-enabled devices turn medical-grade data into actionable information, delivering it directly to the mobile devices or desktops of care providers multiple times per day. This solution enables care teams to monitor patients remotely and proactively, allowing for fast and informed clinical decisions, including early intervention, which can help avoid unnecessary readmissions, and lower the cost of care.

Recently, various low-cost, easy-to-assemble, portable ventilators were proposed to fight the ongoing and future pandemics. These mechanical ventilators are made from components that are generally readily available worldwide. Such components are already associated with day-to-day gadgets or items, and which do not require specialized manufacturing processes.

But many experts are against the usage of these mechanical ventilators in real-life situations, owing to poor reliability and inability of these designs to meet certain clinical requirements. Each design has its own merits and demerits.

ASV. Adaptative support ventilation (ASV) is a closed-loop controlled ventilatory mode, which is designed to ensure optimization of the patient’s work of breathing, automatically adjusted according to the patient’s requirements. ASV combines passive ventilation, with pressure-controlled ventilation with adaptive pressure support, if the patient’s respiratory effort is present. ASV delivers pressure-controlled breaths according to the set minute ventilation, resulting in the best combination of tidal volume and respiratory rate. As the patient’s inspiratory efforts start, ASV delivers pressure-supported breaths according to the set minute ventilation, resulting in the best combination of tidal volume, respiratory rate, and the patient’s inspiratory effort. In ASV mode FIO2 and PEEP are set manually.

Intellivent-ASV. It is also a closed-loop ventilation that adds the monitoring of SpO2 and pressure end-tidal CO2 to best manage ventilation and oxygenation. In intellivent-ASV mode, the clinician sets patients’ sex, height, and choice the following respiratory mechanics situations – normal, ARDS, chronic hypercapnia, and brain injury. Intellivent-ASV determines the target PETCO2 and SPO2 according to the patient’s condition. The ventilator controller adjusts the best tidal volume and respiratory rate to achieve the minute ventilation and PETCO2 set by the clinician combining pressure-control and or pressure support ventilation according to the patient’s inspiratory effort. In intellivent-ASV, FIO2 and PEEP are adjusted according to the patient’s SpO2, following a PEEP-FIO2 table.

Smart-care ventilation. Smart care is an automatic weaning protocol, designed to stabilize the patient’s spontaneous breathing in a comfort zone of a preset defined ventilation and to automatically reduce the ventilatory support. Smart care ventilates the patient with pressure support, which levels are adjusted according to respiratory rate, tidal volume, and end-tidal CO2 to meet the patient’s demand. Smart care classifies the patient a minimum of every 5 minutes into one of eight categories and decreases or increases the pressure support levels accordingly. Smart care assesses and indicates the readiness for extubation after a successful automatic spontaneous breathing trial.

Ventilators are becoming more intelligent with built-in diagnostic features, and are no longer just a therapy device. Intelligent ventilators are designed to improve patient management by analyzing and integrating data from numerous sources and ensuring continuous ventilation adjustment even when specialized staff is not always available. Artificial intelligence techniques can be trained on huge existing data sets, and are capable of handling many variables.

Both closed-loop systems and open-loop (decision support) systems have used all of these tools in the past and are still being used today. The primary benefit of closed-loop systems is that they enable continuous ventilation adaptation to the patient without requiring the clinician’s intervention.

These developments have contributed to better patient outcomes by enhancing the way respiratory support is delivered to patients. 

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