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Navigating New Technologies

Patients’ needs are changing with time, with the evolution of both pathology severity and treatment. Advancement of bioengineers understanding in pathophysiology, medicine, and engineering need to be combined with an interdisciplinary approach to fully address the complexity of ventilation.

Today, mechanical ventilation, as a therapy, represents a double-edged sword: on the one hand, it is a life-saving treatment, but on the other, it is associated with a host of complications. Critical care practitioners know that the duration of mechanical ventilation is directly associated with the incidence of adverse effects. Liberation of patients from mechanical ventilation at the earliest possible moment after they have begun to recover from their initial illness has become the focus of attention in the modern era.

Many advances have been made over the last 50 years in the application of mechanical ventilation to the care of patients with respiratory failure. The work of many scientists, researchers, and experts will ensure that practitioners can provide innovative and state-of-the-art life-saving treatments to critically ill patients in the future.

Technology advances
The computer-based technology has made the modern-day ventilators more doctor and patient friendly. The synchronized ventilators with volume control and or volume guarantee with advanced pulmonary graphics have helped to make weaning from ventilators easier with lesser side effects. The current day ventilators can be connected with central monitors and can be monitored sitting at a distance as well. The concept of E-ICU wherein the monitoring system is electronic, digital, and real time is likely to pick up in the near future.

On the other hand, the concept of gentler ventilation has increased the demand of a CPAP system and heated humidified high-flow nasal cannula (HFNC). Many neonatal and pediatric conditions are helped by these relatively simple ventilation techniques. There is more scope of high-frequency ventilators in current day NICU and PICU care and the need of the hour is to have cost-effective high-frequency ventilators. T-piece resuscitators have replaced self-inflating bags in labor rooms and they are being used as transport ventilators also. With the rising cost of intensive care and many sick children requiring home ventilators, one need to build an appropriate medical support system to help such practices.

From the latest scenario, it has been noted that the intensivists are rapidly moving toward non-invasive ventilation (NIV) and high flow oxygen therapy (HFOT). The addition of HFOT to ventilator make this technique more widely available and implementable technique with no extra cost to it. In recent times HFOT has migrated into the home care environment due to the availability of portable HFNC standalone devices in the market. However, in a hospital environment, it is being preferred as a feature or a mode for smooth transition of NIV to invasive ventilation, as and when required, in high-end mechanical ventilators. HFNC is also proving helpful in supporting the oxygenation of hypoxemic patients and is being well-tolerated by children. Today most of the mechanical ventilators are equipped with HFNC/oxygen therapy. HFNC expands the ventilator’s capacity during the pre- and post-intubation stages. A positive clinical effect on various respiratory parameters has been observed after the usage of HFNC and studies suggest that it may reduce the work of breathing as well.

Patient-ventilator asynchrony exists when the phases of breath delivered by the ventilator do not match those of the patient. Current evidence suggests that the best approach to managing asynchronies is by adjusting ventilator settings. Proportional modes improve patient-ventilator coupling, resulting in greater comfort and less dyspnea, but not in improved outcomes with respect to the duration of mechanical ventilation, delirium, or cognitive impairment. Advanced computational technologies will allow smart alerts, and models based on time series of asynchronies will be able to predict and prevent asynchronies, making it possible to tailor mechanical ventilation to meet each patient’s needs throughout the course of mechanical ventilation.

Patients’ needs are changing with time because of the evolution of both pathology severity and treatments. Therefore, an optimal ventilation strategy is an adaptive process aiming to treat the acute condition and support the gradual weaning from the ventilator or adjust to the natural fluctuations of chronic disorders. To reach the goals, advancement of bioengineers understanding in pathophysiology, medicine, and engineering must be combined with an interdisciplinary approach to fully address the complexity of mechanical ventilation for further improving patients’ treatment.

Road ahead
Buyers continue to demand advance technology and user-friendly ventilators with low running cost, making their purchase cost-effective. Therefore, to meet the buyer’s demand with competitive pricing has become the biggest challenge in the market today. With wider spread availability of ventilators all across the country, the industry is witnessing increased incidence of healthcare associated infections including ventilator-associated pneumonias. There is a great need to impress upon the new generation that there is no replacement of infection prevention strategies in improving the survival and reducing morbidities.

It is nowadays not so obvious that physicians dealing with mechanical ventilation have been sufficiently educated on the technological aspects of these complex medical devices. Physicians attending patients under acute or chronic mechanical ventilation are faced with considerable difficulties to properly understand how these devices work. A major difficulty is the intrinsic complexity of modern control/intelligence algorithms implemented in current devices. This difficulty is increased by the lack of standardization and the fact that, for marketing and commercial strategies, companies building ventilators tend to add new definitions of ventilation modes and variants without disclosing the algorithms with sufficient detail for the user to really understand how the machine is working. The result is that in most cases the physician is using a sort of black box as therapeutic device. Accordingly, it seems necessary that, when being specifically trained to use mechanical ventilation, physicians should be also provided with a sufficient education on the technological issues involved in these modern medical devices. In that way, they will be in optimal professional conditions to select the best therapeutic option for each individual patient. Overall, physicians have to be empowered to make that sea change.

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