Ventilators, So Very High-tech And Yet Completely Rendered Ineffective by Infections

Ventilators, So Very High-tech And Yet Completely Rendered Ineffective by Infections

The dichotomy of huge leaps in technology in ventilators becoming totally ineffective in the face of ventilator-associated infections needs an urgent solution.

Mechanical ventilation, the ability to artificially compensate for life-threatening failure of respiratory function, is often considered the signature technology of intensive care medicine. Unchanging needs for providing effective life support with minimized risk and optimized comfort will continue to be the principal objectives of applying this powerful and steadily improving technology. Important lessons acquired over many years of intensive care unit practice have brought industry closer to meeting those goals, even as advances in instrumentation facilitate putting this hard-won knowledge into action.

Rising demand in the face of economic constraints is likely to drive future innovations focused on reducing the need for user input, automating multielement protocols, and carefully monitoring the patient for progress and complications at an early stage. With passing time, the goals of ventilatory support have been extended and refined to include not only effective gas exchange and offloading of the ventilatory burden but also minimized astrogenesis, avoidance of lingering disability, and improved coordination between the patient’s innate neural controller and the response of machine-delivered breathing cycles. Dramatic improvements in extracorporeal gas exchange now complement those occurring with traditional ventilation. The capacity of mechanical ventilators to ventilate and oxygenate effectively has steadily improved, while the caregiver has become aware of its potential to promote infection, hemodynamic consequences, ventilator-induced lung injury, and diaphragmatic dysfunction that may contribute to, or perhaps even initiate, post–intensive care syndrome. Once an inherently uncomfortable process that invariably required deep sedation, airway intubation, and even paralysis to maintain, artificial ventilation provided by modern machines and extracorporeal devices now offers diverse options (noninvasive as well as invasive) to reduce breathing work load, reduce discomfort, improve oxygen exchange, enhance coordination, and avoid ventilator-induced lung injury.

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.

The concept of gentler ventilation has increased the demand of a CPAP system and heated humidified high-flow nasal cannulae. 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, we need to build an appropriate medical support system to help such practices.

The challenge confronting an Indian intensivist today is to balance the level of care and its financial implications to the patient. There is a need for making cost-effective ventilators with low running cost. With wider spread availability of ventilators all across the country, physicians are seeing 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 survival and reducing morbidities. Medical personnel have to be empowered to make that sea change.

Indian market

The Indian ventilators market in 2017 is estimated at 8075 units, valued at Rs 420 crore. The imported equipment continues to dominate the segment with a 77 percent share by value, and a 62 percent share by units.  The ambulatory and transport models too are seeing a gradual increase in demand. In India, contrary to general perception, refurbished and indigenous ventilators, continue to cater to a niche, regional segment, albeit support as warranty, after sales service, and spare parts availability are now the differentiators among these brands. The popular refurbished models are Evita and Savina series from Draeger; Servo i from Maquet, Puritan Bennett’s 840, and Engstrom from GE. Other models, which are also popular are Verasamed from GE, a couple of models from Siemens, and Evita 2 and Evita 4 from Draeger. Overall, across all segments with intense competition, margins are being compromised as prices are increasingly going south.

The government continues to be a large buyer. Safdarjung Hospital, New Delhi ordered 143 units of high-end systems for its new block on BD India. Getinge was awarded an order for about 200 units by HLL.  Mindray received an order for 147 units from KDLWS (Karnataka Drugs and Logistics Wavehousing Society); 100 units from TSMISC (Telengana State Medical Infra); and 45 units from Gujrat Medical Services Corporation Limited (GMSC). Air Liquide too received an order for 26 units from KDLWS.

Technology advances

The modern ventilator traces its history to technology, which started almost in the late 1600s, when an English scientist, John Mayow came up with the idea of external negative pressure ventilation. The relentless hard work of both doctors and engineers, from the early days of the 20th century has led to leaps in the technology of ventilators and resulted in advanced and computer-controlled life savers that we have come to depend upon today.

Diaphragm pacing technology may soon allow hundreds of patients on mechanical ventilation, including young children and those injured in road accidents, to have lives that are more fulfilling. Currently available systems involve an external transmitter and an implanted receiver, but fully implantable diaphragmatic pacing systems are being developed. The current pacing systems are more affordable and easier to place than the earlier systems. Recently, manufacturers are developing wirelessly connected portable ventilators to have a meaningful impact on patient outcomes. Connecting to cloud-based patient management application, the current bluetooth-enabled devices turn medical-grade data into actionable information, delivering it directly to 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 cost of care.

Way forward

Ventilators have advanced from basic or simple machines to complex, electronic, micro-processing engines with improved capabilities and options/features. The mode options such as volume-based and pressure-based designed to accomplish the pulmonary needs of the critical and anesthetized patients. The advent of next-generation sensors, pneumatic components, and single chip-solutions is improving the efficiency of the device. Additionally, rapid innovation in the field of portability, positive airway pressure (PAP) devices, and improvement in battery life of portable or transportable devices are assisting in the market growth. On the contrary, complications associated with the use of ventilators such as ventilator-associated pneumonia, airway injury, pneumothorax, alveolar damage, diaphragm atrophy, decreased cardiac output, and oxygen toxicity are anticipated to hinder the market growth in coming years.

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