Breathing easy on ventilator quality

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Published: April 29, 2020 3:30 AM

A good ventilator must be a high-precision product, a combination of top-class engineering efforts, optimum manufacturing capability, and robust financial backing.

A ventilator, at its most basic, is any instrument penetrating via the mouth (endotracheal tube), nose, or skin (tracheostomy tube through a stoma, a surgically-created hole in the windpipe) to serve as an artificial airway.A ventilator, at its most basic, is any instrument penetrating via the mouth (endotracheal tube), nose, or skin (tracheostomy tube through a stoma, a surgically-created hole in the windpipe) to serve as an artificial airway.

If one were to name the one hallmark feature of the 21st century, I’d venture to say it is innovation. Our modernity enables us, more than ever, to make, for instance, better predictions. Why? The fundamental reason is technological advancement, which has now enabled us not only to generate humongous volumes of data but also to collate this and make sense of it.

This assertion forces us to address the elephant in the room: If we are capable of making data-based predictions, how did we miss the arrival of Covid-19? The answer is simple. The viral outbreak is a natural disaster. While we cannot predict when or where lightening will strike, we do have sufficient technological proficiency not only to dowse the fire should it arise but also to mitigate damages by natural disasters. The Covid-19 crisis is no exception.

It is a fact that we are currently going through the gravest crisis of our generation, perhaps even in human history. Veritably the century’s black swan event, the pandemic has caused hospitals and medical centres to become a battlefield, with healthcare professionals risking their lives on the front lines to save lives.

Apart from the immense human toll, much virtual ink has been spilt on documenting the damage the pandemic caused to the economic scheme of things. Trade and commerce have ground to a halt. The financial lifeline, not to put too fine a point on it, is in the throes of the viral outbreak.

Against this backdrop, it only stands to reason that nothing but the best of humanity will help us overcome this crisis. Putting the best foot forward is how we can move towards recovery and victory—our tomorrow depends on the steps that we take today. Professor Yuval Noah Harari, noted Israeli historian and author, echoes my thoughts in his article ‘The world after coronavirus’:

“We must act quickly and decisively. We should also take into account the long-term consequences of our actions. When choosing between alternatives, we should ask ourselves not only how to overcome the immediate threat, but also what kind of world we will inhabit once the storm passes.”

So, what are we to do? The first step towards solving a problem is identifying it. The critical challenge, obviously, is developing a vaccine against the disease. With researchers and scientists already engaged in this, success is not a matter of possibility, but merely one of time. However, until then, we are faced with more immediate challenges, which it is imperative we resolve as soon as possible. Let us take a look at one such critical problem.

The crisis
When Covid-19 broke out of China, it caught the world off-guard. Its impact has sent nations into lockdown, while hospitals and medical centres teem with overwhelming activity. As front line healthcare professionals, supporting staff and public servants work tirelessly to tend to infected masses, the world was woken up to a realisation: Most of us were not prepared to deal with a health crisis of such catastrophic levels. This realisation was triggered by shortage of an equipment that is an essential tool in our collective battle against the deadly virus—the ventilator.

Boosting the supply of ventilators across the country and the globe is essential to setting the world on the path to resuscitation. Let us first understand why.
Covid-19 poses the most risk to individuals with respiratory challenges since the virus targets the lungs. In the worst-case scenario, the virus can lead an individual to develop acute respiratory distress syndrome (ARDS). Most ARDS patients need the help of a machine to breathe—this is where ventilators come into the picture. A mechanical ventilator pushes air into the lungs and forces some of the fluid out of the air sacs. Another key step in caring for ARDS patients is supplying them with supplemental oxygen. Thus, doctors also leverage ventilators to optimise patients’ blood oxygen levels.

However, things get trickier when one considers that there are more than one type of ventilator on offer. This begs some questions: Which of these is the right option to help us fight the pandemic? Are any of the incumbent models suitable for dealing with the present unprecedented healthcare crisis? If not, how can we create a machine that minimises risk of the infection spreading to healthcare professionals, while maximising the chances of survival of the ventilated patient? Is it possible to manufacture these at a large enough scale, given the paucity of time and limited availability of components?
Let us explore these questions in detail.

Finding the perfect ventilator
A ventilator, at its most basic, is any instrument penetrating via the mouth (endotracheal tube), nose, or skin (tracheostomy tube through a stoma, a surgically-created hole in the windpipe) to serve as an artificial airway. In the absence of such machines, doctors may have to use a manual resuscitator called a bag valve mask, or an Ambu bag, which forces air into the lungs of patients who are either not breathing or not breathing adequately. Obviously, this cannot be used to help critical Covid-19 patients as it is not suitable for continuous use and needs a highly-trained operator to make use of it.

Then, there are non-invasive, low-cost ventilators. But, these too are not suitable for treating Covid-19 patients as most are not clinician-friendly, and cannot be operated by volunteers that comprise a major share of the frontline Covid-19 healthcare taskforce. Most clinicians prefer invasive mechanical ventilation (via an endotracheal tube or tracheostomy, with breaths delivered by a mechanical ventilator) for patients with moderate or severe ARDS.

Further, ventilating Covid-19 patients, or those of infectious diseases poses a health hazard to healthcare workers tending to them as aerosolised pathogens are likely to be expelled from the ventilation tube at a high velocity—almost none of the currently available designs are equipped to deal with this. A good ventilator design must keep the health of caregivers as a primary consideration.

The ideal strategy to improve survival in Covid-19 patients while preventing lung injury is invasive mechanical ventilation with low tidal volumes and high levels of positive end-expiratory pressure. This primarily aims to provide oxygen, remove carbon dioxide, decrease the work of breathing, and reverse life-threatening conditions such as hypoxemia, or insufficient oxygenation of arterial blood.

Hence, as much as low ventilator inventory is a grave concern due to its shortage being directly proportional to the mortality rate, the absence of a suitable ventilator design is equally worthy of consideration. And, given the aforementioned factors, we can generate a fair idea of what an ideal ventilator looks like, and of what it can do. The good news? We may have already succeeded in developing such a machine.

The best bet
As Covid-19 crisis is a 21st-century problem, our best bet at overcoming it is a truly modern solution. But, what comprises a modern solution? As I mentioned in the beginning, it is innovation. Of course, this alone will not suffice. We need an innovation that is reliable, smart, and safe.

In the wake of the pandemic, most countries have stopped exports of medical equipment, and all global ventilators have been snapped up. Even components for ventilators are in short supply. In India, the cottage industry has inevitably been stirred into action, with every other player claiming to have a ventilator that can meet present needs. In their understandable desperation, driven by the grief of the human tragedy underway, local authorities, government bodies, and corporations are pumping capital into procuring sub-standard products. This, instead of advancing our struggle, is forcing us to take a step back. How, then, do we hit the mark amidst all this noise?

We need to move cautiously and home in on the answer by a calculated process of elimination. Although we are engaged in a race against time, jumping the gun is not an option: we need to make an informed decision by considering valid factors so that we can identify and pick a solution that represents the best of not only the modern industry, but also the modern age.

We cannot afford to treat our ‘suitable ventilator’ as a mere electronic item—it will be a high-precision product of the combination of top-class engineering efforts, optimum manufacturing capability, and robust financial backing. Hence, while scrutinising a ventilator, we need to ask: Who has designed it? Who has manufactured it? Will the product stand the test of time? Can the company maintain the product over the next 3-5 years—not only until our battle with Covid-19 is won but also beyond, for future emergencies?

Hence, considering the lineage of the company creating the new-age ventilator is crucial. The good news is that India, the third-largest startup ecosystem, is well-equipped to breed such innovators. In fact, some serious organisations—such as an IIT Kanpur-based enterprise—are already involved in achieving this objective alongside domain-leading industry players. I am optimistic that we will soon have the right ventilator supplying the breath of life to the world, which is currently waiting with bated breath for the pandemic to subside. Yes, the pandemic will subside—the leading intellects of the modern world will ensure that it does.

The author is Co-founder, HCL, & Chairman, Electronics Sector Skills Council of India. Views are personal

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