Ventilators Challenges and Opportunities

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TOPIC: General Studies 2

• Global crisis – COVID-19

Ventilators in India during COVID-19

As India braces for community spread of the novel coronavirus and a spike in hospital admissions, the government is seeking to ramp up its capacity of ventilators. A large number of ventilators may potentially be required soon.

After a clarion call by the Govt., established manufacturers are ramping up their production with help from private and public sector companies. Meanwhile several brilliant minds have come up with new designs for ventilators which can be made with indigenous components.

• The Railways-owned Integral Coach Factory (ICF) has made an attempt to “reverse engineer” the machines. 
• Private sector carmakers with no experience in this line too, have climbed on to the bandwagon. Firms like AB Industries say they can scale up monthly production to around 350-400 in the next two months.
• Bharat Electronics Ltd (BEL), a PSU under the Ministry of Defence, is in the process of manufacturing 30,000 ventilators. 
• Health Ministry PSU HLL Lifecare Ltd has floated a tender for 20,000. ICF Chennai, maker of Train 18, is attempting to manufacture ventilators.
• Bengaluru-based Skanray Technologies, which has claimed it intends to manufacture 100,000 ventilators, currently has the capacity to build only 5,000 in one batch. The rest of its production would have to come through collaborations. The design would help overcome hurdles like sourcing imported components. 
• Maruti Suzuki India has announced an arrangement with Noida-based AgVa Healthcare to “rapidly” scale up production to 10,000 per month.
• Experiments are also on to find alternatives to imported electronic components such as sensors and displays. We can go to a total, simple user interface without buttons, which can be programmed without display.

Does India have enough ventilators?

India’s state hospitals together have 14,220 ICU ventilators as of now. Additionally, government (and some private) hospitals dedicated for the management of COVID-19 patients have about 6,000 ventilators.

According to recent mathematical modelling by scientists including Dr Raman R Gangakhedkar of the Indian Council of Medical Research (ICMR), around half of those infected and in intensive care would require mechanical ventilation. 

Using this model and other data, think tank Brookings India has estimated that India could, in the worst case, need between 1 lakh and 2.2 lakh ventilators by May 15.

Why are ventilators important in the outbreak?

Ventilators (or respirators) are mechanical devices that help a patient breathe when they are unable to do so on their own. Hospitals have a supply system for gases like oxygen, which are used in ventilators.

• The ventilator takes the compressed gas (oxygen) and mixes it with other gases (because typically what we breathe is 21% oxygen from the atmosphere). 
• It allows you to artificially push in a certain required amount of oxygen into the patient’s lungs and allows them to deflate.
• With COVID-19, the patient sometimes has interstitial pneumonia. The virus causes inflammation in the air passages inside the lungs called bronchioles, causing inflammation in this area and in the alveoli, the tiny sacs that the air is delivered to. Any inflammation means air can’t get in or get out.
• As the space for the exchange of air in the lungs decreases, the patient has to work harder to breathe, which may not be possible indefinitely. A patient can’t be breathing at rates of 40-45 (breaths) a minute and expect to sustain life. At this point, a ventilator allows you to rest the patient’s lungs by giving them oxygen at higher rates. They allow the patient time to heal on their own by supporting a system that would have otherwise failed.

To build a ventilator…

Different types of ventilators deliver air in different modes, and the components would vary depending on the type.

To make a ventilator, one has to have core knowledge of the clinical aspects of the ventilator and the requirements of the doctors using them. These requirements have to then be converted into engineering components that can achieve the required outputs.

Ventilators are a combination of technologies — not only software and electronics, but also pneumatics, as they handle gases. They are also required to adhere to safety standards, and include a mechanism to minimise the risk to the patient in the event the device malfunctions. Based on the mechanism used to deliver the air (flow-delivery mechanism), there are three major classifications for ventilators –

1. Bellow-driven or piston ventilators
2. Turbine ventilators: Although less effective, are the next best option — they have fewer components, and it would probably be easier to scale them up
3. External compressed air driven ventilators: A pneumatic external compressed air-driven ventilator in an ICU setting would be ideal for COVID-19 patients. 

The Way Forward: 

According to industry sources, only about 10% of ventilators in use in India are manufactured in the country. The pandemic has affected global supply chains, even as demand has surged everywhere. With imports slowing, an increased burden now lies on Indian manufacturers, who have limited capacity to scale up production.

To scale up India’s ventilator capacity –

New Ventilators: Data from Indian manufacturers project their total monthly capacity to touch around 6,000 ventilators in a month from now. A Rajkot-based private company has prepared indigenously made ventilators, gifting the first 1,000 such ventilators – Dhaman 1 – free of cost to the Gujarat government, according to a government press release on Saturday. The ventilator was tested on one patient on Saturday too, showing successful results.

Raw material:  At least 40% of a ventilator’s physical components are imported from countries like the US, China, France, and Germany. These include several crucial components like sensors and displays. 

Alternatives: B.S. Murty, Director of the Indian Institute of Technology – Hyderabad, has urged the government to consider the use of ‘bag valve masks’ as an alternative to meet any surge in demand for ventilators. The scientists said that ‘bag valve masks’ are currently hand-powered and therefore not suitable for continuous use as a ventilator. But, they posited, this could easily be remedied by designing similar devices powered by an electrical source, which could be a car battery or conventional power supply. The devices would be made portable, and therefore easy to use in villages and other areas without power supply and could be manufactured in bulk quite inexpensively.

What should have been done for us to be better prepared – 

Ventilators not in use: Between 20,000 and 30,000 ventilators may be lying dysfunctional across the country – in both public and private sector hospitals — either for want of parts or servicing, it needs to be made functional maybe in a simpler manner.

Issue of not storing ventilators for disaster management: In a usual situation, the government has an epidemic and disaster management cell, which is supposed to store ventilators in ‘live’ mode, running and monitored. Our government has not done this, in spite of so much communication and meetings with them. This needs to be considered urgently if the world is truly preparing for yet another pandemic. 

Indigenous Methods: We should not have waited for a global pandemic to help us understand that there are indigenous materials that can be utilised to act as alternative in dire situations. 

Connecting the Dots:

1. COVID-19 might just end up preparing us for another pandemic in the future. Comment.