Buyers continue to rely on imports for the critical-care ventilator equipment, where support is received from vendors in continuous innovation and product improvement.

With steady and aggressive technological advancements, 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. The needs of patients are changing with time because of the evolution of both pathology severity and treatments.

New devices with increased number of ventilation modes and strategies show a promising future in improving outcomes, patient-ventilator interactions, and patient care. Engineering has played and is still playing an important role in this process, not only in improving the technical performance of the ventilators but also in contributing to a better understanding of respiratory physiology and pathophysiology, and of how different ventilation strategies interact with the respiratory system.

Indian Market Dynamics

The Indian ventilators market in 2016 is estimated at 7100 units valued at 360 crore. The imported equipment continues to dominate the segment and is gaining traction as institutions are wary of compromising with this critical care equipment. The ambulatory and transport models too are seeing a gradual increase in demand. In India, refurbished and indigenous ventilators, available at competitive prices, continue to cater to a niche segment.

High-performance turbine-based models are gradually being preferred over compressor ventilators. On average, trigger function and pressurization quality are better with turbine-based ventilators. A shorter triggering delay, a shorter inspiratory delay, and a higher PTP (the amount of assistance received by the patient during the initial part of the effort) are some other factors in the turbine-based ventilator's favor.

Very few tenders were finalized in 2016. The Gujarat government placed an order for 50 machines each on Schiller and Mindray. The Andhra Pradesh government placed an order for 100 units on Air Liquide, which was later increased to 200 units. 2017 saw a 147 units order awarded to Mindray and 25 numbers to Air Liquide by the Karnataka government. The Center had invited a bid for 100 units, which is yet to be closed.

Global Market Dynamics

ventilators

The global ventilators market is estimated at USD 690.8 million in 2016 and is expected to reach USD 1012 million by 2021, reflecting a five-year compound annual growth rate (CAGR) of 7.9 percent, states RNR Market Research. Critical care ventilators contributed the most toward the global market. In terms of percentage share contribution, the segment is anticipated to account for a 48.2 percent share by 2021. The portable ventilators segment is expected to exhibit the strongest CAGR of 7.6 percent from 2016 to 2021 by value. The non-invasive mechanical ventilators market share is expected to grow at a rapid pace because of patients' convenience and less side effects along with faster recovery provided by these ventilators.

Geographically, North America and Europe have been leading the global mechanical ventilators market. The high incidence of respiratory disorders, the implementation of advanced reimbursement policies, the increased level of healthcare awareness, and a strong demand for improved advanced healthcare solutions are some of the prominent factors driving the mechanical ventilators market in these regions.

An increase in per capita income, an improvement in healthcare infrastructure, and a rise in patient awareness about the availability of advanced ventilation solutions promise rapid growth of the mechanical ventilators markets in Asia Pacific, Latin America, and the Middle East and Africa.

The Asia Pacific market is immensely lucrative and is expected to showcase high growth rates over the next 5 years. This rapid growth can be attributed to factors such as the rise in awareness about general healthcare, an increase in medical expenditure, a rise in per capita income, and the development of healthcare infrastructure in emerging economies such as India, China, Japan, and Thailand.

Alok Mazumdar

“Indigenous manufacturers as us have entire capability to cater to the Indian market. Our products are well received on the technical and pricing front. Our handicap is financial muscle, and if under the Make in India initiative, the government manages to support us, there is no reason why we will not displace imports completely.”

Alok Mazumdar,
Director Marketing,
Premier Medical Systems and Devices Pvt. Ltd.

Factors such as rising prevalence of respiratory diseases; rapid growth in geriatric population; increasing incidence rate of preterm birth; urbanization and growing pollution levels; high prevalence of tobacco smoking; and changing lifestyle are fueling the growth of ventilators market. Apart from this, technological innovations in respiratory care devices, namely, non-invasive ventilation technology and portable mechanical ventilators, further supplement the growth of the ventilators market. The increase in preference for homecare and portable ventilators for long-term ventilated patients is expected to be another major factor which will be influencing the market growth. However, concerns regarding the reimbursement; complications associated with the use of mechanical ventilators; resistance from patients and physicians for technology transition; and availability of low-cost products from the local manufacturers pose to restrain the growth of the market.

The global ventilators market is consolidated at the top with five companies accounting for more than half of the global market share. The major players in the market include Philips Healthcare, ResMed Inc., Medtronic plc, Becton, Dickinson and Company, and Getinge Group. Some of the other players in this market are Drger Group, Smiths Group plc, Teleflex Incorporated, Hamilton Medical AG, and GE Healthcare.

Emerging Trendsventilators

Effective ventilators define the breathing pattern with high accuracy by combining cutting-edge technology of actuators, sensors, and digital electronics together with sophisticated data-processing algorithms. In modern ventilators, all relevant ventilation variables are measured by appropriate sensors that provide information to the control unit in order to adjust, in real time, the valves/turbines for delivering the desired ventilation mode. Thermal flow sensors micromachined on a single silicon chip are available and offer the advantages of presenting high sensitivity and accuracy, a wide measurement range, fast response, low temperature and gas composition sensitivity, low dead space, and resistance.

Over the past few years, leading market players have reshaped the ventilators market with the cutting-edge technologies and new product launches to sustain their position worldwide. These technologies offer advanced ventilator breathing circuits that provide exceptional performance in an easy-to-use system, increasing the effectiveness of patient care and reducing the amount of intervention required. The new products employ unique algorithms that offer therapy to patients' individual breathing needs by adjusting to a patient's respiratory rate and target each patient's alveolar ventilation, auto-adjusting pressure support as needed to maintain that target and stabilize ventilation. With the in-built leak management technologies, these devices maintain patient-ventilator synchrony to ensure effective ventilation.

With the increase in the preference for homecare ventilation and portable ventilators, the demand for portable critical care ventilators has increased. This shift in the demand has been the driving force for the leading market players to come up with innovative portable ventilator models. These ventilators drive air into the breathing circuit with a motor-driven piston or turbine. Most devices use positive pressure to deliver gas to the lungs at normal breathing rates and tidal volumes through an endotracheal tube, a tracheostomy cannula, or a mask.

Scientific studies in the past few years have been addressed for devising methods that provide clinically relevant oxygen transfer rates while maintaining a low prime volume of blood in the device, which is required for clinical applications in cardiopulmonary support and ultimately for chronic use.

Outlook

Recent technological advances have the potential to revolutionize the ventilators industry for providing the best of patient care. The future initiatives focus on the development of cost-effective, accurate, miniaturized, and reliable sensors to measure patient variables and actuators to build machines that can reliably provide the desired pressure/flow to patients (e.g., blowers and valves). Application of mathematical models, control systems, and artificial intelligence to tailor the action of the mechanical ventilator to each patient's needs could improve outcomes and comfort, reduce adverse events, and avoid prolonging ventilation, with its associated risks and costs. To reach these goals, advancement of the understanding in pathophysiology, medicine, and engineering must be combined with an interdisciplinary approach to fully address the complexity of mechanical ventilation for further improving patient treatment.

Manju Goyal,Sr. Application Manager-PMLS and SU, Mindray Medical India Pvt. Ltd.
Industry Speak
Nurturing the Turbine Technology for a Better Future

Turbine-based ventilator has always been a subject of debate and discussion for its reliable performance in high-acuity areas. Air-independent ventilators are established firmly in non-invasive ventilation segment and are accepted with few reservations in ICU segment. Some reservations are fact based and some are matter of perception in terms of general characteristics or technical aspect.

Technological limitations in old=generation turbines like lower peak flows which cause air hunger, few ventilation modes, high-noise level of turbine, bulky design, and high cost of turbine maintenance made hospitals prefer conventional ventilators over turbine-based in earlier few years.

These challenges as well as the goal to satisfy latest stringent ICU requirements have created the foundation of revolutionary changes in turbine technology. New-generation turbines are compact in size with low noise level and high-peak flows to guarantee uncompromised ventilation to meet flow demand on breath onset during spontaneous ventilation.

To cover the gap from conventional turbine ventilator to versatile ICU ventilator, many enhancements have been done in areas of lung protective strategies by integrating specific modes like APRV and PRVC-SIMV in conjunction with special maneuvers such as PV tool, occlusion pressure, negative inspiratory force, intrinsic PEEP, etc. In addition, synchrony tools and leak compensation ensures an outstanding NIV performance. To address cross-contamination issue from infectious patients, leading manufacturers improvise the design further by developing detachable and steam-sterlizable inspiratory, expiratory valves, and flow sensor.

Turbine-based ventilators are even ready for most difficult conditions like non-availability of high-pressure oxygen. In these circumstances, turbine ventilators are the only choice being able to work on low-pressure oxygen source.

We expect this reform in turbine technology will lead to make it an ideal choice for all critical care segments to provide best quality of care.

Manju Goyal
Sr. Application Manager-PMLS and SU,
Mindray Medical India Pvt. Ltd.

Kalpa Kumar Ghosh
Industry Speak
Modern Ventilators Reduce Patients' Work of Breathing

Since their initial appearance, mechanical ventilators have become more sophisticated and expanded their application from the intensive care unit (ICU) to the respiratory medicine ward and even to patients' homes for long-term ventilatory support. This was the result of combining the advances in our understanding of respiratory physiology, pathophysiology, and clinical management of patients together with technological progress in mechanical, electronic, and biomedical engineering.

Nowadays, this evolution is still rapid, with new devices and an increased number of ventilation modes and strategies. For instance, modes like CMV, AC, PCV, SIMV, PSV, BIPAP, and APRV are being introduced to improve outcomes, patient-ventilator interactions, and patient care. Engineering had played and is still playing a relevant role in this process, not only in improving the technical performance of the ventilator but also in contributing to a better understanding of respiratory physiology and pathophysiology, and of how different ventilation strategies interact with the respiratory system.

The main objective of mechanical ventilation was originally focused on restoring patient's ventilation. This concept expanded as other variables like, PEEP, FiO2, etc., determining gas exchange, were understood.

During the course of time, ventilators benefitted from the progress in electronics, and started incorporating more advanced monitoring of flow and pressure variables. Improvements in monitoring also allowed the possibility of using real-time variables to control the action of the machine, with intermittent mandatory ventilation (IMV) opening the development of assisted mechanical ventilation as a way to manage the weaning of patients from periods of volume-controlled ventilation.

In modern days, an ideal ventilator should be most advanced in technology, offering features to meet the demands of critical care applications. It should also maintain the much-needed patient-ventilator synchrony and should ensure superior patient comfort. The choice of invasive and non-invasive ventilation modes makes an ideal ventilator universal for use on adult to pediatric patients. Also, an ideal ventilator should focus on safety and patient comfort by way of its advanced modes and, therefore, meet the challenge of different critical situations.

The Indian healthcare industry could well be the next trail-blazing story of our global success. After such a long journey in this field, MEDISYS finds itself today as one of the leaders in the field of indigenously manufactured ventilators that provide an alternative solution to its customers, who look for equipment that are trustworthy and highly cost effective.

Kalpa Kumar Ghosh
Director,
Premier Medical Systems and Devices Pvt. Ltd.

"The overall growth of ventilators market depends on many upcoming hospitals (both in private and public sector) and subsequent increase in the number of ICU beds in India. Our team at Skanray, being in critical care market since many years, understands market trends and need of the customers. We are highly focused on maintaining high quality, safety, and service support to our customers, keeping patient safety first, while offering extremely competitive pricing. Our D&D (Design and Development) team is highly focused and prompt in capturing the voice of the customer and launching new models, which are more robust, reliable, and precise, matching closest to customer needs in ventilator segment. The government's Make in India initiative is indeed encouraging to offer safe and reliable indigenous products to homeland."

Sumit Narang
National Sales Manager-Critical Care,
Skanray Technologies

Rohith Girish

"In recent years, the Indian market has been witness to a revolution in the acquisition and retention of customers. Thanks to new-age tools that harness the power of social media, brands are now able to filter market noise, identify their prospects and engage their customers. Such tools are poised to evolve to greater heights, bringing brands closer than ever to their customer bases."

Rohith Girish
Marketing Manager,
Air Liquide Medical Systems

 

Atul Jabde
Industry Speak
Application in Demand Is Connectivity

A definite requirement for easy-to-use ventilator, with simplified interface has been the primary factor for the last several years. Recent trend shows that clinicians are adopting closed-loop ventilation modes. High-flow therapy and NIV are being widely discussed and their demand is growing up rapidly.

On technology trends

Most manufacturers are inclined toward making single-platform-based product line, so that the product can be customized with various modules as per clinician's requirement. The uniformity of the product helps the hospital in minimizing the cost of training (nursing staff and biomedical engineers), consumables, maintenance, servicing, etc.

Another application in demand is connectivity. Realizing the need for interactions between the clinician's and technicians, all manufacturers are working toward seamless, efficient, and easy connectively between the medical devices and HIS system or remote monitoring or both together. This kind of connectivity will enhance clinical workflow, reduce human error of reporting, and result in overall reduction in operational cost. This communication-bridge (connectivity between the chief intensivist and hospital staff) will reduce morbidity and mortality considerably.

On key growth drivers

  • Reduction in overall cost of equipment due to large competition. Cost-effective newer yet simple technologies
  • Formation of medical service corporation for procuring hospital supplies in many states to develop district hospitals
  • Expansion of corporate chain of hospitals in Tier-II and Tier-III cities
  • Setting up of new large hospitals like AIIMS in many other cities and increasing government budget for healthcare

On challenges and opportunities

While many manufacturers are concentrating on connectivity, compatibility with hospital's existing HIS system is a challenge along with its overall cost. HFOV in adult patient population remains a challenge as well due to limited technology and few manufacturers. This, however, creates an opportunity for new product lines.

Atul Jabde
General Manager-Ventilator Sales,
Schiller

Dr Prabu Anandaraj
Industry Speak
Cost of Ownership

Being a very competitive market, every healthcare equipment company offers some unique features in their products.Hence choosing the right product becomes key for the hospital revenue. While the decision to purchase a healthcare device is made, several criteria are considered.Few initial considerations for analysis could be the initial capital investment, quality, brand reliability, warranty clause, safety standards certification, extended post-sale supports etc.Cost is a sensitive index from consumer stand point as the user not just pays for the product but for the value it imparts on the hospital operation process and profitability.The cost-benefit analysis of a product allows a heuristic approach in choosing the right product from the abundance of choice.

Ventilator being a life-saving device, things of paramount importance are the reliability (performance against odds) and brand reputation (customer engagement, training, excellent service capability, and continuing support). Analysis of total cost of ownership (TCO) of a ventilator during purchase decision will help the enterprise/hospital/institute to determine any direct or indirect cost of owning and maintaining the product over a span of time. TCO considers the sum of initial premium paid for the product and the running cost incurred in maintaining the equipment up and running throughout its lifespan. The running cost includes replacement of spares, scheduled preventive maintenance (PM), AMC or CMC cost, consumables, etc.

Assuming a hypothetical case, if we plot a graph against the total expenditure spent on maintaining ventilators from different manufacturers over say 8 years, then each ventilator will have its own trend of expense incurred.Some ventilators may cost less initially but might turn out to be white elephants over the period of analysis for reasons like spares, PM kit, service, and labor. In another case, the initial cost might be a tad higher but the performance on uptime with low running cost may contribute to the revenue of the hospital. If we plot a graph with total cost incurred versus time, it may show variable figure for different ventilators.The right decision would be to choose the ventilator that helps achieve the break-even faster without compromising the quality of care. Ventilator components that add to the running cost includes but are not limited to the components and consumables like oxygen sensor, flow sensor, preventive maintenance kit, choice of modes, standard accessories, etc.

GE offers its flagship ventilator Carescape R860, which has a proven track record of performance from the legacy Datex-Ohmeda' s Engstrom Carestation ventilator.It is the most advanced ventilator with modern platform offering current-generation technology in navigation paradigm and clinical decision support tools. A third-party commissioned study has revealed that among the most popular brands of ventilators in India, it has the lowest total cost of ownership for a projected period of 8 years.

Dr Prabu Anandaraj
Manager- Clinical Applications,
Wipro GE Healthcare

Eric Noronha
Second Opinion
New Device-A Safer Alternative to Lung Ventilators?

A new technology that re-creates important characteristics of structures in the lung could eventually be a safer alternative to certain types of respiratory and cardiac machines used to treat people whose lungs have failed due to disease or injury.

Using chip technology to precisely mimic blood vessels in the lungs could be a better way to treat patients with lung failure

An alternative to mechanical ventilation is extracorporeal membrane oxygenation (ECMO), which entails drawing a patient's blood and running it through a device that removes carbon dioxide and adds oxygen to it before returning the blood to the patient's body. Traditionally, ECMO has been used mainly as a life-saving measure, if mechanical ventilation does not work or is impossible, and is more commonly used in children. Today's ECMO machines, in which blood flows over a bundle of porous fibers through which oxygen is pumped, are complicated and require specialized expertise to operate. Blood tends to clot in the device, which is very unlike the environment in the lung, so patients must take large doses of anti-clotting medication. This can lead to other dangerous complications such as bleeding in the brain or gastrointestinal system

Stacking layers of biocompatible plastic with microchannels patterned on their surface, Borenstein's team has built a "three-dimensional branching structure" in which larger channels gradually branch into smaller ones similar to the way larger blood vessels branch into capillaries

Other research groups are also pursuing microfluidic-based gas exchange technologies for biological system – something made possible by the proprietary methods to achieve the 3-D branching. While flowing through the device, blood is much less than it is in an ECMO machine. It also puts oxygen and blood into closer proximity, which allows for more efficient gas exchange compared with conventional ECMO.

Eric Noronha
Sr. Manager-Operations,
TBS India Telematic and Biomedical Services Pvt. Ltd.


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