The Indian ventilator market is expected to continue its journey of 10 percent annual growth over the next few years.

The Indian ventilators market has been on a growth path for the last few years. Recent trends indicate that buyers are investing into dedicated ventilators for each segment instead of preferring universal ventilators, as was the practice earlier. This helps the buyers stretch their budget and increase the number of units they buy. The adult ventilator market size remains most significant in the high- and mid-segments.

Health insurance schemes by central and state governments for treatment in private hospitals, formation of medical service corporations in many states for procuring hospital supplies, expansion of corporate chains of hospitals in Tier-II and Tier-III cities, setting up AIIMS-like institutions in many other cities, increasing government budget for healthcare, increasing awareness on usage of ventilators in home and hospital environments, and increased incidence of communicable diseases such as SARS and swine flu are the primary influencers in the Indian ventilators market.

Leading Ventilator Brands (2015)

The ventilator-to-ICU-bed ratio continues to be lopsided in most hospitals. Many mid-sized and smaller hospitals have a ratio as poor as one ventilator for every four to five ICU beds. This also gives ample opportunity for growth in this segment.

Local manufacturers are now beginning to assert themselves in this largely import-dependent market, adding a new third dimension to the prevalent two-dimensional market that consists of advanced ventilators and refurbished ventilators. However, local manufacturers need to establish quality systems and get their products certified from international agencies. Quality systems will help Indian manufacturers sell their products not only in India but also in Asia-Pacific region, but without the standards in place that cannot be done. Low price will not be the only criterion to get orders.

Challenges in future are going to be thrown by the Chinese players who were largely missing in this life-saving equipment market earlier. Cost considerations coupled with long-term service assurance will play an important role in the coming years in the decision-making process of the buyers.

Indian Ventilators Market

Indian Market

The Indian ventilator market has exhibited a steady growth of 10 percent over the last couple of years. The market in 2015 is estimated at 6450 machines, valued at Rs.335 crore. The imported equipment continues to dominate the market with a 58 percent volume share and a 73 percent share in value terms. Within the segment, there are premium and super premium, both with an equal share. The very-high-end machines have a 5 percent share.

The ambulatory or transports have seen traction, with the turbine-driven ventilators gaining popularity. The refurbished ventilators are available in a higher price range now, as the basic model is no longer available for refurbishing. The indigenous players continue to command a niche share as some medical facilities, with limited budgets, prefer a low-end model, and some just to ensure that they meet the formality of offering a ventilator.

Global Market

The global mechanical ventilators market is expected to reach USD 5.5 billion by 2022, states Grand View Research Inc. The global market witnessed a significant growth over the past two decades, and it has been characterized by technological innovation and increasing preference for portable and homecare ventilators.

Critical care ventilators are expected to account for over 40 percent of the market share by 2022 owing to the technological advancements such as spontaneous breathing trial (SBT), AutoTrak, and reporting software that influence better care provision are expected to boost market growth further. Neonatal care is also expected to witness a rise in the market share owing to increase in the neonatal population.

Transport and portable ventilators are expected to grow at a lucrative CAGR of over 7 percent over the next six years. The scope for transport and portable ventilators is extended from ambulatory to homecare. Increasing cases of medical emergencies and growth in the market of point-of-care treatment are vital drivers of segment growth. Hospitals are promoting the use of portable ventilators to provide faster and continuous care to patients even prior to their arrival in the premises. Portable units fulfill the need of patients to obtain home care, thereby increasing their popularity. Upgrading of technological and production systems leading to the development of smaller, highly compact, and robust ventilators providing high performance is expected to propel segment growth.

Global Ventilators Market

North America dominates the mechanical ventilators market in terms of revenue owing to the rising geriatric population in the U.S., which is leading to a corresponding rise in the incidences of respiratory disorders. Asia-Pacific and Latin America are expected to witness lucrative growth of over 7 percent. This growth is due to the presence of untapped opportunities, rising expenditure level, and the introduction of favorable government initiatives.

In emerging economies, such as China and India, a rise in new hospitals has led to a surge in the number of intensive care unit (ICU) beds equipped with ventilators. Attention is turning increasingly toward improved technologies that prevent lung injury, reduce the time that patients have to spend on mechanical ventilation, and improve synchrony between the patient and ventilator. Companies are focusing on developing multimodal ventilators, which act as a one-stop solution for critical care physicians handling a wide range of ICU procedures.

Compared to older methods, these technologies also help to reduce the risk of lung injury from high inspiratory pressure and are more customized to patients with varying levels of complications. They can also promote speaking ability and improve patient comfort during mechanical ventilation.

The increasing preference for non-invasive ventilation in the developed world will be another significant trend over the next six years.

Rising prevalence of chronic obstructive pulmonary disease (COPD), increasing aging population, growing number of critical care admissions, and technological advancements such as rapid innovation in the field of positive airway pressure (PAP) devices, portability, and improvement in battery life of transport and portable devices are the primary influencers in the mechanical ventilators market. Furthermore, improved healthcare infrastructure, rising middle-class income, and government support are other major factors providing impetus for growth of this market. The evolution of patient-friendly, cost-effective, and portable devices further encourages their usage.

Tight budgetary constraints faced by ventilator manufacturers and healthcare service providers and complications such as nasal trauma, oral-pharyngeal laceration, tooth avulsion, laceration of the vocal cords, and hypoxemia may impact the market growth.

Technology Update

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 patients whose lungs have failed due to disease or injury.

By using manufacturing techniques originally designed to make computer chips, biomedical engineers have in recent years made significant progress toward mimicking the mechanisms of certain organ systems, the healthy functionality of which is contingent on very precise chemical and physical conditions. Blood, for example, is extremely sensitive to environments other than the ones it encounters in healthy living systems. The Charles Stark Draper Laboratory in Massachusetts, USA, has designed a new lung therapy, composed of tiny channels molded into a biocompatible polymer that is capable of handling high blood flow rates. If things go as planned, the therapy will be much safer than that used today.

Second Opinion
Medical Equipment Maintenance Outsourcing

Medical equipment management and maintenance has remained a challenge and in many regions, a failure. It has been understood by the experience of several countries that self-maintenance of equipment by users or a pool of hospital-employed engineering staff can no longer be considered as the only component of a sustainable solution. To address the gap in technology management and maintenance hospitals in the country, a model has been conceived on the lines of public-private partnership. The model in principle suggested outsourcing of equipment management and maintenance functions, which includes but is not limited to: assessment (periodic and on continuous basis) of all equipment available in regional/district and sub-district public healthcare facilities; responsibility of calibration, configuration and undertaking "settings" pertaining to all equipment; preventive and corrective maintenance of equipment on a schedule and on-call basis; submission of quarterly report on functional status of equipment; and supportive role in site-preparation, installation, and commissioning, user-training, asset condition appraisals, beyond-economic-repairs status, decommissioning, and overall maintenance of equipment.

A decision to engage in contractual relationships with private agencies for maintenance of medical equipment in hospital should ideally result from a detailed analysis in order to ensure that the outsourcing of a service is the best possible solution among a set of alternatives such as employing engineering within system, undertaking ad-hoc maintenance, dealing independently with manufactures and suppliers on a need basis individually for all necessary equipment, or paying for AMC/CMC for individual machinery.

The criteria based on which this decision could be taken would comprise of: improvement in key performance indicators cost benefit analysis; reduction in administrative constraints; and reduction in risk. The risk arising due to non-delivery of a service is transferred to the private partner by virtue of a commercial partnership engagement. The extent of this reduction in risk to the agency, however, depends on the terms and conditions detailed in the contract. In equipment maintenance, for example, the extent of risk arising due to non-functional equipment would depend upon whether obligation to provide controls, or accessories was given to the private agency or not; or whether any process of maintenance depended on the users.

Eric Noronha
TBS-India Telematic and Biomedical Services Private Limited

It is common for critically ill patients to experience acute respiratory distress syndrome (ARDS), in which fluid builds up in the lungs and prevents the normal exchange of oxygen and carbon dioxide. Mechanical ventilation of the lungs, the most commonly used therapy for such patients, is akin to asking someone to "exercise a broken arm," says Jeff Borenstein, who leads the microfluidic lung project at Draper. The invasive therapy involves forcing high concentrations of oxygen into the lungs at high pressures, and does not allow the diseased or damaged tissue to heal, he says. Even worse, it commonly leads to serious complications including lung tissue toxicity and pneumonia.

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.

The new microfluidic device, which is simpler in design and provides the flowing blood an environment much more like what it encounters in the lungs, could essentially replace the guts of conventional ECMO machines, says David O'Dowd, program manager for biomedical systems at Draper. If things go as planned, it will be ready to test in animals in two years, and ready for human testing in three, he says.

By stacking layers of biocompatible plastic with micro channels 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, but Borenstein says his team's device is unique in the degree to which it mimics the actual biological system - something made possible by the proprietary methods the group used to achieve the 3-D branching. While flowing through the device, blood is much less likely than it is in an ECMO machine to think it should be clotting. It also puts oxygen and blood into closer proximity, which allows for more efficient gas exchange compared with conventional ECMO.

This unique design is what has allowed the team to achieve blood flow rates at least 10 times faster than competing microfluidic technologies. Recently, the group demonstrated a flow rate of 100 mL per minute using bovine blood. Now the goal is to scale it up so it can handle liters of blood per minute without sacrificing the attributes that reduce clotting risk.

Because a device like this would be simpler, more efficient, and would not require patients to take lots of blood thinners, it could be much safer than today's ECMO machines for long-term use. That could be especially useful to help people through flare-ups of common chronic lung conditions like chronic obstructive pulmonary disease (COPD). If the technology can be successfully scaled up and commercialized, he says, it has the potential to revolutionize how we take care of patients who have acute respiratory failure.

The Road Ahead

Despite the strides made, especially with the advent of complex algorithms in the latest ventilators on the market, expert knowledge is still crucial to successful outcomes. The major challenge seen in the ventilator market is due to the manufacturers having no restrictions on the definitions of respiratory support modes, which are confusing for the end-user. In many cases, an algorithm or ventilation mode proposed by a manufacturer as being exclusive for its equipment is based on almost the same concept, but with a different registered trademark name than the option proposed by another manufacturer. Another challenge in the market is related to size of ventilators. Infant-to-adult ventilators seem attractive because they offer single user interface for staff to become familiar with, and also make maintenance easier, but one-size machines definitely do not fit all.

Customers that typically have low awareness and purchasing power are trusting local companies to provide better after-sales support, which might compel MNCs to scale down prices. This may offer huge opportunities for engineering service providers and OEMs. Devices suitable for providing more comfortable and clinically effective ventilator support by specific inspiratory ramps, cycle triggering, expiratory facilitation, leak correction, and real-time ventilator support are the current needs in the marketplace. Thus, a large number of exciting opportunities are waiting for the manufacturers of ventilators in the market.

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