Advances in product technologies are recognizing the opportunity of providing ventilation, not only in critical care settings but also in sub-acute care and homecare settings.

In the decades since ventilators first made their appearance in the ICUs, machines have evolved from devices that ran on manually calculated settings dialed in by respiratory therapists to high-tech devices that utilize software to manage ventilator function and get the right mix of pressure flow and volumes for each patient. Advances made in microprocessors and feedback mechanisms support ventilatory strategies of pressure-limited ventilation (PLV) and volume-targeted ventilation (VTV).

Technological advancements over the years have resulted in significant innovations at the product front. Advances in product technologies are recognizing the opportunity of providing ventilation not only in critical care settings but also in sub-acute care and homecare settings. Realizing the increasing need of clinicians and technicians for ease-of-use of advanced modes, manufacturers are introducing simpler user interfaces. The new modes and techniques of ventilation provide reduction of airway pressure, improved oxygenation, recruitment of alveoli, and redistribution of ventilation to reduce morbidity rates as well as faster weaning. In recent years, strides have been made to address the challenges of lung injury and infection. The issues of manufacturers returning to create neonatal-specific platforms in addition to infant-to-adult models have improved with features designed to give better outcomes, enhanced patient safety, connection to electronic records systems, and making the devices easier to use.

Technology Trends

Traditional invasive products are making way for more portable ventilators and non-invasive products, a trend that is exhibiting tremendous growth prospects supported by improving convenience to patients and reduced healthcare costs. The steep growth in information technology has led the industry to rapidly develop new software, user interfaces, and algorithms that are implemented in the machines by different vendors. This translates into a new generation of highly performing ventilators, often offering several vendor-specific features.

Non-invasive ventilators are increasingly becoming a standard of care in several healthcare institutions worldwide. Combination ventilators, with both invasive and non-invasive options, provide the benefits of the two technologies in one product. While these products are well-embraced by the developed markets, their adoption remains significantly lower in emerging markets, such as Asia-Pacific. With the objective of providing only basic care, healthcare systems in most parts of Asia-Pacific remain underdeveloped, and hence the lower adoption of combination ventilators.

Noninvasive ventilation. New modes of ventilation and protective ventilation are designed to minimize the deleterious effects of mechanical ventilation, which is a fundamental aspect of critical care management. Noninvasive ventilation (NIV), using bi-level positive airway pressure (BiPAP) with various degrees of inspiratory and expiratory pressure applied via a face, nasal, or combined face mask, has become a more common modality to avoid endotracheal intubation or to perhaps shorten the need or period of ventilation by artificial airway. Modern microprocessor-controlled ventilators allow modification of flow rate and flow patterns in providing adequate and safe mechanical ventilation.

Automated weaning protocols. Automated protocols can assess a patient's readiness to wean from mechanical ventilation and alter the level of support according to the assessment of physiologic parameters. A large number of manufacturers are introducing automated protocols to gradually reduce pressure support for patients during weaning from mechanical ventilation. Most of these protocols plan a reduction in pressure support but can increase it automatically in case of need, as detected by dedicated monitoring or by analysis of respiratory mechanics. Automated systems may lead to a reduction in weaning time and length of admission in the ICU, which can translate into significant cost-reduction and greater customer satisfaction.

Advances in mechanical ventilators. The current trends in mechanical ventilation are a constant decrease in the use of assist-control ventilation modes and synchronized intermittent mechanical ventilation in favor of a constant and widespread increase in use of pressure-support ventilation. The new mechanical ventilators have the capacity to deliver invasive and non-invasive ventilation, as well as oxygen therapy, so that the caregivers can use one device, decreasing the amount of disposable circuits and avoiding clutter at the bedside, improving efficiency, and reducing cost of care. The main goal of all mechanical ventilators, including adult devices, with features such as prioritized alarm messages, troubleshooting guides embedded in the user interface, and customizable data displays is to enhance patient safety.

Challenges and Opportunities

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 ventilatory support by specific inspiratory ramps, cycle triggering, expiratory facilitation, leak correction, and real-time ventilatory 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.

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.

Way Forward

Future ventilators are expected to be miniaturized into a single chip, which can also be used for ECG and EEG monitoring, offering enhanced portability to enable transport from one healthcare facility to another. Low-power design using smaller batteries, longer backup time, wireless connectivity to enable remote monitoring from a distant site coupled with leveraged technical expertise, and minimized onsite repair visits could be the focus in coming years. Emphasis on developing devices, incorporating distinctive and proprietary algorithms for new modes of ventilation with adaptive facilities for each patient based on variants and combinations of the classical pressure and volume control modes, could be in limelight in the years ahead.

On technology front, high-flow oxygen therapy mode could be useful to power a high-flow continuous positive airway pressure system accurately, avoiding the use of a less reliable gas blender or venturi-based flow generator. With an adequate humidifier, this mode can also be useful to drive high-flow nasal cannulas, a tool that is expected to have a major role in research and clinics in the next few years.

TBS Telematic and Biomedical Services Private Limited, Bangalore
Second Opinion
Need for Caregivers in the Home to be Trained

Care of the ventilator-dependent child at home is an arduous process. It involves commitment and dedication of the caregivers in the home, as well as support from physicians and medical personnel. A primary and secondary caregiver is identified prior to discharge. A back-up ventilator is provided to all patients who are ventilator-dependent 20 hr/day or when they live long distances from medical or technical assistance. Nurses with pediatric critical care expertise are helpful in assisting families for 8-24 hr/day in the homecare of their child, especially for infants and young children who may be particularly unstable. We recently surveyed knowledge of homecare givers for mechanically ventilated patients. In general, both parents and in-home nurses missed questions about the significance of ventilator alarms. There were no differences in knowledge between nurses and parents based on language spoken, whether the child was part-time versus full-time ventilator-dependent, or those who had responded to an emergency at home versus those who had not. The length of time the child had been on home mechanical ventilation did not correlate with knowledge. This study demonstrated that caregivers of children on home mechanical ventilation should receive training focused more on technical aspects of ventilator alarms and emergency responses. In addition, there is a tremendous need for homecare companies to facilitate this process of training by mutually working toward education of families and caregivers; providing back-up support for equipment check, troubleshooting, and preventive maintenance; and providing 24-hour emergency availability in the event of equipment malfunction. Physicians, respiratory therapists, nurses, other medical personnel, caregivers, and homecare companies can cohesively contribute to the complex and challenging needs of these medically fragile children.

Eric Noronha
TBS Telematic and Biomedical Services Private Limited,

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