The focus has shifted toward improved technologies that prevent lung injury, reduce the time that patients have to spend on mechanical ventilation, and improved synchrony between the patient and ventilator

Ventilator technology today offers a great deal of improvements with respect to enhanced patient safety, automated weaning systems, data connectivity to central alarms and information systems, as well as features to augment patient-ventilator synchrony. User interfaces have been designed to streamline the interpretation of data and customize information to the bedside clinician. Owing to major breakthroughs in hardware and software technology, ventilators have made a quantum leap in capabilities over the previous generation. The pneumatics on many older ventilators have proven to be sound, but in conjunction with advanced electronics and software potential, ventilators can now offer much more in terms of advanced care.

Indian Market

In 2014, the Indian ventilator market was estimated at 6500 units in terms of volume and Rs.266.75 crore in terms of value.

The market for imported equipment was estimated at Rs.217 crore, with 3950 units of sales. GE, Draeger Medical, Maquet Medical, Philips, and Schiller dominate this segment. Other aggressive players include Philips, Mindray, Skanray, Air Liquide, Carefusion, and Hamilton.

The refurbished ventilators market, in 2014, generated a sales of 750 units, amounting to Rs.18.75 crore. These ventilators are preferred by small hospitals and nursing homes in tier-II and tier-III cities, and semi-urban and rural areas. Major players in this segment include Zigma, SOMA, Max Meditech, Fabian HFO (Acutronic Medical Systems), Technomed, and Unitech. This segment is also catered to by resellers/importers who import the products from the United States, the United Kingdom, Germany, and Australia.

Transport, Ambulatory, and Chinese ventilators constitute 7.7 percent of this market, estimated at Rs.5 crore.

The indigenous market, estimated at 1300 units, accounting for Rs.26 crore, is dominated by Max Meditech and Medisys. Air Liquide and Schiller also have some presence in this segment.

Global Scenario

The global ventilators market has witnessed significant growth in the past two decades in the wake of technological innovation. While the increasing prevalence of chronic obstructive pulmonary disease (COPD) will continue to be the primary driver of market growth, new technologies will also make a crucial contribution. Another key reason for the growth of the market is the increasing preference for home-care ventilators and portable ventilators.

Asia is likely to witness high growth rate in the ventilators market in next few years with an emerging economy and improvement in healthcare technologies in the region. Growing demographics and economies in the developing countries such as India and China are expected to offer good opportunities. In these emerging economies, a rise in new hospitals has led to a surge in the number of ICU beds equipped with ventilators. In addition, the integration of physiological principles in system would offer novel avenues for the global ventilators market.

Intensive-care mechanical ventilators are the most widely used type and hold the dominant share in the mechanical ventilators market. The increasing preference for non-invasive ventilation in the developed world will be another significant trend.

Companies are adopting several development strategies to increase their market share in the mechanical ventilators market. Innovation and development of new technologies in the healthcare sector would help the manufacturers to increase their market share. Companies are trying to explore the opportunities in developing economies by adopting agreement and acquisition as key strategies. Product launch is another strategy used by various companies to retain their position in the mechanical ventilators market.

Mechanical ventilators have evolved significantly in the last decade. Advances in technology, an increased understanding of the physiology, and effects of mechanical ventilation have had a profound impact on ventilators use. Innovations in equipment design and functionatity are being developed to improve patient outcomes and increase ease of use for clinicians by addressing two key objectives of simplifying function and mitigating harm.

Advancements in Technology

Modern ventilators offer increased accuracy and flexibility in modes of ventilation. Volume and pressure targets are controlled more accurately and reduce the risk of barotrauma, volutrauma, and atelectasis. The flexibility of modern modes and mode adjuncts, for instance, pressure support ventilation (PSV) for spontaneous breathing and the ability to more accurately control adjuncts like peak inspiratory pressures, allow for increased safety in the increased use of supraglottic devices, ambulatory procedures, and refined adjuncts such as regional anesthesia. Other benefits of new ventilators include single-switch activation and an ability to enter the patient's weight for recommended appropriate ventilator settings. Assisted and controlled ventilation is no longer limited to volume-controlled and pressure-controlled modes. Other forms of ventilation include extracorporeal membrane oxygenation (ECMO) and neurally adjusted ventilator assist (NAVA). With NAVA, bipolar electrodes detect signals traveling down the phrenic nerve to the diaphragm, and use this signal as the stimulus to initiate mechanical ventilations. This allows for very precise volume delivery and a decreased chance of pressure-related complications. Ventilators available today feature volume guarantee in pressure control and in time cycled pressure limited for neonatal specific ventilation. Proximal flow sensing allows for accurate monitoring in the neonatal intensive care unit which facilitates reliable triggering to help improve patient synchrony.

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. Manufacturers are increasingly turning their attention toward improved technologies that prevent lung injury, and reduce the time that patients have to spend on mechanical ventilation.

Improved user-interface. Improvements in the structural design that is combined with technological innovation and a wider range of usage settings on mechanical ventilators has greatly changed the construction, nature of use, and rate of use of disposable apparatus in the devices. An easy access to all the tools necessary for monitoring and evaluating patient vitals and managing ventilator settings, in just a few swipes of the screen has improved workflow efficiency. The ability to customize workspaces and analyze waveforms across an entire 72-hour window is providing users the ability to turn data into information pertaining to clinical decisions.

Manufacturers have developed customized technology that can be adjusted simply and quickly to respond to patient needs. The current crop of ventilators combine personalized, simplified therapy with powerful wireless connected care capabilities for patients with respiratory challenges who are not dependent on continuous ventilation. The built-in wireless connectivity provides quick access to a wide range of therapy parameters. This data, along with therapy statistics and trend data useful for home titration and monitoring, is automatically and securely transmitted to a cloud-based patient management system.

Non-invasive ventilation. This has become a standard of care for the management of acute respiratory failure, but there is a risk of leaks around the mask that may interfere with ventilator performance. Moreover, dedicated NIVs have exhibited more standardized behavior with an ability to avoid auto-triggering or delayed cycling while keeping a short triggering delay despite the presence of leaks. Non-invasive ventilators are specially designed for critically ill patients suffering from respiratory failure, congestive cardiac failure patients and newborn infants.

The refurbished ventilators industry has remained stagnant with substantial reduction in the availability of majority of models sold in India. The availability of newer models has been comparatively slow as compared to models which were sold in high volumes during 2010-13. Imports in 2014 have also been stagnant due to procedures of the customs department and requirement of certain documents, which had a negative effect on transactions.

Rajagopal Geethu
Director,
Zigma Meditech India Private Limited

Major factors influencing the adoption of NIVs include inherent benefits such as reduced infection risk, patient's ability to swallow and speak, and minimized need for sedation. Combination of invasive and non-invasive ventilation modes as well as flexible mask options helps facilitate quick therapy transitions and keeps patients as comfortable as possible, providing the benefit of two technologies in one product.

Automatic transport ventilators. Ease-of-use and minimal needs when it comes to maintenance and repair are key factors to consider in any ventilator product. Advances in technology continue to create ventilators that are smaller, more user-friendly, and easily adaptable to the pre-hospital environment and foster the development of critical care medicine.

Smaller, user-friendly portable ventilators show great potential for more widespread use in the pre-hospital setting. Pre-hospital use of non-invasive ventilation methods (CPAP, BiPAP, and PAV) has been shown to reduce in-hospital mortality rates. The addition of automatic transport ventilators with greater ability to customize settings for CPAP, BiPAP, and PAV would allow pre-hospital personnel to deliver respiratory support tailored to each patient's specific needs.

Industry Speak
Advances in Ventilator Technology

Recent trends indicate that buyers are investing into dedicated ventilators for each segment instead of preferring universal ventilators, as was the earlier practice. This helps the buyer stretch their budget and increase the number of units they can buy. The adult ventilator market size remains most significant in the high- and mid segments. The growth in specialized neonatal ventilator market is now visible.

Technology trends. Technology is advancing each day and leading to the advent of sophisticated features and newer modes of mechanical ventilation. Realizing the clinicians and technicians increasing need 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.

Key growth drivers.

  • Health insurance schemes by central and state governments for treatments in private hospitals
  • Formation of medical service corporations for procuring hospital supplies in many states helps in centralized purchases in larger volumes.
  • Expansions of corporate chain of hospitals in tier-II and tier-III cities
  • Setting up new large institutions like AIIMS in many other cities and increasing government budget for healthcare
  • Increased incidence of communicable diseases such as SARS and swine flu.

Buyer's perspective. Ease of use by clinicians and nursing staff remains a dominant factor in purchase decisions. Secondly, a uniform product platform across varying segments of ventilators (adult/pediatric or infant) reduces training time for the nursing staff, as well as allows interchangeability of the accessories thereby reducing inventory and costs. For buyers expanding their facilities, there is a growing demand for ventilators offering integrated advanced respiratory diagnostic maneuvers and automated weaning modes, to reduce weaning time and lower nursing care requirement.

Hormazd Cooper
Vice President,
Schiller Healthcare India Private Limited

Second Opinion
Technology Trends Shaping the Future

Ventilator is a device which will enable a patient to carry out either partially or completely his/her normal respiratory function. Andreas Vesalius (1555), anatomist and physician from Belgium, is credited with the first description of positive pressure ventilation, but it took 400 years to apply his concept to patient care. The invasive ventilation with tracheal tube was first used at Massachusetts General Hospital in 1955.

Ventilators are indispensable equipment in intensive care unit that caters respiratory support for a variety of medical conditions like severe hypoxia, severe CO2 retention, cardiogenic shock, severe neuromuscular disease, and coma patients. Post-operative patients are also in need of ventilation with mechanical support for variable duration.

Ventilator has come through marked changes from minute volume dividers to present-day modern ventilators with options of modes used for weaning with invasive and non-invasive methods. Modern-day ventilators provide lung protective strategies in ventilation, especially in lung injury and neonatal patients.

Future ventilators are expected to have the following features:

  • Miniaturization into a single chip which can also be used for ECG and EEG monitoring
  • Enhanced portability to enable transport from one healthcare facility
  • Low power design using smaller batteries and longer backup time
  • Wireless connectivity (Internet) to enable remote monitoring from a distant site
  • Leveraged technical expertise nationally and globally and minimized onsite repair visits.

Dr Kirthivasan
Chief Anesthetist,
Frontier Life Line Hospital, Mogappair

Second Opinion
Noninvasive Ventilation

Noninvasive ventilation (NIV) has now become an integral tool in the management of both acute and chronic respiratory failure, in both home setting and critical care units. NIV has been used as a replacement for invasive ventilation but its flexibility also allows it to be a valuable complement in patient management.

Noninvasive respiratory support encompasses CPAP, continuous bi-level positive airway pressure (BPAP), and negative pressure ventilation (NPV).

Noninvasive ventilators. Ventilators employed in NIV range from ICU ventilators with full monitoring and alarm systems normally employed in the intubated patient, to light weight, free standing devices with limited alarm systems specifically designed for noninvasive respiratory support.

Volume assist-control ventilators. Volume-controlled ventilators predominated in the past but have largely been replaced by pressure devices. Volume and pressure control modes have both been shown to be effective in COPD. 

Pressure assist-control ventilators. Technical developments such as microprocessor controlled valves have led to most NIV ventilators now being pressure controlled flow generators.

Continuous positive airway pressure. A continuous positive airway pressure (CPAP) ventilator delivers air at a constant pressure during inspiration and expiration. The patient must be able to breathe spontaneously.

Bi-level assisted spontaneous breathing ventilators. Bi-level positive airway pressure (BiPAP) is pressure-limited ventilation, which comes in the following three types - pressure support ventilator delivers air at a set pressure during inspiration each time a patient initiates a breath; pressure control ventilator automatically delivers a set number of breaths per minute at a set pressure; bi-level positive airway pressure (BiPAP) ventilator delivers different pressures during inspiration and expiration. If necessary, this mode can fully ventilate the patient.

Predictors of successful NIV. Certain parameters may predict successful or failure of NIV. Trials of NIV are 1-2 hours in length and are useful to determine if a patient can be treated with NIV.

Mohd Samiuddin
Pulmonologist,
Global Hospitals, Hyderabad

Second Opinion
Neonatal Ventilators - Latest Innovations

Neonatal ventilation has been the cornerstone in the management of preterm and sick neonates and has been extremely important in improving survival in these vulnerable hosts. The challenge in these ventilators is to measure the extremely small tidal volume and shorten the response time in the process of synchronization, which has become the standard of care. The microprocessor based technology which is able to measure extremely low tidal volume of 1-2 mL has made it possible to reduce the probability of volutrauma and optimize the benefits of volume controlled or volume guarantee modes of ventilation. The use of flow sensors in neonatal ventilators is responsible for reducing the response time to 50-60 ms in which the ventilator responds by giving a breath after sensing the patient's efforts.

The use of pulmonary graphics in neonatal ventilators has made it possible to pick up extubation at the earliest and optimize PEEP or PIP as the desired goal to reduce chronic lung disease, which is a formidable morbidity in preterm neonates. The use of high frequency oscillation and nitric oxide in neonates has also been extremely helpful in providing ventilator assistance in difficult situations like congenital diaphragmatic hernia and persistent pulmonary hypertension. The disadvantages of inspired high oxygen concentrations in neonates is well known with a saturation target of 91-95 percent manually is a challenging task and the recent use of automated closed loop control of inspired oxygen concentration is likely to help clinicians in meeting their target saturations more closely.

Use of neonatal extracorporeal oxygenation is the last armamentarium in the hands of a neonatologist when all attempts for cardio respiratory stabilization have failed and fortunately now we are able to offer such strategy to neonates of more than 2 kg. The technology is making the survival of sick neonates possible and also trying to make the life of neonates better.

Dr Pankaj Garg
Senior Consultant, Department of Neonatology,
Sir Ganga Ram Hospital, New Delhi

 

Currently, the use of a portable mechanical ventilator is a mainstay of critical care patient transport via both air and ground. The potential benefits of widespread automatic transport ventilator use on advanced life support (ALS) ambulances are significant. There has been a gradual introduction of automatic transport ventilators as an addition to ALS protocols. These simplified ventilators provide more consistent minute volume than traditional positive pressure ventilation with a bag-valve device. There is also evidence that the use of automatic transport ventilators may allow paramedics to complete other tasks related to patient care, as they are not directly involved in manual ventilation. Prolonged manual ventilation with a bag-valve device is harmful and often increases patient mortality. The introduction of automatic transport ventilators into ambulances could have significant impact on patient outcomes, particularly in rural areas with longer transport times.

The advances in ventilator modalities - in conjunction with a better understanding of patient physiology and the effects of positive pressure ventilation on the body - have revolutionized the mechanical ventilation process. Compact, rugged computing modules lay the framework for lifesaving advancements in today's ventilator technologies. Increased ventilator control is paving the way for optimum patient health as well as reduced hospital stays and associated costs. Innovations in ventilators continue to adapt to a rapidly changing environment. Each improvement focuses on safety while providing another option in delivering the best form of ventilation based on the patient's condition and need.


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