Buyers Guide

A Breath of Life

It is a device which was designed to provide mechanical ventilation (artificial respiratory support) to patient. Today the technology of ventilators has advanced by leaps and bounds, finds out Sonal Shukla

Picture Courtesy: Meditronics

They work as an invisible thread between life and death as they are rightfully uitilised to provide artificial respiration to the patient. Yes, we are talking about ventilators. As the failure of a mechanical ventilation system may result in death, ventilators are dubbed as critical life systems. Hence, reliability is the word to ensure that mechanical ventilation systems are safe. They are used in a hospital setup, particularly in critical care and post operative care units to provide oxygenation to patients who cannot breathe on their own. At times, they may also be used in the high dependency area, wards, or to transport seriously ill patient. Ventilator is applicable to all range of patients from neonates to adult and the reasons for applying a ventilator is whenever the patient for whatever medical reason cannot breathe or take sufficient breaths on his own effort. "Even though they are categorised for adult, paediatric and neonatal, most present day ventilators can treat all age groups" states Dr Robert D'Costa, Chief of Critical Care, Wockhardt Hospital, Mumbai.

Constitution

A ventilator comprises a compressible air reservoir (or compressed air can be piped into the ICU), oxygen source, electronic control unit, a set of valves and tubes and a disposable or reusable patient set. The air reservoir is mixed by a mixer to deliver air/oxygen mixture to the patient. The oxygen content of the inspired gas can be set from 21 per cent (ambient air) to 100 per cent (pure oxygen). When inspiration is complete, the patient exhales passively due to the lungs' elasticity. Pressure and flow characteristics can be set mechanically or electronically. Ventilators usually have battery back-up mechanisms to enable ventilation to continue for sometime in the absence of power.

The ventilator market in India is huge with major players being, Maquet, Draeger, Birds, L&T, Meditronics, Schiller, GE, Newport, Viasys, Respironics, Hamilton, Bear and Taema-Horus.

Variety

Depending on their use, ventilators can be broadly classified as anaesthesia ventilators, ICU ventilators, transport ventilators or non-invasive ventilators. Depending on their constitution and level of sophistication, they can be further classified as electrically operated, pneumatically driven or microprocessor-based ventilators.

Anaesthesia ventilators are used during surgery; ICU ventilators, as the name suggests, are customised for an ICU set-up. "ICU and anaesthesia ventilators functionally are the same, except in anaesthesia when it comes with a mixer attachment for the purpose of using various anesthetic gases," informs Dr D'Costa.
The ones used for EMS and ambulances are normally known as transport ventilators. They mainly work as mechanical Ambu Bags (manual resuscitator— ambu bag is one of the most common manual devices used to ventilate and oxygenate patients in medical practice) for transport. Such a ventilator needs to be simple and portable. Says Dr D'Costa, "The transport ventilators need not have too many sophisticated modes as they can add to weight and thus portability suffers. It can have Positive End-Expiratory Pressure (PEEP) and other minor controls but not all the modes seen in an ICU ventilator."

Ventilators can sometimes be also used non-invasively. In such cases, a face or nasal mask is used as the interface instead of conventional tube that goes into the patient's trachea. Now-a-days, the trend is moving towards using non invasive ventilation to reduce the risks associated with intubation, like Ventilator Associated Pneumonia (VAP) which could develop in a patient, who is mechanically ventilated for more than 48 hours after intubation and is a leading cause of death among hospital-acquired infections.

Contemporary Ventilators

The era of digitisation has dawned in ventilators as well. Most ICU ventilators now use microprocessor-driven logic control systems of sensors and valves to ventilate the patient. "All modern ventilators today have microprocessors for faster and better use of complex algorithms that improves patient comfort level on the machine. This is achieved by modifying flow and volume characteristics of gases which are desired by the patient." says Dr D'Costa
This microcontroller or microprocessor then can further be connected to various other derivatives like display monitor, printer and networking and other facilities related to computers. In addition, they have sophisticated transducers that monitor the delivered gas and also the gas that returns from the patient. The microprocessor use this information to decide the amount ventilation gas required, on a breath-to-breath basis. This kind of feedback-based system uses a servo system. In the future, more sophisticated ventilators will use superior processing systems to deliver and monitor gases delivered to patients and display this information on LCD screens as numbers and also as elegant graphics.

The Ideal One

A wide variety of newer modes are today customised to deal with patients suffering because of bad lungs. So, what features make the ideal one? "A user-friendly ventilator with minimal manipulations like use of fewer control knobs is liked by the doctors, today. Touch screen type is topping on the cake," opines Dr P N Kakar, Director of Anaesthesia and Pain Management And Chair Central Infection Control, Max Healthcare, New Delhi. A versatile alarm system, a log book of various alarms and a locking mechanism make it more useful.
A ventilator which also displays various respiratory parameters along with lung mechanics on the screen is better than the one which does not do the same.

Experts also believe that the ventilator should be equipped to ventilate a patient of wide age group-from an infant to an adult. They must have a battery back-up and apnoea ventilation (when a patient stops breathing while weaning off the machine, the machine takes over by changing the mode to controlled ventilation from a spontaneous mode). It should also be versatile having different modes like volumes, pressure cycle and a good alarm systems which sometimes can be set automatically saving staff time. Today, doctors also look for ventilators which can be easily transported or portable in a hospital set-up or occupy the minimal possible space by the side of the bed of the patient in ICU.

"The latest generation of ventilators has newer modes like Proportional Assist Ventilation (PAV)" - Dr Bharesh Dedhia Chief of Critical Care Services Jupiter Hospital, Thane

"All modern ventilators today have microprocessors for faster and better use of complex algorithms" - Dr Robert D'Costa Chief of Critical Care Wockhardt Hospital, Mumbai

Technological Advancements

The technology for ventilators has advanced from a mechanical 'bag-type' resuscitator to a fully microprocessor-based ventilator with various ventilatory control and spontaneous modes. Earlier, these modes were restricted to only few modes like volume-controlled mode.

Sensing and monitoring ventilation delivered to patients using sophisticated transducers has made breathing support more comfortable to patients and has aided delivery of ventilation exactly as required by patients. This has reduced the need for sedation and paralysis by medications for ventilator support of patients and has in turn reduced ICU stay and reduced complications related to mechanical ventilation.

"Ventilation can also now be delivered through tight fitting comfortable masks for certain categories of patients like Chronic Obstructive Pulmonary Disease (COPD). This obviates the need for putting in an endotracheal tube in certain types of patients, thus reducing complications related to ventilation. This is an important advance in our ability to treat patients," explains Dr Shivkumar Iyer, Director, ICU, Jehangir Hospital, Pune.

"The latest generation of ventilators has newer modes like Proportional Assist Ventilation (PAV), in which the patient triggers the machine which then determines how much assistance does the patient need as per patient's respiratory requirement and muscular effort," explains Dr Bharesh Dedhia, Chief of Critical Care Services, Jupiter Hospital, Thane. One such latest model that has come is Neural Control of Ventilatory Assist (NAVA) which determines the breathing based on the sensing of neural traffic flowing to the diaphragm. This breakthrough technology by Maquet is based on the principle of picking up signals from the brain that control the patient's breathing, via a catheter. This means that synchronisation between the patient and the ventilator is improved significantly. NAVA allows the patient's own breathing requirements to control the ventilator via the brain's respiratory signals. These are called as Edi signals and are picked up via a catheter in the diaphragm. The electrical activity is then transmitted to the ventilator. "It is very sophisticated and more and more patients can be ventilated comfortably due to enhanced patient ventilator synchrony with lesser complications because of NAVA," says Dr Dedhia.

Another company—Trivitron, in association with Hamilton Medical AG, a Swiss manufacturer of 'intelligent ventilators' recently launched Hamilton G5, world's first 3D ICU ventilator in India. The new Hamilton G5 ICU ventilator is focused on improved user interface and high patient safety. It scores better in comparison to the conventional modes due to its user-friendliness and simple operations. It's ventilation cockpit's lung displays real time tidal volume, lung compliance, resistance and patient activity in synchrony with actual breaths, irrespective of lung mechanics. Suitable for infants, paediatrics and adult patients, it has an integrated autopilot that automatically applies lung protective strategies through intuitive operation and monitoring, thereby improving patient safety and reducing error chances. It works on a new concept of Adaptive Support Ventilation (ASV), which is reportedly more responsive than conventional modes in adapting to the patient's breathing activity. ASV is also popular as it requires fewer user interactions and gives fewer alarms. The automated P/V tool present, helps in finding the best Positive End-Expiratory Pressure (PEEP), based on respiratory mechanics.

Says Dr Kakar, "As one looks back, one wonders how with the old ventilators we could take care of our patients. Today, with the touch screen and a single knob, with all the parameters displayed on the screen, one is knowledgeable about what the machine is doing to the patient and how are the patients faring on the machines." Albeit futuristic, but experts feel that, the pace at which technology is evolving it would not be far away when one would be carrying a ventilator in the pocket and going to work! And when would this happen? "It is difficult to answer that today, but I am sure in the minds of scientists, this idea is on the forefront. Weaning from the ventilator would become easier and a day would come when these ventilators could communicate with the human minds faster," Dr Kakar envisions.

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Maquet Medical India

SERVO-I Controlled ventilation: Pressure Control (PC) Volume Control (VC) Supported ventilation: Pressure Support (PS) / CPAP Combined ventilation: SIMV (VC) + PS SIMV (PC) + PS Optional ventilation modes Controlled ventilation: Pressure Regulated Volume Control (PRVC) Supported Ventilation: Volume Support (VS) Combined ventilation: SIMV (PRVC) + PS (included in the PRVC option) Bi-Vent Non invasive modes: Nasal CPAP Non Invasive Ventilation (NIV) Pressure Support Non Invasive Ventilation (NIV) Pressure Control Optional functions: Automode (Pressure / Volume / PRVC) Nebulizer Open Lung Tool Y sensor measuring CO analyser Alarm output connector for external alarm Menues with only two main levels Maquet Medical India Pvt. Ltd. 102 Pressman House, 70 A Nehru Road, Vile Parle - East, Mumbai 400 099 India Tel: + 91 22 6675 5551 or 2 or 3 Fax: 6702 1114 Mobile: + 91 98196 96221 Toll Free Service Response: 1 800 222377 ( 1-800 ACCESS) Emergency Response: 9821 627838 ( 9821 MAQUET)

L & T Ltd.

EV700 Electronically controlled and pneumatically driven with latex free ascending bellows 6.4" colour touch screen display with navigator wheel Adult and paediatric application Ventilation modes: CMV, PCV and Spontaneous/Manual Optional SIMV mode Fresh gas compensation Driving gas: medical grade air or Oxygen Tidal volume: 40 ml to 1500 ml Frequency: 4 - 60bpm IE Ratio: 2:1 to 1:4 Peep: off, 3 - 20 cmH2O Display for PEEP, Mean Plateau, Expiratory Tidal Volume, Minute Volume, and frequency Optional FiO2 measurement (option for selection between paramagnetic and galvanic oxygen sensor) Inspiratory pressure monitoring Automatic self test and leak test Latex free bellows Auto-clavable canister Alarms for low pressure, high pressure, oxygen failure & low battery Battery backup Supplied with driver gas hose, corrugated tube and power cord Larsen & Toubro Limited Medical Equipments & Systems Marketing Headquarters Powai Campus Mumbai - 400072 Tel: 022-67053204 / 3223 Fax: 022-67051267 Email: ebgmed@LNTEBG.com Website:www.lntmedical .com

Meditronics

ICU Ventilator NEUMOVENT GRAPH For Adult and Pediatric: Volume controlled (VCV), assist/control Pressure controlled (PCV), assist/control Pressure support (PSV) Continuous positive airway pressure (CPAP) SIMV (VCV) + PSV Mandatory minute ventilation (MMV) + PSV Tidal volume assured + PSV APRV (BIPAP) mode Non invasive ventilation For Neonate: Pressure controlled (PCV), assist/control Pressure support (PSV) Continuous positive airway pressure (CPAP) SIMV (PCV) + PSV Time cycled, pressure limited (TCPL), with continuous flow Battery backup: 2 hours Graphic display: With In-built Graphic Display for waveforms and loops Pressure waveforms Volume waveforms Flow waveforms Pressure-volume loops Respiratory Mechanics: Online calculation of following Auto PEEP Dynamic and static compliance. Inspiratory and expiratory resistance. Non-forced vital capacity. Tidal Volume: 10ml to 2500ml Alarm system: alarm for all required parameters with Activated alarms Log book: It presents a list with all the activated alarms (EVENTS)of the last 24hours Meditronics 101, Shiv Ind. Estate,K.B.B Marg, Mumbai Tel: +91-22-23703303 Fax: +91-22-23791272 Email: sales@meditronicsasia.com Website:www.meditronicsasia.com

Healthcare India Pvt.Ltd.

CHRISTINA Type: Neonatal/Pediatric ICU Ventilator Marketed by: Schiller Healthcare India Pvt. Ltd. Features: 10.5 TFT color monitor Effective representation of all relevant respiratory parameters such as tidal volume, minute ventilation, flow, oxygen concentration, temperature, compliance and resistance. Trend Representation Integrated heated humidifier Jet Depression 0 to 6 mbar Modes: Controlled Ventilation CMV / PCV Assisted-Controlled Ventilation, S-PCV Intermittent-Mandatory Ventilation Synchronised-lntermittent-Mandatory Ventilation, S-IMV High-Frequency Oscillatory Ventilation, HFOV (Optional) Spontaneous Ventilation, CPAP with Apnea Monitoring Manual Ventilation with PEEP and Plateau Nasal - CPAP and Insufflation Graphical representation: Graphs: Pressure (P), volume low (V) and Flow (V'), Loops: P'-V, P-V' or V'-V Measuring function for frozen graphs by means of measurement and reference cursor Numerical display of measured points as well as their difference and quotients Schiller Healthcare India Pvt Ltd D C Silk Mills Compound, Kondivita Lane, Andheri (East), Mumbai - 400059 Tel: 022 - 66920520 Fax: 022- 28263525

Draeger Medical

Carina Company Draeger   Model Medical   Parameters: carina   Model: PCV Yes CMV Yes Spontaneous Yes Stroke/   manual mode Yes SIMV mode Yes BIPAP Yes PEEP and CPAP Yes Battery   backup Yes Pressure   loops display Yes Respiration   rate display Yes Tidal Volume Yes Alarm system Yes Locking   mechanism No Touch screen No Log book Yes IE ratio settings Yes Connected to   central monitor Yes Pressure cycles Yes Respiratory   parameters Yes Adult and Neonatal and pediatrics application Only adult Draeger Medical India Pvt Ltd Goldline Business Centre, Next to Chincoli Bunder Fire Station, Link Road, Malad - West, Mumbai - 400 101 INDIA Fax: +91 - 022 28712311 Tel: +91 9867885564 Email:: prathiksha.b@draeger-medical.co.in Web: www.draeger.com