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Tuesday, August 11, 2020

The business of breathing: What does it take to build a ventilator, who can do it?

What does it take to build a ventilator, and who can do it? What hurdles must India overcome to accomplish such a massive scale-up before the pandemic can potentially overwhelm the health system?

Written by Prabha Raghavan | New Delhi | Updated: April 2, 2020 2:52:50 pm
The business of breathing: What does it take to build a ventilator, and who can do it? A respirator system at University Medical Centre Hamburg-Eppendorf. Demand is high worldwide; slowing imports put extra burden on Indian manufacturers. (Reuters Photo)

As India braces for community spread of the novel coronavirus and a spike in hospital admissions, the government is seeking to ramp up its capacity of ventilators. A large number of ventilators may potentially be required soon, and the Railways-owned Integral Coach Factory (ICF) has made an attempt to “reverse engineer” the machines. Private sector carmakers with no experience in this line too, have climbed on to the bandwagon.

What are ventilators, and why are they important in the outbreak?

Ventilators (or respirators) are mechanical devices that help a patient breathe when they are unable to do so on their own. Hospitals have a supply system for gases like oxygen, which are used in ventilators.

“The ventilator takes the compressed gas (oxygen) and mixes it with other gases (because typically what we breathe is 21% oxygen from the atmosphere). It allows you to artificially push in a certain required amount of oxygen into the patient’s lungs and allows them to deflate,” said a specialist who works in the intensive care unit of a large hospital in Mumbai. “With COVID-19, the patient sometimes has interstitial pneumonia.” The virus causes inflammation in the air passages inside the lungs called bronchioles, causing inflammation in this area and in the alveoli, the tiny sacs that the air is delivered to. “Any inflammation means air can’t get in or get out.”

As the space for the exchange of air in the lungs decreases, the patient has to work harder to breathe, which may not be possible indefinitely. “A patient can’t be breathing at rates of 40-45 (breaths) a minute and expect to sustain life. At this point, a ventilator allows you to rest the patient’s lungs by giving them oxygen at higher rates. They allow the patient time to heal on their own by supporting a system that would have otherwise failed,” the specialist said.

Does India have enough ventilators?

India’s state hospitals together have 14,220 ICU ventilators as of now. Additionally, government (and some private) hospitals dedicated for the management of COVID-19 patients have about 6,000 ventilators.

As of Monday, India had 1,251 confirmed cases of the disease, only a small fraction of the global total of 7.22 lakh, but the number of infections will almost inevitably rise faster than at present. According to recent mathematical modelling by scientists including Dr Raman R Gangakhedkar of the Indian Council of Medical Research (ICMR), around half of those infected and in intensive care would require mechanical ventilation. Using this model and other data, think tank Brookings India has estimated that India could, in the worst case, need between 1 lakh and 2.2 lakh ventilators by May 15.

Dr Rajesh Chawla, senior consultant for respiratory medicine and critical care at Delhi’s Apollo Hospital, expressed optimism about availability. “Talking to all our intensivists, as of now, there is no shortage of ventilators because very few patients are requiring them. Most are just on oxygen. This is probably also because other (non-COVID-19) patients have decreased tremendously,” Dr Chawla said. “In a situation like Italy’s (which had nearly 98,000 infections and 11,000 deaths until Monday), any country would have a problem. But as of now, it (the situation in India) seems okay.”

The Apollo Group has around 1,000 ventilators nationwide, most of which are in use.

Also read | IIT-Kanpur to make portable ventilators for coronavirus patients

What does it take to build a ventilator?

Different types of ventilators deliver air in different modes. Ashok Patel, Chief Executive Officer of AB Industries, which makes Max ventilators, said the components would vary depending on the type.

“To make a ventilator, one has to have core knowledge of the clinical aspects of the ventilator and the requirements of the doctors using them. These requirements have to then be converted into engineering components that can achieve the required outputs,” he said. “Ventilators are a combination of technologies — not only software and electronics, but also pneumatics, as they handle gases. They are also required to adhere to safety standards, and include a mechanism to minimise the risk to the patient in the event the device malfunctions.”

The business of breathing: What does it take to build a ventilator, and who can do it? An employee works on a respirator system as the spread of the coronavirus disease (COVID-19) continues, in Buenos Aires, Argentina March 27, 2020. (Reuters Photo: Agustin Marcarian)

Based on the mechanism used to deliver the air (flow-delivery mechanism), there are three major classifications for ventilators, Patel said: bellow-driven or piston ventilators, turbine ventilators, and external compressed air driven ventilators.

A pneumatic external compressed air-driven ventilator in an ICU setting would be ideal for COVID-19 patients. Turbine ventilators, although less effective, are the next best option — they have fewer components, and it would probably be easier to scale them up, Patel said. “A COVID-19 patient’s lungs are relatively stiff and the air passages are swollen. Low-flow gas will not help. You would need higher pressure and high flow,” he said. The idea is to ensure timely treatment to ensure the lung cells are not permanently damaged.

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And what will it take to scale up India’s ventilator capacity?

According to industry sources, only about 10% of ventilators in use in India are manufactured in the country. The pandemic has affected global supply chains, even as demand has surged everywhere. With imports slowing, an increased burden now lies on Indian manufacturers, who have limited capacity to scale up production.

Data from Indian manufacturers project their total monthly capacity to touch around 6,000 ventilators in a month from now. Firms like AB Industries say they can scale up monthly production to around 350-400 in the next two months. Bengaluru-based Skanray Technologies, which has claimed it intends to manufacture 100,000 ventilators, currently has the capacity to build only 5,000 in one batch. The rest of its production would have to come through collaborations.

Read | Not enough ventilators, so PSUs and corporates start ramping up production

There is also the question of raw material. At least 40% of a ventilator’s physical components are imported from countries like the US, China, France, and Germany, according to Patel of AB Industries. These include several crucial components like sensors and displays. (See box)

Skanray Managing Director Vishwaprasad Alva said: “In a usual situation, the government has an epidemic and disaster management cell, which is supposed to store ventilators in ‘live’ mode, running and monitored. Our government has not done this, in spite of so much communication and meetings with them. We have been talking to them since 2012-13. The previous government also did not do this.”

The business of breathing: What does it take to build a ventilator, and who can do it? Doctors receive instructions for a respirator system at the intensive care unit of the University Medical Center Hamburg-Eppendorf in Hamburg, Germany, March 25, 2020, as the spread of the coronavirus disease (COVID-19) continues. (Source: Axel Heimken/Pool via Reuters)

So what is being done to address the situation now?

Bharat Electronics Ltd (BEL), a PSU under the Ministry of Defence, is in the process of manufacturing 30,000 ventilators. Health Ministry PSU HLL Lifecare Ltd has floated a tender for 20,000. ICF Chennai, maker of Train 18, is attempting to manufacture ventilators.

In the private sector, Skanray is working with BEL and Mahindra & Mahindra to simplify the design of ventilators, and could start a collaboration with Tata, too. Simplifying the design would help overcome hurdles like sourcing imported components. Maruti Suzuki India has announced an arrangement with Noida-based AgVa Healthcare to “rapidly” scale up production to 10,000 per month.

Experiments are also on to find alternatives to imported electronic components such as sensors and displays. “We can do away with the display. We can go to a total, simple user interface without buttons, which can be programmed without display,” Skanray’s Alva said. He said Tata and M&M, which design their products from scratch, could look for certain automotive components that can be used for medical purposes in an emergency like this.

Skanray and its collaborators are looking at a timeline of 5-6 weeks to push out these ventilators. “With the measures that the government is taking… it might flatten the curve. You could give yourself time to be ready,” he said.

Here’s a quick Coronavirus guide from Express Explained to keep you updated: What can cause a COVID-19 patient to relapse after recovery? | COVID-19 lockdown has cleaned up the air, but this may not be good news. Here’s why | Can alternative medicine work against the coronavirus? | A five-minute test for COVID-19 has been readied, India may get it too | How India is building up defence during lockdown | Why only a fraction of those with coronavirus suffer acutely | How do healthcare workers protect themselves from getting infected? | What does it take to set up isolation wards?

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