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Ventilator- Breathing Machine

What is a ventilator?

A ventilator is a medical device that helps in carrying out breathing in patients who are unable to breathe on their own.

A ventilator does this by pumping in oxygen into the lungs and taking out carbon dioxide from them.

Since it provides passive breathing to the patient, it is, therefore, also called a breathing machine.

Patients who need a ventilator are usually seriously ill and require a stay in the intensive care unit (ICU). Patients who need a ventilator for the long term may be kept in award or at home; however, under good medical supervision.

The ventilator may deliver oxygen using:

• Face mask or helmet(Non-Invasive method)

• Breathing tube (Endotracheal tube- Invasive method)

What are the parts of a ventilator?

A ventilator consists mainly of three parts, which are of utmost importance for its’ functioning.

1. Power source: this supplies energy to the ventilator for functioning. It consists of a battery and an external source.

2. Conversion unit: this unit converts input to output in the form of oxygenated air to be supplied to the patient.

3. Monitoring unit: this unit ensures and regulates the amount of air mixture being supplied, monitors the patients’ condition, and other sizeable factors like the pressure, timing, or flow.

Apart from these, there are a few other important parts without which the ventilator wouldn’t be able to cater to its’ purpose.

• Tubes: a network of tubes which is the delivery method to supply oxygen-air mixture and to remove the excess carbon dioxide.

• Humidifier: adds heat and moisture to the air before it reaches the patient.

• Blender: A blender to supply a precise mixture of gas to the patient.

• Filters: A set of filters to clean out the inflow and outflow of air supply. The filter prevents dust and other small particles from entering the airway or exiting into the atmosphere.

What is the cost of a ventilator and its’ associated services?

Premium or high-acuity ventilators, most commonly found in hospital ICUs,can currently cost between Rs. 5 lakhs – Rs.7 lakhs if manufactured in India. The foreign manufactured ventilators can cost anywhere, starting from Rs. 11 lakhs to Rs. 40 lakhs, depending upon the quality and import costs. Factors that can contribute to this price range includes user configurability options and built-in safety features.

Pricing of the ventilator use varies across the country depending on whether the service provider is a private or government hospital. Prices can average between Rs. 2500– Rs. 5000 for a day’s service. Typically, government-run hospitals charge less and may have a lower price. Private hospitals usually charge higher amounts and could be upwards of Rs. 10000 a day.

Who needs a ventilator?

You need a ventilator when you are unable to breathe adequately to maintain a sufficient level of oxygen in the blood. The lack of oxygen leads to damage to the cells and organs, leading to death. Thus, ventilator forms a life support system when you are critically ill.

The ventilator may be required in a variety of conditions, which may affect your ability to inhale air inside or inability to absorb oxygen from the lungs.

Thus a ventilator is required in the following settings:

Surgery (during surgery and recovery):

A ventilator carries out breathing for you during a major surgery. Usually, major operations are done under general anesthesia, which causes impairment in the ability to breathe.

Moreover, even after surgery, you may be kept under a ventilator for some time. It helps you overcome the effect of anesthesia and surgery.

 

Lung conditions:

The conditions that affect the airways or lung tissues, causing the inability to exchange air properly. These conditions are common indications for the use of the ventilator:

Pneumonia: here, the air sacs in the lungs get filled with fluid or pus instead of oxygen, which doesn’t allow the air exchange. It usually occurs due to infections such as bacteria, viruses, fungus, etc.

Covid-19 infection also causes pneumonia, which affects your lung’s ability to absorb oxygen.

Acute Respiratory Distress Syndrome: in ARDS, the air sacs in your lungs get damaged, which causes seepage of the fluid from the surrounding blood vessels. This leads to the accumulation of fluid within the air sacs affecting the air exchange.

ARDS can occur due to multiple causes such as infection- bacteria, viruses (SARS-COV2), sepsis, surgeries (heart or lung), injury, etc.

Asthma: in asthma, the small tube-like airways become narrow, reducing the amount of air that can be inhaled inside.

COPD: this affects the old individuals. The smaller airways and lungs get affected, leading to impaired air exchange.

Respiratory distress syndrome in newborns: this condition affects newborn typically premature babies (born before 34 weeks of pregnancy). These babies lack a special liquid in their lungs called surfactant, which resists the expansion of lungs on inhalation.

 

Brain and nervous system conditions:

These conditions affect the areas of the brain or nerves that regulate breathing.

• Head injury

• Stroke

• Spinal cord injury

• Multiple sclerosis, myasthenia gravis, coma, etc.

 

Sepsis

In sepsis, the infection spreads in the bloodstream and causes overt immune reaction. This event leads to the dysfunction of multiple organs and their damage.

 

Sudden cardiac arrest

Sudden inactivity of the heart results in loss of circulation of blood through the lungs.

 

Drug overdose and build of toxins

Accumulation of drugs and toxins affects your ability to breathe and exchange air.

Central nervous system problems which cause inefficiency of breathing (E.g., Cerebrovascular Accident).

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Why Covid-19 patients need ventilator support for breathing?

Covid-19 is caused by a new virus from the coronavirus family called the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS CoV2). Ventilators are essential for critically ill Covid-19 patients who are unable to maintain enough oxygen levels in their blood.

The virus in the respiratory tract damages the hair-like projections called cilia. The function of the cilia is to expel out fluid from the lungs. Their damage leads to fluid accumulation in the lungs (within the air sacs),which restricts the air exchange. The infection also causes oozing of fluid into the air-filled sacs, further hampering the oxygen supply to the bloodstream.

This accumulation of fluid, in turn, causes a fall in oxygen and a rise in CO2 levels in the blood.

A ventilator helps by pushing in oxygen into the lungs and taking out CO2, allowing air exchange by artificial means. This provides the life support and reduces the load on the lungs while it fights the infection and tries to recover from it.

The ventilator consists of a humidifier, which adds heat and moisture to the air-oxygen mixture to match the body temperature.

Medicines are given to relax the respiratory muscles. The ventilator is usually fitted by means of a facemask, nasal masks, or mouthpieces.

 

The need of the hour

According to the WHO, about 70-80% of people with Covid-19 recover without needing intense treatment. The remaining 20-30% of people may become seriously ill and develop difficulty in breathing. This mostly includes the elderly and people with underlying problems like high blood pressure, heart and lung problems or diabetes. Due to complications, these people tend to need a ventilator to reduce stress on their lungs.

Recent reports suggest that there are about 50,000 ventilators that are available across the country in various medical facilities. With a population of more than 1.3 billion, India,like other countries, faces a dire shortage of ventilators.It is estimated that more than 100,000 to 200,000 units are required to manage the epidemic.

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How the ventilator functions?

Once the patient is prepared, and the tube is put inside the patients’windpipe, the ventilator is turned on.

• Air mixing: The air is mixed with a regulated amount of oxygen through a gas mixer and monitored using the equipment. The data can be pre-set into the monitoring device.

• Heating and humidification: The air is heated, and moisture is added through a humidifier before passing it through the windpipe.

• Volume, pressure,and breathe regulation: The amount of air pushed into the lungs,and its pressure is regulated with the help of the monitoring equipment. The ventilator can be set to a number of breaths per minute. Alternatively, it can be set on a mode where it delivers air as and when required.

• Exhalation of air: The exhaled gas (carbon dioxide) is taken out through a different tube outside the patients’ mouth and is controlled by a valve.

The ventilator helps to hold the lungs open so that the air sacs do not collapse. This is called positive end-expiratory pressure (PEEP).

How is the ventilator put?

Before putting someone on a ventilator, the doctor ensures the following things:

• Intravenous line: set up an IV line to instill medicines and fluid in your body.

• Medicines: drugs that help to induce sleep and allows them to manage pain.

• Oxygen reserve: some amount of air is held to carry out the procedure safely. It can be done by asking you to take a few deep breaths or giving oxygen through a mask.

There are two main ways to deliver oxygen from the ventilator into your lungs:

 

Non-invasive method

Here the oxygen is passed into the lungs without inserting anything into the respiratory tract. This method uses a face mask or helmet to deliver oxygen. The technique is suitable for people who are relatively less sick and are able to carry out breathing to a certain extent. It is also used for the weaning of the ventilator- where it helps you to adapt to breath on your own after the removal of the breathing tube (endotracheal tube).

 

Invasive method

This technique delivers the oxygen by using a breathing tube (endotracheal) that fits into your throat or windpipe. This is used when you are severely sick and have very low oxygen levels. The method ensures direct passage of oxygen into the lungs maintaining a better flow of air.

The breathing tube is passed through your mouth across the vocal cords to fit into the windpipe. This is done under medicines that induce sleep and resists pain.

If the ventilator is put for a longer duration, then the breathing tube is passed directly through your neck. This involves making a cut in your neck and fixing a special device called a tracheostomy tube. The breathing tube is then attached to this tube.

In both the techniques, the breathing tube restricts you from talking till the time it is kept inserted.

 

Non-invasive method advantages Invasive method advantages
• Non-invasive and less discomforting

• Allows you to talk

• Allows you to swallow or cough

• Needs lesser medicines

• Less chances of fluid tracking into the lungs causing aspiration pneumonia

• Allows better delivery of oxygen to the lungs

• Maintains good flow of oxygen and the pressure

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What to expect while being on a ventilator?

Being on a ventilator can be a vivid and discomforting experience. Being on a ventilator, you tend to experience issues with the following things:

Discomfort: The ventilator itself does not cause any pain;however, it can be discomforting due to the presence of a tube in the mouth.

Speech: Moreover, the person is not able to talk as the tube lies between the vocal cords within the windpipe.

Feed: Eating by mouth is also not possible with the tube already occupying the mouth. You usually receive nutrients through the vein (intravenous injection). Sometimes, you are fed with a nasal tube that goes into the stomach via the food pipe.

Breath incoordination: Sometimes,patients try to breathe out when the ventilator is trying to push air in. This working against the ventilator makes it harder for the ventilator to help. You may receive medicines (sedatives or pain controllers) to manage this. Sometimes, medications that temporarily prevent muscle movement (neuromuscular blocking agents) are given to allow you to breathe with the ventilator.

These medicines are typically given when you have a very severe lung injury.Before the ventilator is removed, the medication,however, is stopped.

 

Day To Day Care

When on a ventilator, you will be monitored closely to check for improvement in the condition or development of any complications.
The day to day care would involve the followings:

Blood tests: the tests help in monitoring the levels of oxygen, carbon dioxide, and other substances in your blood. Blood may be taken multiple times a day to check for response to the treatment.

Chest X-ray: the test checks for the development of any abnormality such as pneumonia, fluid in the chest or collapse of the lungs.

Suctioning: this is done to several times a day to prevent spillage of fluid into the lungs preventing pneumonia.

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Are there any complications of ventilators?

Though a ventilator is a life-saving device, it can also predispose you to its own complication. These complications can sometimes be serious and life-threatening.

Following are the complications of the ventilator:

 

Lung Infection

It is one of the commonest and serious complications. The breathing tube that goes through your mouth into the windpipe (trachea) can act as a source of microbes. This causes infection in the lungs leading to pneumonia called ventilator-associated pneumonia (VAP).

This type of pneumonia is often serious and is difficult to treat. It can further degrade your condition and make it difficult to treat. The infection is treated with antibiotics. Sometimes, the infection is caused by bacteria that are resistant to multiple antibiotics. This is even more difficult to treat and needs specific antibiotics.

 

Other lung issues

• Pneumothorax: sometimes, the air pressure in the lung ruptures it and leaks into a space between the lungs and the chest wall. The air collected in this space, in turn, causes compression of the adjacent lung, restricting its expansion on inhalation.

• Lung collapse: it is a common issue where the air spaces within the lungs fail to expand fully and becomes collapsed. This restricts the air exchange in the involved part of the lung.

• Lung injury: passing too much oxygen or air with high pressure can cause damage to the lung.

 

Sinus infection

The sinuses present in your face can also get infected while you are ventilator. Typically, the infection is caused by bacteria, but in case you are immunocompromised (diabetes), a fungus can cause a more serious infection.

 

Vocal cord damage

Passing a breathing tube across your vocal cords can cause its damage. If you face any difficulty in breathing or speaking after removal of the tube, you should contact your doctor.

 

Respiratory muscle weakness

Non-use of the respiratory muscles such as diaphragm while on a ventilator makes them weak. This can make your muscles inefficient that may need sometime before adapting to

 

Blood clots in legs and lungs

Being bedridden for a long time while on a ventilator causes decreased flow in the veins of your leg. This tends to form clots in your legs, leading to swelling and pain. Sometimes the clot may dislodge from legs towards the heart and blocks the arteries to the lungs. This causes sudden onset of breathing difficulty and is called pulmonary embolism.

 

Bedsores

Similarly, being on the bed for a long period tends to damage your skin at the areas of pressure points, causing sores and ulcers. Once formed, they can be difficult to treat, especially if you have diabetes.

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How is the patient taken off the ventilator?

Before removing the ventilator completely, you usually undergo a process called “weaning”. The process allows you to adjust back to normal breathing by gradually reducing the ventilator support.

You are usually weaned off once you recover enough from the problem.

• Frist Weaning trial: You are given an opportunity to breathe on your own while staying connected to the ventilator. Mostly this has a positive result, and you may start breathing independently on the first trial. Once successful breathing is restored, the ventilator is stopped.

• Repeated weaning trials: If you can’t breathe on your own during the short trial, weaning is repeated later. If regular attempts to wean over a long period doesn’t work, you may need to use the ventilator long term.

• Successful weaning: Following a successful weaning,the breathing tube is removed. You may cough during the removal, and your voice may become hoarse for a short time.

If the long term ventilator use doesn’t help, you may be put on another special device called extracorporeal membrane oxygenation (ECMO). This device functions by adding oxygen and removing carbon dioxide from the blood while it circulates through the machine.

You may be kept on ECMO for multiple days to weeks to allow your body to recover.

What are the safety features available in ventilators?

A failure in the functioning of the equipment may lead to death. As a result, the mechanical ventilators are also referred to as life-critical systems. A reliable power supply is the bare minimum of needs to ensure dependency on a ventilator. A careful design is hence needed to ensure a malfunction won’t endanger the life of a patient.

• In the absence of power, the ventilator is equipped with a hand driving mechanism to provide power for the safe functioning of the respirator.

• An anti-suffocation valve is another safety feature that opens up to the atmosphere to secure the patient’s breath when there is a lack of power.

• Ventilators are also manufactured with alarms or sounds to notify the health personnel in case of an emergency or malfunction.

• A few models of ventilators come equipped with other fail-safe mechanisms, including compressed-gas tanks, air compressors, or backup batteries, to resume normal functioning in case of power failure.

• Most of the batteries on a ventilator have a life of about 3 years, after which they need to be replaced.

• Ventilators may last for about a period of 10 years, depending on the amount of usage and maintenance.

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