Apollo Hospitals, India's largest healthcare provider, said it had 1,000 ventilators across its network hospitals. The hospital chain - without specifying the number - said it had dedicated a portion of those ventilators for treating COVID-19 patients.
Hospitals are now earmarking isolation wards to treat COVID-19 patients so that other patients and staff are protected from the novel coronavirus infection.
A ventilator is a mechanical breathing device that can blow air and oxygen into the lungs. Ventilators are critical for the care of people with lung failure, which can be one of the complications suffered by patients with severe COVID-19.
While on paper 1,000 ventilators sounds a big number, what will be available for COVID-19 patients in reality is much lower as hospitals have to reserve ventilators to treat non-COVID-19 cases such as heart attacks, strokes and other emergency cases.
There is a huge cost element, too, in using ventilators. A ventilator costs anywhere between Rs 5-15 lakh.
"Generally, we keep three ventilators for 10 beds ICU. These machines are expensive, so hospitals typically bill them as part of ICU charges, some bill them separately as well," said Dr. Rajendra Patankar, Chief Executive Officer of Pune-based Jupiter Hospital.
The average ICU charges per day in Mumbai is Rs 4,000. In some high-end tertiary hospitals, the charges will go upwards of Rs 20,000 per day. These are conservative estimates taken from publicly available information. More than two-thirds of the ICU billing constitutes ventilator charges.
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As per a Brookings report, the country might need anywhere between 110,000 - 220,000 ventilators by May 15 in the worst-case scenario. The number of ventilators today available in the country is a maximum of 57,000. Most of those available ventilators cannot be put to use.
But, experts say we may struggle if COVID-19 cases surge in days ahead as nearly 3 percent of COVID-19 patients would require ventilators. Experts across the spectrum ranging from doctors to engineers and entrepreneurs are trying to solve the ventilator puzzle.
India has reported a total of 1,251 positive coronavirus cases as of March 31 morning.
Addressing ventilator shortage
The government has declared essential technical features for COVID-19 ventilators.
As per the government specification, a ventilator should be turbine, compressor based because the installation sites might not have central oxygen lines. Among other features, the machine should have invasive, non-invasive and CPAP features to make them versatile. They also need to have 200-600 ML tidal volume, Lung Mechanics Display and continuous working capability for 4-5 days.
But, to get ventilators of those specifications will take time. Moneycontrol earlier reported that companies were running low on inventories. Getting components from China has become difficult due to the disruption of the supply chain. Sources have told Moneycontrol that China, too, has started clamping down on exports of ventilators and related components to shore up its own requirement.
“To tackle the shortage of ventilators India should go in for two-three models, one an low-cost respirator model for epidemic and a high-end technology ICU model," said Rajiv Nath, Forum Coordinator - Association of Indian Medical Device Industry (AiMed), the domestic medical devices trade lobby.
AiMeD said it contacted seven of its ten major manufacturers, which had confirmed that the current production capacity of ventilators was 5,500-5,750 pieces per month. This is where defense labs, big automotive and capital goods companies are coming to rescue.
Maruti Suzuki India, Mahindra & Mahindra, Bharat Forge, Tata Motors, Hyundai and public sector BHEL, BEL and DRDO are coming up offering their expertise to rapidly scale up production of ventilators.
For instance - SkanRay, Mysuru-based ventilator manufacturer has created a consortium with BEL, BHEL and Mahindra to ramp up production from standard 2,000 units per month to 30,000 units per month by May.
Similarly, Delhi-NCR-based Agva has tied up with Maruti to scale up production from 400 units per month to 10,000 pcs per month by May. Others are similarly gearing up to address the challenge.
"The aim is to produce 50,000 ventilators per month by May," Nath said.
SkanRay, the leading ventilator manufacturer, has created a consortium with BEL, BHEL and Mahindra to ramp up production from standard 2,000 pieces per month to currently 5,000 pieces per month and 30,000 pieces per month by May. Similarly, Agva has tied up with Maruti to scale up production from 400 pieces per month to 4,000 pieces per month in April to 10,000 pieces per month by May. Others are similarly gearing up to address the challenge.
No frill 'Ambu Bag'
While the conventional ventilators are expensive, hard to produce and not portable, experts say we may have to find other ways to tide over the ventilator shortage if we begin to see a surge of cases.
One of the solutions put forward was the bag-valve mask, often called by the proprietary name of ‘Ambu Bag,’ used for resuscitation in emergency situations.
"The ‘bag valve mask’ is currently hand-powered and, therefore, not suitable for continuous use as a ventilator. It would be easy to design a similar device powered by an electrical source, which could be a car battery, apart from the conventional power supply. It could be made portable, and therefore adopted in villages and other areas without a power supply and be inexpensive enough to manufacture in bulk," said Prof BS Murty, Director - IIT Hyderabad and Prof. V. Eswaran of the Department of Mechanical and Aerospace Engineering, IIT Hyderabad.
Mahindra & Mahindra is working on an automated version of the Bag Valve Mask ventilator (commonly known as Ambu bag). Once proven, Mahindra says this design will be made available to all for manufacturing. Bag Valve Mask can be used and thrown away, removing the possibility of cross-contamination.
Anand Mahindra, Chairman of Mahindra Group announced it will cost below Rs 7,500.
CPAP - an interim solution
Another interim solution that companies have started working on is converting Continuous Positive Airway Pressure or CPAP machines as breath support devices for COVID-19 patients.
CPAP machines help people with sleep apnea breathe more easily. It is also widely used in premature babies whose lungs are not fully developed and require respiratory support. A CPAP machine increases the air pressure in a person's throat to prevent airway from collapsing when inhaled.
Bengaluru-based InnAccel is working to develop a CPAP that can be used for COVID-19 patients needing breathing support.
InnAccel develops and markets a portable CPAP machine called 'Saans' – that runs on a battery where there is no power source. It can also be hand-pumped if the battery fails.
"A bag valve mask is the simplest level of ventilation. We should use it but I don't think that is anyway adequate for COVID-19 patients. But, there are intermediate modes between absolutely high-end ventilators and a rudimentary bag in mask. CPAP is one mode," said Siraj Dhanani, co-founder and CEO of InnAccel.
Dhanani said they were working on a prototype based on their CPAP platform to develop devices for COVID-19 patients.
The government specified ventilators should have basic modes such as pressure control, volume control and pressure support ventilation, along with CPAP.
Doctors and engineers are also scrambling to figure out how to modify their ventilators to serve a large number of patients with limited resources.
A team at Delhi-NCR based hospital chain Max Healthcare was able to split their ventilator, which can be used for upto four patients if necessary.
The critical care experts at Max Healthcare extensively tested the device and determined that it worked very well on all functional and patient safety parameters. The device is to be used only in case of dire shortage of ventilators and when we have a large number of patients needing ventilator support. It is not simple as it sounds though.
"My team and I then designed a simple but ingenious device, which can be safely attached to the ventilators, splitting the airflow into four distinct streams for 4 patients. We even produced this device in-house using the 3D printing facilities at Max Healthcare,” said Yudhvir Singh, Head - BioMedical Engineering, Max Healthcare.
Currently, Max Healthcare has 254 adult ventilators across its network. It is not Max alone; other hospitals have also started work on splitting ventilators.Follow our full coverage of the coronavirus pandemic here.