Running head: LOW COST POSITIVE PRESSURE MECHANICAL VENTILATION 1

Case Study

Challenges of Adopting Low Cost

Positive Pressure Mechanical Ventilation

Sachit D. Wijesinghe

I am deeply indebted to

Dr. C.A.Gihan Senarath Piyasiri

[MBBS, MD (ANAESTHESIOLGY), FRCA]

&

Dr. Harendra Cooray

[MBBS, DCCM, MD (EMERGENCY MEDICINE)]

(Emergency Physician ETU Neurotrauma Centre NHSL)

For their invaluable advice, insight, and patience

throughout the duration of this project.

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LOW COST POSITIVE PRESSURE VENTILLATION 2

“A ventilator in the hands of a healthcare worker who understands the physiological needs of

ventilation is like a scalpel in the hands of an experienced surgeon. The effective utilization

of the tool is merely based on the skills and knowledge of the individual using it.”

~ Sachit Dayan Wijesinghe

A testament to the healthcare workers on the front line of COVID – 19.

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LOW COST POSITIVE PRESSURE MECHANICALVENTILATION 3

I. Abstract

A rudimentary, low-cost, positive pressure, pulmonary mechanical ventilator with

minimal automation may adversely affect the prognosis and medical outcome while possibly

giving rise to complications that increase morbidity and mortality in patients of respiratory

diseases; while complicating the process of weaning (i.e. the gradual withdrawal of

ventilatory support).

II. The need for low cost mechanical ventilation

Respiratory diseases are becoming more common in developing countries due to the

rise in tobacco smoking (Nadia Aı¨t-Khaled, 2001) and air pollution (Chan-Yeung M1,

2004). These respiratory diseases such as Adult Respiratory Distress Syndrome (ARDS)

require mechanical ventilation to aid the movement of air into and out of the lungs (Patel,

2020).

However, general mechanical ventilators which are used in hospital ICUs are too

expensive for use in resource-poor countries as they are highly sophisticated and have costly

service contracts for long term use. For example, The Central African Republic has 3

mechanical ventilators for a population of over 4.7 million and ten countries in Africa have

no ventilators. (Davidson, 2020). Due to these discrepancies in the quality and access of

healthcare; “a young adult with a lower respiratory tract infection is still over six times more

likely to die in a low-income country than in a high-income country (Murray, 2017)”.

Even if major cities may have adequate ICU ventilators, hospitals in rural areas may

lack them. These areas have a higher incident rate of organophosphate poisoning (i.e.

poisoning due to a chemical compound used in commercial insecticide), the treatment for

which involves mechanical ventilation (Katz, 2018). In Sri Lanka, this would require

relocating the patient to a base hospital that has mechanical ventilators. The provision of a

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LOW COST POSITIVE PRESSURE VENTILLATION 4

low-cost ventilator at a rural area hospital could facilitate the treatment of patients with

organophosphate poisoning in situ.

There is also a need to scale up production to meet demand during a pandemic such as

the Severe Acute Respiratory Syndrome (SARS) outbreak of 2003 (Ghee-Chee Phua, 2008).

This demand cannot be met due to the sophistication of ‘hospital grade’ mechanical

ventilation. At the time of writing, Medtronic increased their ventilator production rate to 500

ventilators per week to meet ventilator demand for the Sars-CoV-2 Virus (Verdict Medical

Devices, 2020). A minor increase that is simply not enough to meet the surge in demand for

ventilators during a global pandemic. Global distribution systems could also be affected by

pandemics and geo-politics (e.g. foreign aid, governments trying to secure a lead in their

healthcare systems by holding back limited stocks for use in their own countries).

Therefore, there is a need for inexpensive ventilators that can be manufactured at

scale by sourcing existing parts or material available locally. (Massachusetts Institute of

Technology, Department of Mechanical Engineering, 2010). It is due to the above reasons

that low-cost ventilators are required.

III. Significance of the problem

a. Advantages

Low cost mechanical ventilators commonly deliver breaths by

“compressing a conventional bag-valve mask (BVM) with a pivoting cam

arm, eliminating the need for human operator for the BVM (Massachusetts

Institute of Technology, Department of Mechanical Engineering, 2010).” The

use of a BVM has several benefits.

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i. BVMs are inexpensive and are frequently used in hospitals and

ambulances (Massachusetts Institute of Technology, Department of

Mechanical Engineering, 2010).

ii. These BVMs can be used on patients that need invasive or non-

invasive mechanical ventilation (Massachusetts Institute of

Technology, Department of Mechanical Engineering, 2010).

iii. A closed system BVM that utilizes a duck bill valve along with a

separate expiratory disc valve, can provide a high concentration of

oxygen (i.e. FiO2) (Andres L. Mora Carpio, 2020) to the patient,

provided that the hospital oxygen gas flow supply is greater than the

patient minute ventilation (Kovacs, 2015), calculated as respiratory

rate times tidal volume (Andres L. Mora Carpio, 2020).

iv. Open lung ventilation can be obtained by using a Positive End

Expiratory Pressure (PEEP) valve, that is an adjustable pressure valve

placed over the expiration port to incorporate PEEP functionality

(Nickson, 2019). The PEEP functionality increases the surface area for

gas exchange by reopening and stabilizing collapsed or unstable

alveoli (Jackson, What is positive end-expiratory pressure, 2019).

b. Disadvantages

Utilizing BVMs in low cost ventilators increase the risk of Ventilator

Induced Lung Injury (FF, L, PRM, & P, 2018).

i. Improper mechanical ventilation can cause extra alveolar air to be

present in locations where it is not present under normal circumstances

(Diaz & Heller., 2019). This is known as pulmonary barotrauma,

which can give rise to a host of additional complications. Pulmonary

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Barotrauma can be due to elevated plateau pressure (pressure on the

alveoli) caused by breath stacking (also called auto-peep), a result of

ventilator asynchrony. The elevated plateau pressure (pressure on the

alveoli) can cause the alveoli to collapse.

ii. PEEP should be carefully used as an elevated PEEP leads to

overdistention of healthy alveoli (i.e. volutrauma) (Jackson, What is

volutrauma in mechanical ventilation?, 2019).

iii. This overdistention of alveoli can trigger an inflammatory reaction (i.e.

biotrauma).

iv. The inflammatory reaction needs to be managed to prevent the onset of

a cytokine storm, which is an overreaction of the body’s immune

system which can cause programmed cell death (i.e. apoptosis) in

organs. (George, n.d.).

v. Current low-cost ventilators make it hard to manage PEEP and other

ventilator settings due to the lack of diagnostic data required to make

these precise adjustments. For example, PEEP levels should be synced

with the tidal volume, peak inspiratory and plateau pressure while

monitoring the patient’s hemodynamics (i.e. blood circulation).

vi. If the PEEP level is not adequate for open lung ventilation, the sheer

stress induced by repetitive alveolar collapse and re-expansion of a

collapsed lung may cause damage to alveoli, known as atelectotrauma

(Attar & Donn, 2002).

vii. Low cost mechanical ventilators do not consider the need for heating

and humidification of inspiratory air for intubated patients. Lack of

warm humid inspiratory air causes moisture loss in the trachea and

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bronchi, this reduces lung compliance and lung surfactant (Hess &

Kacmarek).

IV. Conclusion

In emergency situations where there is an absence of general mechanical

ventilators, patients that have a depressed state of respiration and require minimal

breathing assistance or patients that are fully sedated after endotracheal intubation can

be assisted by employing low cost mechanical ventilators.

However, Patients who are being weaned off mechanical ventilation or

patients that require a higher quality of mechanical ventilation due to adversely

affected respiratory physiology will require a more advanced hospital grade ventilator

that allows tighter control of ventilator settings.

Unless ventilator induced lung injury can be reduced, the use of low-cost

mechanical ventilators is not feasible as an alternative to general mechanical

ventilators. While mechanical ventilation plays a pivotal role in the fight of

respiratory diseases, they are still an intensive care therapy that requires expertise,

training, and highly skilled labour to succeed.

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