key: cord-0708304-71kbdfdr authors: Iyengar, Karthikeyan; Bahl, Shashi; Raju Vaishya,; Vaish, Abhishek title: Challenges and solutions in meeting up the urgent requirement of ventilators for COVID-19 patients date: 2020-05-05 journal: Diabetes Metab Syndr DOI: 10.1016/j.dsx.2020.04.048 sha: 50af6c83496a18db5e332a7b4495b61ba88298b0 doc_id: 708304 cord_uid: 71kbdfdr Abstract Background Severely affected patients in the COVID-19 pandemic need Ventilators, we chart the challenges faced by the health care systems in procuring these machines and the role of 3-D printing technology in building ventilators. Aims We tried to find the current role, availability and need of ventilators in the COVID-19 pandemic and the role of applied innovative technologies is assessed. Methods We have done a comprehensive review of the literature using suitable keywords on the search engines of PubMed, SCOPUS, Google Scholar and Research Gate in the second week of April 2020. Results We found in our review that there is an acute shortage of the ventilators and the manpower to operate these sophisticated machines. There is significant deficiency in the production and supply chain of the ventilators. Many of the seriously ill patients who require hospitalization may need ventilator support. Non-invasive ventilation is not recommended in these patients. Conclusion As the respiratory illness due to COVID-19 pandemic spreads worldwide, health care systems are facing the tough challenges of acquiring ventilators to support patients. All steps involved in the supply chain management of ventilators are being escalated to produce more ventilators for the coronavirus frontline. Innovative applications of Additive medicine like 3-D printer technology may play key role in delivering sufficient ventilators. Mr Severely affected patients in the COVID-19 pandemic need Ventilators, we chart the challenges faced by the health care systems in procuring these machines and the role of 3-D printing technology in building ventilators. We tried to find the current role, availability and need of ventilators in the COVID-19 pandemic and the role of applied innovative technologies is assessed. We have done a comprehensive review of the literature using suitable keywords on the search engines of PubMed, SCOPUS, Google Scholar and Research Gate in the second week of April 2020. We found in our review that there is an acute shortage of the ventilators and the manpower to operate these sophisticated machines. There is significant deficiency in the production and supply chain of the ventilators. Many of the seriously ill patients who require hospitalization may need ventilator support. Non-invasive ventilation is not recommended in these patients. As the respiratory illness due to COVID-19 pandemic spreads worldwide, health care systems are facing the tough challenges of acquiring ventilators to support patients. All steps involved in the supply chain management of ventilators are being escalated to produce more ventilators for the coronavirus frontline. Innovative applications of Additive medicine like 3-D printer technology may play key role in delivering sufficient ventilators. Keywords: COVID-19; Coronavirus; Pandemic; 3-D printing; Ventilators. COVID-19 pandemic is an infectious disease which is caused by novel coronavirus. It is a highly contagious disease which begun in Wuhan in China at the end of December 2019 [1] and now has spread across the globe to around 200 countries, in a short period of three months and has affected more than 2.1 million individuals and has caused death in more than 145 thousand patients [2] . It can present as a mild infection (such as common cold) to a serious respiratory illness (such as pneumonia). The droplets of saliva and the discharge from the nose of the infected person while sneezing are the main sources for the spreading of coronavirus. There is no particular treatment or vaccine available for this disease at present. The seriously ill patients suffering from COVID-19 need respiratory support, as their lungs get damaged by the coronavirus leading to breathing difficulties. Ventilators are needed in such cases for supplying adequate oxygen (O 2 ) into their lungs and also removing the carbon dioxide (CO 2 ), as a lifesaving supportive measure. The ventilators are one of the most vital medical devices needed to keep these critically ill COVID-19 patients alive. There has been a drastic increase in the number of patients struck by COVID-19 pandemic in the hospitals and ICUs worldwide. However, sufficient ventilators are not available in the hospitals at present. An influential report from Imperial College London estimates that 30% of patients admitted in hospitals due to COVID-19 are expected to need the mechanical ventilation [3] . In a recently published study, Yang et al. [4] described their experience from Wuhan, China of the COVID-19 patients who were admitted in the ICU. 56% of their patients required noninvasive ventilation at admission and out of these 76% further required invasive mechanical ventilation. The mortality rate in the individuals who were on non-invasive ventilation was 79% and 86% in those who required invasive mechanical ventilation. They advised against the use of non-invasive ventilation for the patients with pneumonia. Non invasive ventilation like CPAP and hood are not preferred because they lead to increased aerosol generation and pose risk to healthcare workers. According to the WHO [5] , one in six COVID-19 patients has significant difficulty in breathing and may require ventilator support. However, the patients who require ventilator support have low survival rates of 20% because many of these infected patients (40%) develop acute respiratory distress syndrome (ARDS), which has a high mortality. This has brought the availability, procurement and increasing production of ventilators to meet ever-growing need to our health care systems. We assess the current role of ventilators in managing the COVID-19 pandemic and strategies to help meet the world-wide demand (Table 1) . The present outbreak of COVID-19 pandemic has resulted in the dramatic increase in the number of patients who need respiratory care. Health care systems worldwide are facing the extreme shortfall of ventilators particularly mechanical ventilators and their components. The shortage of ventilators has already been experienced by most of the countries who are extremely hit by this pandemic [7] . One of the main reasons for the shortage of ventilators is the issues related to their global supply chain. Due to the worldwide spread of infection, the exports of the medical equipment's including ventilators have come to a halt. The situation has been become so alarming that as many as fifty four countries have stopped exporting the goods related to medical field including ventilators [8] . The production of medical machines such as ventilators demands more intensive capital and expertise. Lot of efforts are urgently required to reduce and minimize the gap between the requirement and the supply of ventilators. Currently, there are very few companies all over the world that possess the expertise to manufacture ventilators. The suppliers to these companies should be supported to maximize the supply of raw materials needed produce these devices. In addition to this, efforts should be made to encourage more new industries to start producing cost-effective ventilators. Sharing of ventilator technology in this need of hour can prove to be very useful for the treatment of COVID-19 patients. Government agencies must put in their best efforts to coordinate this sharing strategy and play a critical role in closing the gap between the need and availability of these medical machines. If the coordinated effort is not put in, then it may result in the situation where the patients may not get the care and treatment they need especially in intensive care units. This will in turn lead to the drastic situations seen already in some of the countries such as Italy and USA. The European Union has issued a statement that its utmost priority should be to help and support the already existing manufacturers of ventilators in order to ramp up their production [9] . Thousands of experts, entrepreneurs and volunteers around the world are developing a different potential solution: creating open-source ventilators [10] . With access to relatively simple designs, makers in Africa or South America could build ventilators quickly and cheaply using already available hardware and infrastructure and since all the intellectual property of these projects will be free to use and licensing, copyright issues won't get in the way of builders. Apart from the shortage in the supply of ventilators, their high cost is a barrier to procure by most developing and underdeveloped economies. Hence, there have been several innovations done out of necessities by the doctors, engineers and engineering companies in India. Electronic and vehicle manufacturing companies 6 | P a g e have been roped in to manufacture ventilators quickly and at low cost. The engineering institutes have also been working to design and manufacture low cost and simplified versions of the ventilators. Postgraduate Institute of Medical Education and Research, Chandigarh has come up with a prototype for an affordable Artificial Manual Breathing Unit (AMBU) operating device, as a substitute to the ventilator. One ventilator is used for eight patients through a ventilator splitter [11] . Additive Medicine (AM) technology can quicken the designing and developing process of the main parts of the ventilator is the need of the hour. In this time of distress, 3D printing application of AM has been emerging as a promising technology which has the capability to produce the parts of the ventilator in a very short time [12] . Recently, the first 3D printed ventilator was developed in the Spain. The aim of producing these 3D printed machines is to bridge the gap between the availability and requirements of ventilators for the seriously ill COVID-19 patients. However, their efficiency, durability and most importantly safety has to be confirmed, before these could be produced on a large scale. The 3D printed ventilators can be designed and developed using the Leitat-1 Technology [13] . It is a field device that has been simplified, reducing the number of components needed for an easier assembly. This technology involves incorporating other parts found on the market and their assembly is very fast, so that a large number of these machines can be made in a shorter time span. Attempts are being made in other countries also like Canada where the designers, scientists, engineers and manufacturers are asked to design a ventilation system that is simple, accessible and easy to manufacture, whether through additive or subtractive manufacturing methods [14] . • The article is a narrative review using search engines of the currently available literature on role and availability of ventilators in the COVID-19 pandemic and not a systematic review, due to paucity of literature available currently. • Hence as COVID-19 pandemic evolves, new information will be available and add further knowledge on the topic. As the respiratory illness due to COVID-19 pandemic spreads worldwide, health care systems and national governments are facing the tough challenges of acquiring ventilators to support patients. All steps involved in the supply chain management for ventilators including manufacturing, procurement, storage, distribution and delivery to the coronavirus frontline has to be equivalent to that of a war setting. Innovative applications of Additive medicine like 3-D printer technology may help to ensure the availability of ventilators to the patients and prepare us for such future viral outbreaks. None A Novel Coronavirus from Patients with Pneumonia in China Impact of non-pharmaceutical interventions ( NPIs) to reduce COVID-19 mortality and healthcare Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study How ventilators work and why COVID-19 patients need them to survive coronavirus Mercedes F1 to make breathing aid 2020 Allocating Ventilators in a Pandemic Export restrictions threaten ventilator availability 2020 President von der Leyen and Commissioner Breton discuss solutions with industry to ramp up production of products needed to tackle the crisis Covid-19: The race to build coronavirus ventilators 2020 How India's fighting COVID with low cost ventilators and face shields. The Times of India UEA launch project to 3D print ventilator parts and masks 2020 Leitat presents first medically validated, industrialized 3D printed emergency respiration device 2020 Medically approved emergency 3D printed ventilator goes into production 2020 Title:-Challenges and solutions in meeting up the urgent requirement of Ventilators for COVID-19 patientsOn the behalf of all the authors in paper, I corresponding author hereby accept that there is no conflicts of interest.