Mechanical Ventilators: How They Work and Their Importance During the COVID-19 Pandemic

What is a Mechanical Ventilator?

A mechanical ventilator, commonly known as a ventilator or respirator, is a medical device that provides mechanical ventilation by moving breathable air into and out of the lungs, to deliver breaths to a patient who is physically unable to breathe, or breathing insufficiently. Mechanically ventilated patients may be incapable of breathing, or breathing adequately, on their own due to illness, drug overdose, or injury to the lungs, chest or brain. Mechanical ventilation is a life-sustaining intervention for many critically ill patients.



How Do Ventilators Work?

Modern Mechanical Ventilators typically consist of a control unit that houses electronic and pneumatic controls and a separate breather unit that attaches to the patient. The breathable air source is typically room air or oxygen enriched air from a central supply. The control unit monitors and regulates settings related to breathing such as volume and rate. It alerts caregivers of any changes in a patient's status. The breather unit contains valves and sensors that distribute the controlled breathable air into the patient's airway via an endotracheal tube (ET) or tracheostomy tube. Exhalation is usually passive as the breath is mechanically pushed into the lungs and the recoil of the lungs pushes air back out during exhalation. The unit can be operated via controls or programmed settings. Advanced models add capabilities to monitor airway pressures, exhaled gas contents and more.



Modes of Ventilation

There are different modes of mechanical ventilation to meet various patient needs. The most common are:



- Controlled mechanical ventilation (CMV) - The ventilator controls both inhalation and exhalation. It provides periodic, consistent breaths.



- Assisted-controlled ventilation (ACV) - The ventilator initiates and sustains inhalation. Exhalation is partially assisted by the patient.



- Synchronized intermittent mandatory ventilation (SIMV) - The ventilator provides mandatory breaths according to a set rate. Additional breaths are patient-triggered.



- Pressure support ventilation (PSV) - The ventilator supports the patient's own breathing with an adjustable pressure to overcome airway resistance.



- Proportional assist ventilation (PAV) - Support varies with the patient's effort to improve patient-ventilator synchrony.



The Importance of Ventilators During the COVID-19 Pandemic

The COVID-19 pandemic has highlighted the crucial importance of mechanical ventilators. When people are infected with certain respiratory viruses like SARS-CoV-2, the virus that causes COVID-19, it can cause pneumonia. In severe cases, pneumonia can cause the lungs to fill with fluid or inflammation can make it very difficult to breathe. In such cases, a ventilator provides breathable air and allows the lungs to rest and heal.



During the initial outbreak of COVID-19 in Wuhan, China in early 2020, the shortage of ventilators was a major concern as cases overwhelmed the healthcare system. Images emerged of patients in hospitals lying untreated on gurneys and floors as there were not enough ventilators. The sudden surges of COVID-19 cases in New York, Italy, Brazil and other cities also challenged healthcare capacities and ventilator availability. Projections estimated up to hundreds of thousands of ventilators could be required in the U.S. alone. This led many companies to ramp up ventilator production to meet demand. Various initiatives explored ways to modify Ambu bags, CPAP machines and other pneumatic devices to serve as makeshift ventilators if necessary. Many countries issued guidance on ventilator allocation policies in anticipation of shortages. While availability has expanded since the initial outbreak surge, ventilators remain a crucial resource for managing critically ill COVID-19 patients.



Ventilator-Associated Pneumonia (VAP)

With any long-term ventilation there are risks involved. One common complication is ventilator-associated pneumonia or VAP. It occurs in 9-27% of intubated patients. VAP develops when harmful bacteria enter the lungs through the artificial airway. Risk factors include extended ventilation periods, supine patient positioning and underlying comorbidities. Bacteria reaches the lower airways by traveling down the endotracheal tube or through microaspiration around the cuff. Symptoms include fever, increased secretions and changes in sputum color and character. Treatment involves targeted antibiotics however it prolongs ventilation, increases costs and mortality risk. Preventive measures focus on strict hand hygiene, oral decontamination, elevation of the head, selective decontamination of the digestive tract and minimization of sedation.



The Future of Ventilator Technology

Innovation continues in ventilator design, materials and capabilities. Areas of development include:



- Minimally invasive ventilation techniques for non-intubated patients using interfaces like mouthpieces or nasal masks.



- Advanced modes fine-tuned for pediatric or specialized lung conditions.



- Digital connectivity to integrate devices with monitors and electronic health records.



- Portable, rechargeable designs for transport and home use.



- Built-in lung monitoring through sensors, gas analysis and imaging to improve synchrony and weaning.



- Intelligent alarms and custom parameters optimized to individual patient physiology and genetics.



- Universal ventilator designs able to interface with any patient regardless of interface type using modular components.



While their basic function has remained the same, technological advances will continue to enhance modern ventilators and optimize patient support in critical care and beyond. They represent a lifesaving medical advancement and their needs have certainly been highlighted during the global COVID-19 pandemic response.

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