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| EDITORIAL |
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| Year : 2022 | Volume
: 2
| Issue : 3 | Page : 83-84 |
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Innovations help when there is unexpected demand
Ravindran Chetambath
Department of Pulmonary Medicine, Baby Memorial Hospital, Kozhikode, Kerala, India
| Date of Submission | 26-Jun-2022 |
| Date of Acceptance | 13-Jul-2022 |
| Date of Web Publication | 17-Aug-2022 |
Correspondence Address:
Prof. Ravindran Chetambath
Department of Pulmonary Medicine, Baby Memorial Hospital, Navaneeth, Sarovaram Biopark Road, Civil Station PO, Kozhikode, Kerala
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jalh.jalh_22_22
How to cite this article:
Chetambath R. Innovations help when there is unexpected demand. J Adv Lung Health 2022;2:83-4 |
Oxygen supplementation is an integral part of the management of various respiratory diseases developing hypoxemia. Its importance has been highlighted during the COVID-19 pandemic. Severe respiratory manifestations of COVID-19 are managed with oxygen.[1] Supply of oxygen can be through oxygen cylinders, oxygen concentrators, or liquid oxygen.[1] Despite most people experiencing mild or uncomplicated symptoms, approximately 15% of patients diagnosed with COVID-19 require oxygen support.[2]
Despite using oxygen medically for over 100 years and the WHO classifying it as an essential medicine in 2017, large population groups, especially in developing countries, do not have access to adequate supplies. The WHO has consistently raised alerts about the ongoing and persistent shortages in Africa, the Middle East, and other developing countries. As COVID-19 patient care protocols have evolved, medical-grade oxygen is considered essential for the treatment of critically ill patients, such as invasive ventilation and low- and high-flow oxygen therapies. In regions such as Africa, South America, and Asia, the surge in demand for medical oxygen to treat COVID-19 exacerbates preexisting gaps in medical oxygen supplies, leading to substantial supply shortages in these counties, oxygen demand has increased 100–200 fold.[3] COVID-19-related mortality rates among low- and middle-income countries are as high as 19% in Yemen,[4] which also reported a medical oxygen shortage crisis.[5] The unequal distribution of available oxygen between urban and rural areas has led to increased unmet needs for oxygen by patients in rural areas. The National Innovation Center are supporting hospitals and health-care workers to restore malfunctioning or out-of-condition oxygen equipment, designing oxygen delivery systems, and distributing them free of charge.[6]
Thefirst area includes medical products. One of the ways to ensure oxygen plants in hospitals generate oxygen at the point of use is by pressure swing adsorption oxygen plants. These can be transported and installed on-site in hospitals in the form of systems, which are quite compact. Although requiring a large, upfront operational investment, pressure swing adsorption plants are a sustainable local solution that can be achieved by developing partnerships among local governments and the private sector.
Health information is a second area that needs attention. It is imperative that we strengthen the existing health information system to monitor oxygen requirements and availability effectively to ensure timely external response when oxygen demands increase.
The third area is health-care financing. The government budgeting systems need to focus on effective, sustainable investments in systems that can enable oxygen production at local levels in hospitals, and manufacturing plants at national levels, that can supply oxygen when the local system is under pressure and in need.
Leadership/governance is the fourth area that needs attention. The overarching building block is leadership to ensure adequate political commitment at the national and local levels for policy formulation/implementation, including budgeting and logistics management of oxygen as an essential medical supply. Mobilization of resources at local levels is also required, as is facilitation of the formulation of policies.
Along with these measures, there should be collective efforts at the end-user level to conserve oxygen. This is possible by optimal utilization of oxygen delivery, close monitoring of patients' health status as well as oxygenation status, and newer innovations to deliver maximum oxygen by increasing pressure behind the delivery. The COVID-19 pandemic offers the opportunity to refocus efforts on the basics of acute care, knowing that improvements in oxygen will benefit patients both now and in future.
About 20%[7] to 67%[8] of COVID-19-infected patients who are admitted to the hospitals and 100% of mechanically ventilated[9] patients suffer from acute respiratory distress syndrome (ARDS). This pathophysiology decreases lung compliance and demands a high flow of medical oxygen to maintain the arterial oxygen levels in the affected patients. Extrinsic positive expiratory pressure (PEP) can improve oxygenation by direct and indirect mechanisms and thus reducing the need for medical oxygen. However, costly and sophisticated machines are required to provide this positive airway pressure, adding to the treatment cost and investment expenses by the health-care facilities.
PEP for the management of cardiogenic or noncardiogenic pulmonary edema/ARDS is provided using dedicated noninvasive ventilatory machines such as continuous positive airway pressure (CPAP) or Bilevel positive airway pressure (BiPAP) or by the invasive ventilators. However, such machines are expensive, which demands a larger investment by the hospitals and a higher cost of treatment for the patients. Apart from these, there was high demand for these equipments as the number of hospitalized patients was unexpectedly high. Many of these equipment are costly and short of supply due to the high demand. This created an unprecedented situation, where many patients requiring oxygen and PEP devices were denied of these, leading to poor outcomes.
Moreover, the high expiratory pressure from the device during patients' expiratory phase will result in aerosol generation that can escape through the expiratory valves in the mask leading to a higher risk of infection transmission. As the COVID-19 pandemic continues to affect more and more people worldwide, there is a growing demand for such machineries and not all can afford it. The large volume of consumption of such devices and hospital beds has led to the scarcity of the same, making the health system inefficient in providing adequate treatment for all.
The authors, Paul and Mathew,[10] in this issue through an article, “SWIPER device (self-working water-based instrument for PEP by resistance) and its effectiveness in improving oxygenation in acute pulmonary edema, during the COVID-19 pandemic: A pilot study” discuss a simple self-working device called SWIPER device which can provide a PEP. They have demonstrated the effectiveness of this device in improving oxygenation in patients with acute pulmonary edema, which was quantified using pulse oximetry. SWIPER device is effective in significantly increasing the SpO2 in patients with acute pulmonary edema by providing PEP. This device is not a replacement for the existing positive airway pressure-providing electrical devices. This appears to be a simple hospital-based innovation to optimize oxygen delivery when there is very high demand.
| References | |  |
| 1. | Ukor NA, Adebisi YA, Uwizeyimana T, Ahmadi A, Ekwebelem OC, Fadele P, et al. Community distribution of oxygen: A unique COVID-19 intervention. Trop Med Health 2021;49:39.  |
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| 5. | Devi S. Yemen's health system has “collapsed”, warns UN. Lancet 2021;397:2036. |
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| 7. | Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020;323:1061-9. |
| 8. | Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: A single-centered, retrospective, observational study. Lancet Respir Med 2020;8:475-81. |
| 9. | Arentz M, Yim E, Klaff L, Lokhandwala S, Riedo FX, Chong M, et al. Characteristics and outcomes of 21 critically ill patients with COVID-19 in Washington State. JAMA 2020;323:1612-4. |
| 10. | Paul A, Mathew S. Swiper device (self-working water based instrument for positive expiratory pressure by resistance) and its effectiveness in improving oxygenation in acute pulmonary edema, during the Covid 19 pandemic: A pilot study. JALH 2022;2:92-7. |
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