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The need for ventilators
in the developing world: An opportunity to improve care and save lives
He
drive to breathe is a fundamental human and biologic behavior, regulated by a
complex system of checks and balances in the body. When respiratory mechanics
are deregulated by injury, infection, coma, or a host of other conditions, the
biologic equilibrium shifts into a state of respiratory failure. When this
occurs, mechanical ventilation can be a life saving therapy. While commonplace
in developed countries, critical care is at its infancy in many developing
countries where basic technology is often not available. Thus, while many lives
are saved in developed nations through the provision of mechanical ventilation,
patients in many developing nations often die from otherwise reversible causes
due to lack of resources, education, and training.
In this viewpoint paper, we will explore arguments in support of
and against the provision of one vital resource – mechanical ventilators – in
resource–poor settings. Furthermore, we will address both the benefits and
challenges in implementing a program of increased provision of mechanical
ventilators. Lastly, we will provide some solutions to address potential
barriers to this initiative.
BURDEN OF RESPIRATORY FAILURE IN DEVELOPING
COUNTRIES: A CHALLENGE
Much of our data about the burden of respiratory failure worldwide
comes primarily from developed nations. Unfortunately, because the disparity in
quality of care within developing countries is wide no reliable comparative
epidemiological data of critical illness syndromes, such as acute lung injury
and sepsis, are available. While respiratory failure may be fairly easy to
diagnose clinically (such as hypoxia or increased work of breathing), it is a
consequence of a primary disease process (ie, pneumonia) – thus, as a secondary
process, collection of epidemiologic data are challenging in resource–poor
settings. This results in the comparative epidemiology (between
resource–intensive and resource–poor settings) of critical illness and
respiratory failure being heterogeneous [3,4]. Furthermore, mortality after critical
illness is related to both clinical decisions to limit intensive care and the
consequences of the disease; therefore, countries with the resources to provide
intensive care for patients with comorbid illnesses will have a perceived
higher burden of critical illness associated with these disorders compared to
countries which do not initiate treatment in the first place.
With a potentially high burden and mortality of respiratory
failure in developing nations, the provision of mechanical ventilators may help
save lives if implemented in a thoughtful fashion. Thus, good outcomes in this
patient population may contribute to healthier patients with better future
productivity and economic potential. Despite this, several barriers to
implementing a greater number of ventilators exist, including perceived high
cost, the need for education, and a lack of research in ventilator protocols
for resource–poor settings.
BENEFITS OF THE PROVISION OF VENTILATORS IN
DEVELOPING COUNTRIES
As previously mentioned, the epidemiologic data regarding the
burden of respiratory failure in developing countries is poor and may
potentially be underrepresented due to large proportion of uncultured data in
patients in whom intensive care was never initiated in the first place due to
perceived futility of treatment. Although classically thought to only benefit a
small segment of patients, mechanical ventilation actually can help a wide
variety of patients including patients with injury, non–communicable diseases
(NCDs), and communicable diseases such as the human immunodeficiency virus
(HIV) and malaria. For example, while it has been recognized that NCDs are
beginning to account for a larger burden of disease in developing countries decompensate
NCDs (ie, heart failure exacerbations) commonly require critical care and
mechanical ventilation. In the same vein, a patient with HIV infection may also
decompensate from the acquisition of opportunistic infections and require
mechanical ventilation.
Youth
are often are disproportionately affected by critical illness and respiratory
failure in the developing world; thus, a large amount of patients who have many
years of contribution to society needlessly die due primarily to a lack of
resources and education Furthermore, the limited data comparing critical care
in Europe versus developing nations confirms that patients in developing
countries tended to be younger and had an improved prior health status thus,
the potential for recovery and productivity exists. An example of this
situation is care for young patients with traumatic brain injury (TBI). In
developed nations, TBI outcomes have significantly improved through careful
adherence to the Brain Trauma Foundation guidelines, which emphasize
appropriate respiratory care and oxygenation of the brain–injured patient In
developing countries, unfortunately, many of these young patients are not given
a chance for survival because of the lack of basic ventilators for respiratory
support.
While mechanical ventilation can be viewed as a prolonged task in
some patients, the majority of patients would only require a short course of
mechanical ventilation. This is because the four most common admission criteria
requiring ventilation in intensive care units in developing countries are
postsurgical treatment, infectious diseases, trauma, and per partum maternal or
neonatal complications the majority of these processes are reversible over a
short period of time. Therefore, the provision of a short duration of
mechanical ventilation has the potential to help patients with a variety of
reversible pathologies.
ARGUMENTS AGAINST THE PROVISION OF VENTILATORS IN
DEVELOPING COUNTRIES
A primary argument against the provision of ventilators in
developing nations is centered on the increased cost of the intervention. While
tackling prevention, communicable diseases, and NCDs, the strain that providing
ventilators puts on funding agencies can be substantial. Furthermore, at a very
high cost per ventilator even in developed countries (average anywhere from US$
20 000 up to US$ 100 000), ventilators by no means are a cheap intervention. To
address these issues, basic ventilators for developing countries are being
developed at much lower costs. While the capabilities of these machines are not
nearly as robust as more expensive machines used in developed countries, the
vast majority of patients even in developed countries are ventilated for a
short duration and require the “minimal settings” that most ventilators can
provide. In addition, the majority evidence–based maneuvers do not require
complex ventilation strategies (ie, lung–protective ventilation and can be
provided with a basic ventilator. Lastly, as mentioned above, funding
priorities can continue to be met, as ventilators will improve care for
patients with diseases under well–funded projects (ie, decompensate HIV,
malaria, NCDs). Even if funding for basic ventilators is provided, it will be a
disproportionately small amount of funding as compared to other disease states
such as HIV
While
we have explored the cost to society and funding agencies as a barrier to
implementing mechanical ventilation in resource–poor settings, a likely
important reason for ceasing (or, not even starting) intensive care in
developing countries is the family’s inability to keep up with the cost of
caring for the patient – in the extreme case, sometimes driving families into
poverty. On the other hand, if cost to the family was not an issue (as is the
case in many developed countries), the challenge may shift to clinical ethics;
because of religious or cultural beliefs coupled with a misunderstanding of
treatment effectiveness (a situation that is often faced in developed countries
as well), patients receive mechanical ventilation long after it will be of any
benefit. Therefore, an ethical framework would be necessary to advise both
doctors and patients of possible decisions on the withdrawal of care or
transition to “comfort” care. Furthermore, if demand outstrips the supply of
ventilators, decision rules will need to be put into place to ethically select
which patients with benefit the most from the therapy.
Aside
from cost, another compelling argument against the provision of ventilators in
resource–poor settings is the inadequacy of current systems to appropriately
care for patients on ventilators and the ventilators themselves [13]. The initial of care for the patient with
respiratory failure (ie, from trauma) is often in the field, and appropriate
emergency medical services (EMS) training must involve appropriate initial care
and triage of these patients.
It must be understood that mechanical ventilation is a complex
task more than just merely “turning on” the machine. The act of putting a
patient on mechanical ventilation requires the provision of an end tracheal
tube (or tightly–fitting non–invasive face mask), making adjustments to the
machine to meet patient needs, responding to ventilator crises, adequate
sedation of the patient, and appropriate patient weaning and eventual
liberation of the patient from mechanical ventilation. Second, ventilators can
be vulnerable machines and require appropriate maintenance. Third, ventilators
require both electricity and compressed oxygen, both potentially scarce
resources in developing countries; in order to fulfill the ethic principle of
equity, basic oxygen and electricity must be available throughout a region
before considering the institution of mechanical ventilation. Thus, it is
apparent that beyond simply providing ventilators to resource–poor settings,
appropriate systems must be put into place to address issues of both care of
the ventilated patient and care of the ventilator itself; the opportunity cost
of this may involve shifting resources from other public health priorities,
thus system changes need to be implemented in a thoughtful, evidence–based
manner.
OVERCOMING BARRIERS TO THE PROVISION OF MECHANICAL
VENTILATION
Reaching to goal of delivering high quality respiratory care is
lofty, but very possible with a systematic approach to funding, education, and
research. First and foremost, educational initiatives would be needed to
address several issues; not only would physicians and nurses need training on
appropriate care of the ventilated patient, but staff would also need to be
trained on the care and maintenance of these machines. Second, systems would
need to be in place to create protocols for complex processes to provide
consistent evidence–based care to patients – checklists have been proven very
successful in this regard. Third, several protocols from developed countries
will likely need to be modified to best meet the needs and resources of
developing countries [14]. Fourth, government systems would need to
be in place to assure consistent power (i.e., electricity) and oxygen for the
machines. Fifth, a triage system would likely be needed to “regionalize” care
for sick and complex patients who require more advanced therapies beyond basic
ventilator management. Sixth, from a donor and funding perspective, greater
education needs to be provided to donors that critical care and mechanical ventilation
can be cost–effective, and that most evidence–based critical care interventions
tend to be inexpensive [1]. Furthermore, the economic implications and
advantages of decreasing mortality in young populations would need to be
stressed. Lastly, research should be performed in resource–poor settings to
focus on needs assessment, education, implementation, and cost–effectiveness.
While the necessary steps above seem complex, we have already proven that the
global health community can tackle complex obstacles – the successful
implementation of HIV care (one of the most complex diseases known to modern
society) in some of the world’s most destitute regions is proof of this.
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