New Delhi: One of the first red flags raised when the novel coronavirus pandemic began progressing in India was is issue of insufficient ventilators. That there were only 50,000-odd ventilators in the country, when cases of viral infections rose in March, had sent the alarm bells ringing.
Four months on, the scramble is now more about beds equipped with oxygen cylinders to give patients quick oxygen support and avoid a situation where they might need ventilators.
This, even as the government continue to procure ventilators and indigenous manufacturers attempt to produce these machines.
According to government data, the percentage of hospitalised patients on a ventilator has been steady at 1-2 per cent, while 3-4 per cent need intensive care.
Importance of oxygen
Doctors have said that requirement for oxygen support or ventilators depend on the severity of the illness.
Dr Karan Madan, associate professor at the Department of Pulmonary Medicine and Sleep Disorders in the All India Institute of Medical Sciences (AIIMS), said, “Data from China show that about 85 per cent patients have mild symptoms, 15 per cent need oxygen and about 3-4 per cent need ventilator support.
“So both oxygen and ventilators are important for the management of the disease, depending on the severity of lung involvement. Mild and moderate cases improve with oxygen therapy, that is why time is important. If the patient is drowsy then s/he may be put on ventilator support.”
One of the defining parameters of whether a patient needs to be hospitalised or merely isolated in a Covid Care Centre is the oxygen saturation levels in her or his blood.
Oxygen saturation is the measure of the blood’s ability to carry oxygen. If it falls below a certain level for prolonged periods, there are risks of organ damage, sometimes irreversibly.
The latest clinical management protocol for Covid-19 patients issued by the Ministry of Health and Family Welfare says: “The defining clinical assessment parameters are Respiratory Rate of more than or equal to 24 and oxygen saturation (SpO2) of less than 94 per cent on room air (range 90-94 per cent).”
Normal oxygen saturation values are 95-99 per cent.
The Delhi government has taken a decision to give people on home isolation a pulse oximeter to monitor their oxygen levels so that a sudden unmonitored drop in oxygen saturation can be avoided.
The Covid-19 treatment guidelines issued by the National Institutes of Health also say: “Hypoxemia (abnormally low level of oxygen in blood) is common in hospitalised patients with Covid-19.”
Oxygen saturation, explained Dr S. K. Sarin, head of the five-member committee assisting the Delhi government on Covid-19 and director of the Institute of Liver and Biliary Sciences, is a function of the alveoli — bubble-like sacs that are the functional units of lungs.
The SARS CoV2 virus multiplies inside the alveoli so that oxygen available in the lungs is decreased.
“Patients reach the hospital gasping. When the respiratory rate is up from the normal 14 to 24 per minute it is moderate disease, and when it is 30 it is severe. Unless we give oxygen, patients will soon tire out and collapse,” said Dr Sarin.
“It’s normally on day three that symptoms become worse. In such a situation, one would need to increase the concentration of oxygen from the usual 20 per cent, or the pressure/flow can be increased. Administration of oxygen early on can preclude the need for a ventilator,” he added.
The World Health Organisation too cites data from China to underscore the importance of oxygen therapy in Covid-19 patients.
“Data from China suggests that although the majority of people with Covid-19 have mild illness (40 per cent) or moderate illness (40 per cent); about 15 per cent of them have severe illness requiring oxygen therapy, and 5 per cent will be critically-ill requiring intensive care unit treatment,” reads an interim guidance on oxygen use by the WHO.
It adds, “In addition, most critically-ill Covid-19 patients will require mechanical ventilation…For these reasons, Covid-19 treatment in healthcare facilities should be equipped with pulse oximeters, functioning oxygen systems including single-use oxygen delivery interfaces.”
What is an ‘oxygen bed’
An ‘oxygen bed’ needs one of the three things — a piped oxygen supply, an oxygen concentrator or an oxygen cylinder.
Depending on whether this is being set up from scratch or it is just a matter of adding a few more beds and extending a pipeline, the cost per bed could be “anything between a few thousand to a few lakh”, said a doctor at a government facility.
An oxygen concentrator can cost about Rs 1-3 lakh depending on its capacity and sophistication. A cylinder costs about Rs 7,000-8,000 but as demand keeps rising, supplies often become an issue, especially in remote areas.
A statement issued by the health ministry Sunday read: “As of 28th June 2020, the Covid-related health infrastructure has been strengthened with the availability of 1,055 dedicated Covid hospitals with 1,77,529 isolation beds, 23,168 ICU beds and 78,060 oxygen supported beds; 2,400 dedicated Covid Health Centres with 1,40,099 isolation beds, 11,508 ICU beds and 51,371 oxygen-supported beds have also been operationalised.”
Often the real constraint is of manpower. In many hospitals, especially in the government sectors, patients on oxygen share a cylinder. There are no pitfalls of that practice except that the cylinder empties quickly.
A senior doctor at the Lok Nayak Jai Prakash (LNJP) Hospital, who didn’t wish to be named, said, “When a cylinder empties, another one has to be wheeled in. We are so short of orderlies that replacing a cylinder, even if one is available, sometimes becomes a problem. We have piped supply too but that covers only a small fraction of the beds.”
Ventilators being procured
The PMCARES fund had last week allocated Rs 2,000 crore for supply of 50,000 ‘Made-in-India’ ventilators to government-run Covid-19 hospitals in all states.
Out of these 50,000 ventilators, 30,000 are being manufactured by Bharat Electronics Limited. The remaining 20,000 are getting manufactured by AgVa Healthcare (10,000), AMTZ Basic (5,650), AMTZ High End (4,000) and Allied Medical (350).
So far 2,923 ventilators have been manufactured, out of which 1,340 ventilators have already been delivered to the states/union territories (UT).
The top recipients of these ventilators include Maharashtra (275), Delhi (275), Gujarat (175), Bihar (100), Karnataka (90) and Rajasthan (75). By the end of June 2020, another 14,000 ventilators will be delivered to all states/UTs.