
Nvidia Releases Low-Cost, Open-Source Ventilator Design - bcaulfield
https://blogs.nvidia.com/blog/2020/05/01/low-cost-open-source-ventilator-nvidia-chief-scientist/
======
rkangel
There have been a lot of these 'open source ventilators', and they kind of
miss the point. It's easy to make something that performs the basic
functionality.

I have spent basically every waking hour of the last month and a bit working
on a ventilator for my employer (part of Ventilator Challenge UK - project
recently suspended). Making something that delivers air in the right duty
cycle for breathing is easy. There's a few more things you want to do:

Blend O2 and Air ("FiO2"). Ventilators need to deliver Oxygen rich air to
patients, but not usually 100%. Blenders are harder than you'd think to make.
Note also that having pure O2 in your system means that there's a load of
stuff you have to get right to prevent fire.

Alarms. This is the big one. most of the implementation (even taking account
the next feature), was about checks and associated alarms, for blockages,
failures etc. Making sure that we beeped loudly if something looked wrong.
Note that 'not beeping' is a much WORSE failure than 'not ventilating'. If
something goes wrong (including complete hardware failure of the ventilator),
as long as a healthcare practitioner is aware and responds, then there isn't
an issue. If the ventilator is happily ventilating away but something is
obstructed then the patient might die (there are backup checks like pulse
oximetry on the patient, but they're slow).

Assisted breathing. Driving a solenoid on and off at a particular rate and
duty cycle gets you 'mandatory breathing'. That is great for keeping someone
alive. If you're not unconscious though, it is both incredibly unpleasant and
doesn't help you get weaned off and get better. What you want is a device
capable of sensing attempted breaths and using the ventilation to 'help' them.
This feature isn't 100% necessary - the early plans in the UK were for a
massive shortage and for the simplest things we could get in a hurry. It
quickly became clear that actually we needed ventilators to help people
recover.

~~~
jschwartzi
Yes. We spent as much time testing our alarm and monitoring system as we did
doing gas delivery changes. And even on the gas delivery side, simple things
like the patient changing positions while the ventilator delivered a breath
could be damaging without following the standards explicitly. I think there
are about 2 or 3 thousand different little functional requirements for
building a ventilator. It took us about a year to get to first prototypes and
then another year to get to the first passing of our system-level tests.

Even just our alarm system was very complicated, with cross-checking alarms
and even cross-checking that the audio was indeed playing back. Things like
playback tones and frequencies and alarm indicator colors and flash
frequencies are highly regulated with relevant standards. And nuisance alarms
are almost more important to avoid than having enough actual alarms. No alarm
is as useless as the one the clinician turns off because it's the 4th time
this hour it's gone off and the patient has been fine every time.

These are not easy devices to build, and selling something that doesn't meet
the applicable standards and isn't substantially equivalent to something
marketed today is unlikely to be particularly safe. You can easily do more
harm than good by giving someone an untested ventilator.

~~~
Justsignedup
Thank you for pointing it out. In addition to false-positives... it would
really suck if a LED died, or a speaker died, and suddenly a critical alarm
isn't going off. Redundancies upon redundancies are critical for these
systems. The not cheap for a reason.

------
nichohel
I appreciate the effort, but it looks like we aren't going to need nearly as
many ventilators as expected because COVID lung problems are different than
other lung conditions and seem not to respond well to invasive ventilation.

[https://www.youtube.com/watch?v=Elgct0nOcKY](https://www.youtube.com/watch?v=Elgct0nOcKY)

[https://www.reuters.com/article/us-health-coronavirus-
ventil...](https://www.reuters.com/article/us-health-coronavirus-ventilators-
specia/special-report-as-virus-advances-doctors-rethink-rush-to-ventilate-
idUSKCN2251PE)

[https://www.cnn.com/2020/04/22/health/coronavirus-
ventilator...](https://www.cnn.com/2020/04/22/health/coronavirus-ventilator-
patients-die/index.html)

The video in particular is telling, highlighting the difficulty in getting a
hospital to change what is considered the standard procedure in the face of
new conditions (told by a frontline doc).

We are going to be up to our eyeballs in excess ventilators. Maybe they'll be
handy for the next pandemeic ...

~~~
carbocation
The report that you cite of 25% mortality for COVID patients on a ventilator
is in line with COVID causing ARDS. There is currently no reason to believe
that it causes some fundamentally different process from other ARDS-inducing
diseases.

Our experience at MGH also puts severe COVID lung disease squarely into the
ARDS category, and it responds to standard ARDS ventilation protocols[1]. Our
mortality to date is shy of 20%.

Data over anecdote.

1 =
[https://www.atsjournals.org/doi/abs/10.1164/rccm.202004-1163...](https://www.atsjournals.org/doi/abs/10.1164/rccm.202004-1163LE)

~~~
thebigspacefuck
From what I understood, with ARDS, it was necessary to medically induce a
coma/paralysis and, in order to have highest chances of survival, required
staff to monitor and posture patients every 8 hours.

Even if ventilator supply was not a constraint, would there be other
constraints caused by staffing that would limit effectiveness of ventilators?

Note: I am NOT a doctor or involved in health or medicine in any way. My
source for this information is this MedCram lecture on Youtube:
[https://www.youtube.com/watch?v=okg7uq_HrhQ](https://www.youtube.com/watch?v=okg7uq_HrhQ)

~~~
carbocation
Staffing is definitely an issue as you point out, but what you’re describing
is what would happen if we were to run into a capacity issue, which we likely
would have without the lockdown but which we have not (at least, in MA).

------
Nokinside
> Traditional ventilators, by contrast, can cost more than $20,000

Traditional ventilators (ventilator) are very different from bag valve masks,
resuscitators, PAP and CPAP, BiPAP machines.

This Nvidia design is not alternative to that $20,000 hospital ventilator.
It's emergency-response ventilator alternative these other cheap designs you
can already order from Amazon. You can't keep people long time in this kind of
device without serious risk of damage to the lungs.

~~~
baybal2
Very few countries managed to produce emergency ventilators from scratch. Out
of hundreds of ambu bag squeezer designs, find at least one that reached the
assembly line.

Not a lot.

Only 4 countries on record now managed to start mass production of designed
from scratch emergency ventilators.

Expanding existing capacity would've been an incomparably better option.

~~~
Nokinside
One German manufacturer recently explained how their company has already
outsourced almost all parts and manufacturing phases that can be easily
scaled. The company does design, final assembly testing, calibration and
quality control. I suspect that the internally used testing and manufacturing
equipment and protocols are the hardest thing to scale.

~~~
baybal2
No, from my experience in OEM manufacturing since 2007 I can say it isn't.

------
dogma1138
All these designs are cool projects but other than being a distraction and
some PR nothing will come out of them.

There are plenty of proven designs that can be manufactured cheaply, the price
of the end units especially for things like ventilators isn't often due to
complexity and manufacturing costs but due to the costs of maintaining a
supply chain, manufacturing and providing support (including liability) for
the healthcare market.

None of these things seem to solve these issues other than potentially
removing liability to who ever decides to manufacture those units.

Any thing can be built with off the shelf parts but the reason why most
medical devices aren't it's because you need to take special care in your
supply chain.

Ventilators use valves that aren't that different and often the same valves
that are available for a plethora of other applications like industry and
agriculture but the fact that it's the same valve doesn't mean that it's the
same supply chain.

The suppliers for medical equipment make sure that say the lubricants that are
used are safe and that no one can say replace o-ring used in the valve from
one supplier to another without recertifying the entire thing making sure that
the new o-ring meets the exact same specs.

For things like electronics then you have a whole other world of safety from
things like resistance to liquids (anything from blood splatter to leaking IV
bags), EMI to make sure it won't interfere with any other devices or be
susceptible to interference on it's own and ESD to make sure there could no
chance of sparks especially in devices that pure or high concentration oxygen
can flow through or devices that will be near oxygen feeds.

And heck even if all that isn't the reason for ventilators being expensive and
the true reason is IP Licensing/Patents then the US government and every other
government can easily either compensate the IP holders directly or simply
withdraw protection on the IP in question.

Many countries have already had legislation in place to allow governments to
suspend IP protection or grant protection to violators during an emergency.

~~~
sremani
The effort towards the design of ventilators likely would have started when
there was peak anticipated demand. The NY Governor was asking for 40,000
ventilators last month. So, we should not dismiss the effort.

There will be lots of wasted effort during the sprint to plug things in a
hurry. But it may not be really wasted effort, given that projects like these
can be fountainheads to unknown future innovations or relations.

~~~
dogma1138
I don't understand why there needs to be a design effort.

Other countries simply took existing designs for ventilators and shifted
manufacturing capacity e.g.:

[https://www.timesofisrael.com/iai-defense-ministry-
inovytec-...](https://www.timesofisrael.com/iai-defense-ministry-inovytec-
convert-missile-factory-to-produce-ventilators/)

So overall I don't see why the "design" was ever the bottleneck.

~~~
iancmceachern
Background: I design medical devices like this for a living and have for
nearly 20 years. I also want to applaud the efforts of everyone working to
leverage their professional experience toward helping us all through this.

I agree with this comment 100%. What the world needs now is more of the
ventilators we already have designed, not new designs. With any new medical
device comes a bunch of teething pains, finding and fixing bugs in the
hardware and software design, training, testing andd iterative improvement of
all these things as new issues are identified. All of this requires
significant clinical support and companies that do this stuff typically employ
dozens of clinically trained folks to aid in the introduction and development
of the clinical aspect of the device. All of this time and effort is just not
available now, any and all clinical resources need to be focused on treating
patients, not helping engineers find bugs in their systems.

I believe this because an alternative exists, we do not need to reinvent the
wheel, we just need more of the wheels we've already invented.

To be clear, I do however believe there is a lot of value in investing heavily
and exploring all potential novel treatments and devices that could help fight
this. I just don't see a value add to designing new respirators vs. Just
making more of the designs we have now. I could be wrong, there could be
significant manufacturing or other clinical advantages which i am not aware
of.

~~~
bluGill
We might need new ventilators, but we don't know what the requirements are
until then our existing designs are better than anything new : we know they
work and can be made. All we need is to scale production and that is much
easier.

As we learn more we might discover things that make the current ventilators
not optimal at which point it is worthwhile to design something new.

~~~
dogma1138
We know the requirements fairly well, we just need more ventilators not new
ones.

The ventilators we have aren’t the problem and their cost and design also
don’t impact the production capacity that much what impacts it is the fact
that most medical manufacturers never had to operate on such scales and those
that even come close tend to big the big international players with global
manufacturing that is heavily reliant on China.

There is a plethora of designs for ventilators of all types from emergency
CPAP machines to multi-mode life support for ICU’s.

Those designs have already been validated and there is a huge bank of
knowledge to support them.

All these pump/turbine based respirator not to mention the pneumatic Ambu bag
auto-squeezers don’t really bring anything new to the table they just
introduce an untested hardware and software.

Like seriously half the ventilators that were shown were an ambu bag and
actuator and a micro controller attached to some pressure sensor yes it’s a
very simple respirator but do we really need 50 university teams coming up
with a design variation?

And as far as discovering something new the only thing we discovered so far is
that people were put on a ventilator and even more so intubation way too early
and that has negatively impacted their survival rate which is one of the
reasons why the demand for ventilators has dropped.

~~~
bluGill
None of that contradicted anything I said. Maybe we will learn something
tomorrow that means a new ventilator design would work better, but until then
like you say, there is no need to design any when the existing designs work.

~~~
dogma1138
But this is the thing these aren’t new designs.

Everyone of these ventilators is basically an existing design just with
different off the shelf components.

None of these projects created a new design or a new ventilation mode.

The vast majority of these are CPAP machines some maybe able to provide APAP
in firmware.

If you look at the designs they are basically split into two categories the
ambu which just basically compress an off the shelf ambu bag with an actuator
or pump/turbine based machines that are essentially very similar to those
which are given to people suffering form sleep apnea.

I don’t think there is even a ventilation mode we haven’t thought of yet even
the most advanced ventilator on the market are mechanically very simply
machines the cost is usually based on the brand and which modes they support.

This isn’t a field in which you can have a major breakthrough and not to
dismiss this effort it’s not a field in which a breakthrough is needed.

Ventilators are cheap by medical standards even at $20,000 a pop the cost
isn’t the issue the issue is that simply we never needed to produce them at
such quantities in such a short time frame and for that you don’t need a new
design you just need to accept that you aren’t going to reinvent the wheel and
just take a proven design and make more of them and sort the licensing after
this.

The fact that some teams had a working prototype within a day should be a very
strong indication that there isn’t much here.

Having a turbine and a microcontroller to set the positive pressure on the
outlet or having it set up how many times per minute an ambu bag should be
compressed and at which rate isn’t a particularly difficult engineering
challenge to conquer.

This is why there are now 100’s if not 1000’s of virtually identical designs
out there from various teams across the world.

Yes anyone can build them in their garage and yes if the world have ended it
would’ve been better than nothing but we have real options out there that can
be just as easily manufactured if we actually had the will.

~~~
bluGill
Exactly my point.

------
clarkevans
This design is licensed only for "use in response to the COVID-19 pandemic".

[http://op-vent.stanford.edu/license.pdf](http://op-
vent.stanford.edu/license.pdf)

------
ultrasounder
Atmega328p and no Arduino boot loader? Jokes apart, it’s pure inspiration to
see someone like Bill Dally work out of his garage on a project like this.
Kind of reminds me of Jim Williams a rekmowned apps engineer from Linear Tech
who pretty much created the apps engineering discipline. Anyone willing to
roll their sleeves and learn OpAmps/ADC look no further than App notes on
Linear Tech website

~~~
ineedasername
_> Atmega328p and no Arduino boot loader_

Forget about that, I'd expect something from Nvidia to at least be able to run
Doom.

------
OliverJones
We should be careful here. Smarts and creativity go a long way, but they're
not a substitute for the years of training and experience of health-care
professionals. Other commenters have mentioned delivering mixtures of gas as a
requirement. I'll add sterilizing the equipment between uses.

It's true that the durable medical equipment (DME) industry is ripe for
disruption. But that disruption isn't going to come from cheap stripped-down
equipment, even if that equipment has stunningly wonderful software in it.

DME industry disruption will come from figuring out how to break the
innovation-restricting stranglehold of Group Purchasing Organizations on
health care supply chains. That's harder to pull off than quick-turn
prototypes. What's needed is market disintermediation. That's a political and
financial challenge, not a gadget-creation challenge.

Somebody once said to me, "software is the most complex thing ever invented."
But that can't be right: look at a modern airplane. It has software in it, but
it has plenty of other complexity. DME is the same way.

Creativity like Dr. Daily's is great. Really great. But it alone doesn't solve
hard problems. If we software types claim it does, we're setting people up for
disappointment.

------
ineedasername
There are already FDA approved designs in production & available at similar
costs. [0] For this immediate problem, We don't need more designs.

[0] [https://www.global-medical-solutions.com/Allied-
Healthcare-M...](https://www.global-medical-solutions.com/Allied-Healthcare-
Mass-Casualty-Ventilator-EPV100_p_9461.html)

------
yalogin
All these designs should reduce the eventual price of ventilators after the
COVID-19 passes. If we all know it’s not going to happen. The cheaper
alternatives will be used to reduce manufacturing costs but they will keep the
price same. That’s just how the medical industry works.

------
antisocial
“The best minds of my generation are thinking about how to make people click
ads.” –Jeff Hammerbacher

This is the kind of work I would like to see the best minds of my generation
to work on.

I am not saying that I am one of the best minds of my generation, but I
couldn't work for ad-network companies. I took consulting gigs only when I was
trying to gain some big data exposure, and was in that field only for three
years over three different occasions.

I would like to see more and more people to stop working for ad-tech
companies.

------
tasty_freeze
Keep in mind that this wasn't made by nvidia. It was a personal project of
nvidia's chief scientist, Bill Dally.

------
thanksforfish
I'm curious if these companies are OK with the risk that people make these
devices, destroy their lungs, and then sue. It's great PR, but the previous
systems were expensive for more reasons than just manufacturing cost.

~~~
ekianjo
> but the previous systems were expensive for more reasons than just
> manufacturing cost.

namely lack of competition, regulatory capture, and price not paid directly by
end users, for the most part.

~~~
La1n
Not extensive testing and willingness to take responsibility if something goes
wrong?

~~~
jshevek
Both sets of causes contribute to inflated costs, and probably others as well.

------
Dowwie
Bill Dally is remarkable human being -- an inspiration!

------
bobowzki
It's quite a good start but far too simple to be of any practical use in a
ARDS patient. A PEEP valve is absolutely essential.

------
stopreformation
Will this work with Linux?

~~~
jschwartzi
Linux is a really bad operating system to use in this application. To do gas
delivery safely and reliably you need to be using a Real-Time Operating System
like QNX, VXWorks, OpenRTOS, etc..

~~~
solarkraft
I think it was a joke about NVidia actively working to make their cards suck
on Linux. Besides: You could, especially now with real time capability moving
into being a standard kernel feature.

~~~
jshevek
When someone makes one of these cancerous ironic joke comments, responding in
earnest is a good way to remind people of the culture here.

~~~
khazhoux
To me the comment was neither cancerous nor ironic. We don't need to excise
all humor from our discussions on HN. Humor itself isn't a problem -- though
of course no joke appeals to all people.

~~~
jshevek
> _We don 't need to excise all humor from our discussions on HN._

This isn't really relevant here, unless you are trying to create a strawman or
frame this as a false dilemma of extremes. You can have a sense of humor while
also keeping the conversation substantive.

[Edit: Assuming solar is correct: ]

Comments like the above are cancer when they inspire more of the same, and not
long ago would have been appropriately dis-incentivized by the community.

[And if solar turns out to be wrong, then replying in earnest is still a good
response.]

------
kats
Nice!

