Tonya Zeiger RRT, CPFT

Associate in Pulmonary Medicine

Mayo Clinic

Jacksonville, FL

DisclosuresTonya Zeiger:

Consultant/Speaker/Advisory Board for Actelion/United Therapeutics

This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with the Pulmonary Hypertension Association. Neither PESG, nor PHA, nor any accrediting organization support or endorse any product or service mentioned in the is activity.

PESG and PHA staff has no financial interest to disclose.

Commercial Support was not received for this activity.

Learning ObjectivesAt the conclusion of this activity, the participant will be able to:

1. Formulate and express an appropriate plan of action for their

patient's oxygen prescription based on their patient's necessary flowrates.

2. Differentiate between portable oxygen liter-flow requirements

with portable oxygen concentrators (POCs), demand valve

oxygen systems, self- fill oxygen tanks, continuous flow tanks

and liquid oxygen systems.

3. Think through viable alternatives for the outpatient who requires a high Oxygen (4-15 LPM) flow.

All time favorite quote…

“There is no more potent vasoconstricting force than hypoxemia. Therefore, no pulmonary hypertension medication can work optimally in a hypoxic environment…”

Dr. Charles Burger

To patients it’s usually phrased as: All of the medications you take are to open up your blood

vessels. When you let your Oxygen levels drop to <90% and don’t use your Oxygen appropriately, your body’s response is to constrict those same blood vessels your medications are trying to open up.

Oxygen (O2) Challenges Mass marketing to patients

Misinformation from suppliers and/or manufacturers regarding equipment capabilities

Disappointment and anger when you relay the inability of the equipment or devices capabilities to the patient and/or the patient’s family

Difficulty with getting appropriate portable oxygen systems for patients within their insurance allowances

Challenges with O2 companies “reimbursement” issues and multiple CMNs required or delayed equipment delivery to the patient

What do we “need” to script? The constantly evolving question…

Oxygen saturation <89% or PO2 <56 mmHg at rest on room air (can be with sleep but patient will NOT receive a portable source of O2 with the prescription)

If Oxygen saturation is > 88% or PO2 is > 55mmHg and you want portable Oxygen provided, you need to exercise the patient or show a desaturation (on room air) to these numbers or less

During the same “visit” you must place the patient on supplemental Oxygen and show that the patient has improvement while on the additional O2. They want to see that the patient does not desaturate to < 89% SpO2 or <56 mmHg with exertion (if that’s how you qualified the patient).

O2 titrationFIO2 SaO2 Heart Rate Activity

.21 98% 65 sit/rest

.21 87% 115 after 2 minutes walking in hall

2 lpm continuous flow

nasal cannula

98% 58 sit/rest after 10 minutes (preload)

3 lpm continuous flow

nasal cannula

92% 105 at 1 min walking in hall, patient's SaO2

decreased to 89%. Increased flow to 3

lpm for additional 3 minutes

3 lpm continuous flow

nasal cannula

97% 72 Recovery - 1 minute post exercise

Pulse oximetryCan be extremely useful for:

• Establishing a baseline value in patients with stable disease

• Monitoring of patients with exercise-related dyspnea.

• Titrating oxygen flow setting in patients on long-term oxygen therapy, provided their

disease is stable and they have good circulation. In general, the goal should be to maintain

SpO2 > 90% during all activities.

• Evaluation of patients with severe disease (FEV1 < 50% predicted), cyanosis, or cor

pulmonale for possible respiratory insufficiency/failure.

• Assessment of patients with acutely worsening symptoms, especially dyspnea, and

determination of the severity of the exacerbation.

Use with caution if:• SpO2 values < 80% - Pulse oximeters can overestimate oxygen saturation, particularly in those with

darkly pigmented skin.

• Poor perfusion (cold digits) due to hypotension, Raynauds’s, hypovolemic shock, cold environment, or

cardiac failure - May result in the machine not providing a reading (or an inaccurate reading).

• Anemia- Oxygen delivery to tissues is inadequate but SpO2 is normal.

• Carbon monoxide poisoning- Carbon monoxide binds to hemoglobin, resulting in inadequate oxygen

transport despite normal pulse oximeter readings.

• Movement, shivering patient, heart arrhythmias-Oximeter may not be able to identify an adequate pulse

signal.

• Nail polish, dirt, artificial nails- Can cause false low readings or no readings

Additional necessities The patient must have a face to face visit with the ordering

physician within 30 days of the prescription and have noted the necessity for Oxygen supplementation in his visit note

The qualifying testing must be within 30 days of the prescription AND delivery of the equipment NOTE: Acknowledgement of the order receipt IS NOT the same as

delivery of the equipment

If the patient’s liter flow is >4 lpm, Medicare requires documentation of desaturation while the patient is on 4 lpm

If these qualifications are not met, the DME company WILL ask that you have an additional face to face visit and new qualifying testing.

Oxygen prescription requirements What is the order for?

Patient requires oxygen What is the amount required?

Patient requires Oxygen at 2 LPM continuous flow How do you want it administered?

Patient requires Oxygen at 2 LPM continuous flow via nasal cannula When is it necessary?

Patient requires Oxygen at 2 LPM continuous flow via nasal cannula with sleep and exertion

If patient requires Oxygen for portability, it must also be included in the prescription (if there’s a preferred method of delivery) Patient requires Oxygen at 2 LPM continuous flow via nasal cannula with sleep and

exertion. Liquid O2 is required for patient portability.

Diagnosis codes Physician NPI (on original script) Is patient mobile in their home? Length of need Physician signature

Portable Oxygen options Standard aluminum tanks of compressed Oxygen Standard aluminum tanks of compressed Oxygen with demand valve

conserver Patient only gets O2 upon inhalation

Portable Oxygen Concentrators (POCs) Can be either demand or continuous flow

Self fill Oxygen systems Can be either demand or continuous flow Home concentrator’s ability to provide flows diminishes as patient is

filling their portable tanks Portable tank is filled with whatever concentration the patient’s home

unit concentrates to (can be as low as 86% O2) May not be an issue when patient requires low flows but at high flows can be

insufficient

Liquid Oxygen

Top question on everyone’s mind…

How can I get the highest liter flow for my patient with as much portability as possible????

Demand or “Pulse” Conserver DevicesCONSIDERATIONS

What is the patient’s respiratory rate?

What is the continuous liter flow required?

Will the conserver allow continuous flow, if necessary?

How quickly does the patient respond to oxygen flow increase?

Conserver technology has been integrated with various current oxygen options

Types of Demand or Pulse Conserving DevicesPneumatic Senses initial negative pressure as patient starts to inhale Delivers a fixed pulse of O2 at beginning of inhalation, followed by a

continuous flow until it senses the beginning of exhalation Thus, some have a dual cannula (1 attached to sensing port; 1 to oxygen port)

ElectricIntermittent-breath delivery: Senses breath initiation and fires based on the setting of the device If setting is #1,will deliver 1 pulse of a fixed volume of O2 for every 4 breaths

sensed; #2 will deliver a pulse of O2 every other breath; #3 will deliver a pulse of O2 on 3 out of 4 sensed breaths; #4 will deliver it every breath

Provides a fixed volume and variable frequency device

Every – breath delivery: Uses smart technology to sense negative pressure that patient generates at

inhalation The solenoid opens every time the sensor signals; length of time it remains open

depends on “pulse” setting. The higher the pulse setting, the longer it is open, thereby increasing flow to the patient

Provides variable volume but fixed frequency (i.e., delivers a pulse with every sensed breath. Number on the dial controls the amount delivered per pulse, and while manufacturers compare it to L/min, in truth its actual dosing is in cc / breath

Oxygen tank sizes and usage chartsPneumatic

Electric

Intermittent-breath delivery

Every – breath delivery

Portable concentrators or self-fill systemsImages are NOT scaled. Size/proportions, weights and specifications are on subsequent slides.

Portable Oxygen

Concentrators

PortableOxygen

Concentrators

Home Fill Oxygen SystemsInvacare Homefill System

Adds on to any 5 lpm or 10 lpm Invacare concentrator to fill oxygen cylinders from size M2 – D.

Oxygen: Output from 5-Liter concentrator:

0 - 3 lpm (while filling cylinder) Cylinder Filling Times:

M2: 24 min; ML4: 55 min;

ML6: 75 min; M6: 60 min;

M9: 125 min; D: 3.5 hrs

Devilbiss ifill System

Stand alone concentrator and fill system. Fills cylinders M4, M6, ML6, C, D and E.

Unable to find data regarding output of concentrator while filling tanks.

Can provide 0.5 – 6 lpm (when not filling cylinder)

Cylinder Filling Times:

M4 : 60 Min; M6: 75 Min;

ML6: 90 Min; C: 130 Min;

D: 215 Min; E: 350 Min

WARNING! Demand devices for all Oxygen delivery

equipment operate differently (including portable oxygen concentrators). If you titrate your patient’s need based on what you have in your office, it may be VERY different than what the DME company is going to supply. Could order an O2 titration to be done by the DME

company

If the patient is purchasing a POC, let them know that some companies offer a 30 day trial and have them seek one out Costly and disappointing if they pay for something that

cannot provide them with what they need.

Things to look for regarding POCs Look at whether it can provide continuous flow

Could be an issue if they are planning on using it for overnight trips and it has to be connected to a CPAP or BIPAP machine

Consider what your patient requires in your office If they only require low flows, they may be able to be fine

with a POC that will only provide demand flow but if they require higher flows, they may need a different portability option

Look at the total amount of Oxygen it can produce If it only has the capability of concentrating 900 ml/minute, it

cannot give the patient 2 LPM

What about patients who need more than 3LPM Oxygen flow? Standard aluminum tanks of compressed (100%) Oxygen

Don’t last very long Cumbersome for patient

Portable Oxygen Concentrators (POCs) that provide continuous flow up to 3 LPM with a high flow (reservoir) conserving device Continuous flow models tend to be heavier than pulse dose models Oxygen concentration delivered is < 100%

Self fill Oxygen systems Possibly OK with continuous flow with high flow (reservoir) conserving device Home concentrator’s ability to provide flows diminishes as patient is filling their portable

tanks Probably only a viable option for patients who require up to 5 LPM due to concentrator flow delivery

decreasing while tank is being filled and portable tank Oxygen concentration < 100%.

Liquid Oxygen Has the ability to give up to 15 LPM (100% oxygen) with continuous flow Cumbersome for patient (both for filling and carrying) VERY limited DME companies to provide

High Flow Conserving Devices

OxyMask by Southmedic

OxyArm

by Southmedic

Pendant Oxymizer

Mustache Oxymizer

High flow reservoir conservers Cannot be used with pulse flow devices Should not be used with added humidity

Concerns regarding bacterial growth in reservoirs if they get wet

Higher cost of delivery for DME companies Smaller DME companies may not supply them

MUST be prescribed as the delivery device Be clear on the prescription that the flowrate prescribed is

WITH the use of the conserver Patient requires 4 lpm continuous flow via nasal oxymizer

with exertion

CAN decrease the required oxygen flow by 25-50% Needs to be individually titrated with the device Depends on the patient’s respiratory rate and tidal volumes Flowrate adjustments should NOT be assumed

Transtracheal Oxygenation Must have appropriate/specialized care for insertion and

follow up Surgical insertion initially

Follow up care can be challenging Many questions regarding who “manages” the

follow up

Many DME companies decline providing the necessary supplies for the therapy Supplies are costly

Medicare coverage is the same no matter what the cost of supplies (to the DME company) are

Decreases the necessary liter flows required to keep the patient oxygenated (by decreasing the patient’s pharyngeal dead space)

What High-Flow Users Need to Know!

High-flow users need to be aware of the following:

Pulse systems. High-flow users prescribed 6 lpm or more must use continuous flow from either compressed or liquid oxygen systems.

Liquid oxygen. For portable use, liquid oxygen is more efficient than compressed oxygen. Liquid oxygen is stored under less pressure (21 psi) than compressed oxygen (2,000 psi), meaning that liquid oxygen does not need the extensive and weighty physical protection that compressed oxygen requires.

The liquid oxygen container is simply a thermos type container that minimizes warming and evaporation.

How Long Will High-Flow Oxygen Last?

Settings * (lpm)

Dual D Cylinders

ECylinders

Caire’s High-Flow

PuritanBennett’s

Companion T

4 3.4 2.7 4.4 4.4

6 2.2 1.8 2.9 2.9

8 1.7 1.3 2.2 2.2

10 1.3 1.1 1.8 1.8

12 1.1 0.9 1.5 1.5

15 0.9 0.7 1.2 1.2

Compressed Oxygen Systems Liquid Oxygen Systems

Duration Estimates (in hours)

* All also have these settings: 0 (Off), 0.5, 1, 2, 2.5, and 3

There Are Answers to Difficult Oxygenation Issues It can be frustrating and time consuming, but it is achievable.

Teamwork between the MD’s office and home oxygen company is imperative to reach an acceptable compromise between patient comfort, portability, and overall effectiveness

If the patient feels it’s too cumbersome, he or she won’t use it.

If it’s ineffective and the patient doesn’t do better with it, he or she won’t use it.

Once the patient is comfortable with the delivery options and understands the pros and cons of each device, he or she can make an informed decision. Together you can come up with a viable action plan.

TAKE HOME MESSAGES!!!! Keep in mind that the numbers on the demand (or conserving device)

ARE NOT equal to liters per minute but ARE related to ml / breath and vary by device.

No matter how adamant a patient or DME provider is regarding the capability of equipment, always question.

There is NO PORTABLE Oxygen concentrator to date that can or will provide > 3 LPM to a patient

If they are using demand equipment, during a crisis, the patient may be better off changing from demand to continuous flow Oxygen during the crisis moment (even if the available “number on the dial” is less)

Always ask your patient if they fill their portables at home or if they are delivered full from their DME company Especially important if the patient is desaturating with their portable

tanks but stays appropriately saturated with tanks provided by your institution

Obtaining CME/CE CreditIf you would like to receive continuing education credit for this activity, please visit:

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