Oxygen Delivery Systems: Performance Variables that May Affect Outcomes

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Oxygen Delivery SystemsPerformance Variables
that May Affect Outcomes

• Robert McCoy BS RRT FAARC

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Gaps Between Titration Settings at Discharge Vs.
Titration on Home Device

• Premier pulmonary rehab reviewed 65 patients post
  discharge
• Treadmill test to evaluate ability of home device
  to meet 90 saturation goal.
• 60 did not meet target 20 needed setting
  adjusted upward 40 could not be titrated at any
  setting (replaced device).

Source Changes in Supplemental Oxygen
Prescription in Pulmonary Rehabilitation, Limberg
et al, Resp Care Nov 06 Vol 51 (11), pg 1302.
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Oxygen Delivery is Fixed, Patients are Variable

• Patient variables
• Respiratory rate
• Tidal Volume
• Ventilation/perfusion
• Heart rate
• Conditioning
• Secretion
• Psychological

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The Goals of LTOT

• Maintain proper oxygen saturations at all
  activity levels
• Rest, exercise, sleep
• Travel, work, social
• Prevent
• Exasperations, hospitalizations, physician visits
• Equipment related complications
• Efficiency
• Provide the best therapy at the lowest cost

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Solutions for LTOT and Exercise?

• Understand the patients oxygen needs at all
  activity levels and titrate for effective
  oxygenation
• Understand the capabilities and limitations of
  oxygen delivery systems
• Monitor the patient for changes and trends in
  oxygenation
• Oxygen equipment is a tool in the hands of a
  knowledgeable person to gain positive results

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Graphic on Response to Increased Respiratory Rate
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Adequate Saturation

• What is acceptable?
• Why?
• Based on?
• Patient variability
• Oximeter variability
• Trends

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Performance variables impact the accuracy of
pulse oximeters The graphs indicated the
variability of pulse oximeters tested on human
subjects at different oxygenation ranges
White Paper Maximizing the Laboratory Setting
for Testing Devices and Understanding Statistical
Output in Pulse Oximetry Paul B Batchelder,
RRT Clinimark Laboratories, Colorado November 30,
2006
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Oxygen Delivery Fundamentals
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Pulse OCD
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Demand OCD
Note Varying Tail Flow at Same Setting
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Average Total Dose Setting
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Full Dose vs. Useful Dose
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Portable Oxygen Systems
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Equipment Variability

• OCD settings
• Maximum dose
• Impact respiratory rate
  has on dose
• Oxygen purity
• Delivery system
• Cannula
• Others

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Liquid Oxygen (LOX) Options
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Issues Related to Liquid Oxygen

• Portables have the best weight to range ratio
• Purity is 99.8
• Quiet (so are cylinders)
• Highest (practical) flow capabilities for a
  portable
• You have to use it or loose it they leak
• Fixed range they have to be refilled
• No heat, electricity or noise (stationary)
• Going the way of the dinosaurs??

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Concentrator Filling PortableNon-Delivery Systems

• No delivery costs or scheduling
• Issues
• Fill times
• Use times
• Oxygen purity
• OCD/ dose capability
• Electricity

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Liquefier and auto Dose
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Clinical Oxygen Dose Recorder (CODR)

• The CODR records heart rate and oxygen saturation
  data provided by the Pulse Oximetry system,  flow
  and pressure data from the oxygen delivery
  system, and tracks breath rate and inhale/exhale
  ratio (IE ratio) by monitoring the flow in the
  oxygen delivery tubing, and displays this data in
  real time to enable the clinician to view  the
  effects of the oxygen devices delivery
  performance on a patient as they rest and
  exercise.

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CODR

• The CODR is an inline device that connects
  between any O2 delivery device and a patient
• Monitors and collects the patients breathing
  data.
• Monitors and collects the oxygen flow / dose
  data.
• Interfaces with a pulse oximeter to give SaO2 and
  Heart Rate data.
• It sends the above data to a PC via an RF
  wireless transmitter, or saves the data to an SD
  Card for later analysis.
• Header information can be added to a file with
• Patient ID
• Clinician ID
• Oxygen device
• Oxygen device flow setting
• Other comments can also be added
• An accompanying PC program shows all of this data
  in real time as well as saving the information
  to a file for viewing later.

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Continuous Oxygen Recording Device CORD
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Screen Data
The waveforms can be turned on or offor can be
recorded for viewing later
This area shows the patient data
This area shows the oxygen dose data
This shows oxygen dose graphically
This graph shows breath pressure
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Trend Data
File information (Header Data) shown here
Patient Breath Rate
IE Ratio
SaO2 Heart Rate
Oxygen Dose
Comments and alerts show up here
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Research

• Evidence based, historical check the dates
• Equipment, is it still available
• Equipment performance varies, you need to know
  how the device operated
• If it is not available and does not perform like
  current products, evidence is of little value for
  practical purposes
• Patient selection
• How were the patients selected and what were the
  variables on the day of testing
• Methods and material
• Conclusions

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Hospital Days Per Year
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Current

• Limberg T, Colvin R, Correa M, Costello R, Morgan
  C, Ries A. Changes in supplemental oxygen
  prescription in pulmonary rehabilitation, Respi
  Care 2006 51111302 (abstract)
• Subramaniam V, The Difficulty in Oxygenating an
  Ambulatory Server Chronic Obstructive Pulmonary
  disease patient, AARC 2007 Abstract
• McCoy R, Gay P, Petty T, Cain C, Lotz G. Portable
  Oxygen Concentrating Device Comparison during
  Exercise, ATS International Conference Abstract
  2007

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Research New Products and Procedures to
Continually Improve

• New Products are entering the market
• How are they developed
• How are they tested
• What is their value and need
• New procedures come from research or experience
• What works? How do you know?
• Patients are the best teachers of procedures that
  work for them

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Understand the EnvironmentAdapt to Meet
Patients Needs

• The home is not the hospital
• Uncontrolled environment
• Patient driven
• Understand the patients and educate on how to get
  the best results from their therapy
• Patients will tell the clinician what they want,
  you tell them what they need. negotiate

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Conclusion

• LTOT Factors That Influence Effective Delivery
• Patient variables
• Equipment variables
• Environmental variables
• Recommendations
• Titrate the oxygen patient on the device and the
  activity level they will be using oxygen
• Educate the patient on factors that could impact
  therapy
• Monitor the patient for changes

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Robert McCoy bmccoy_at_inspiredrc.com
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References

• 1. New Problems in Supply, Reimbursement and
  Certification of Medical Necessity for Long Term
  Oxygen Therapy. Summary of the Third
  Consensus Conference held in Washington, DC,
  march 15-16, 1990 Am Rev Respir Dis
  1990142(3)721-724
• 2. Nocturnal Oxygen Therapy Trial Group.
  Continuous or nocturnal oxygen therapy in
  hypoxemic chronic obstructive lung disease a
  clinical trial. Ann Intern Med 198093,391-398
• 3. Petty, TL, Bliss, PL Ambulatory oxygen
  therapy, exercise, and survival with advanced
  chronic obstructive pulmonary disease the
  Nocturnal Oxygen Therapy Trial revisited. Respir
  Care 200045,204-213
• 4. Bliss PL, McCoy RW, Adams AB Characteristics
  of Demand Oxygen Delivery Systems Maximum Output
  and Setting Recommendations Respir Care
  200449(2) 160-165
• 5. Doherty DE, Petty TL Recommendations of the
  6th Long-Term Oxygen Therapy Consensus Conference
  Respir Care 2006 51(5) 519-525
• 6. Oxygen Therapy in the Home or Alternate Site
  Health Care Facility2007 Revision Update.
  Respir Care 2007 52(1) 1063-1068