Got Oxygen? Assessment and Titrations of Portable Oxygen Systems

KITTY COLLINS, RRT, BSHS SENIOR RESPIRATORY THERAPIST CARDIOPULMONARY REHABILITATION ST. DAVID’S MEDICAL CENTER AUSTIN, TX [email protected]

Objectives  Discuss Medicare guidelines for home oxygen therapy  Describe variances in portable oxygen therapy devices  Explore selection of portable oxygen therapy to the individual in pulmonary rehabilitation

I will be mentioning several products in this presentation and am not endorsing any particular one.

Questions? What is a safe level of oxygen to give someone with COPD? You have a patient in Cardiac or Pulmonary Rehab that requires 4 LPM CF (continuous flow) to maintain an O2 Sat of > 90% on the Treadmill at 1.0 mph. The patient uses a POC (Portable Oxygen Concentrator) @ the physician prescribed setting of 3 LPM with activity. Is this acceptable? Would it be acceptable at a setting of 4?

Wearing Oxygen Embarrassment wearing in public Associated with a stigma Reduced sense of taste and smell Nose dryness Runny nose Sore ears Fear Difficulty receiving appropriate oxygen and supplies

Removing Stereotypes

Wearing Oxygen is a Huge Adjustment

NOTT (Nocturnal Oxygen Treatment Trial) Study

Hospital Oxygen

Portable Oxygen Delivery Systems

Qualifying for Home Oxygen  An arterial PO2 < 55 mm Hg or arterial oxygen saturation < 88% breathing room air or  An arterial PO2 56-59 mm Hg or arterial oxygen saturation < 89% with evidence of:

1) Dependent edema suggestive of CHF 2) Pulmonary Hypertension or Cor Pulmonale 3) Erythrocythemia with Hematocrit > 56%

Oxygen Reimbursement STATIONARY OXYGEN

$180.92 2015/137.04 2016/$77 (Latest proposal)

PORTABLE OXYGEN

$16.00 (Latest proposal)

Medicare Changes to LTOT

Deficit Reduction Act 2005-Medicare Improvements for Patients & Providers 2008

 36 month cap on reimbursement for stationary concentrator  After 36 months small stipend for O2 checks every 6 months and must continue to provide maintenance & supplies  Must provide oxygen if patient travels or moves out of their area  No Medicare reimbursement for RT services for home oxygen assessment

Competitive Bidding July 2013 The Competitive Bidding program means companies (DME’s-Durable Medical Equipment) that provide oxygen equipment submits bids to Medicare reflecting the lowest price they can provide for the supplies. Medicare then chooses approved companies (called contract suppliers) and sets the price based on the bids that they received

End Effect of Competitive Bidding Medicare reimbursement for oxygen services decreased by 41% DME companies are unable to provide extra services and deliveries due to the cost of providing the service There is a new proposal to decrease Medicare reimbursement services to DME providers by 25% more!!!

Oxygen Delivery Fundamentals

IF – Intermittent Flow & PDPulse Dose Used 80% of the time in home care for portable oxygen Delivers volume not flow Requires an interface that will deliver a breath Few clinicians understand IF capabilities and limitations

Tank Duration – IF(Intermittent Flow) vs CF(Continuous Flow)

Where and How are Patient’s Assessed? Hospital discharges – usually on CF compressed gas Physician’s offices Home care Pulmonary Rehabilitation

Oxygen Prescription CMN-Certificate of Medical Necessity  Diagnosis  Oxygen Flow Rate  Duration of Use, Frequency, and LPM 24/7 for lifetime) PRN does not meet requirement

Duration of Need (2

Oxygen Assessment-ATS (American Thoracic Society) Recommendations Rest Exertion Sleep Altitude

Stationary Oxygen Concentrators  Little service needed  Low cost to provider  Produces oxygen 85%-95% purity Flow range 1-5 LPM  Some units can go to 10 LPM

Portable Oxygen Systems

Portable Oxygen Tanks Cylinder purity typically 99% Issues:Size/Weight 1. Delivery, storage, and distribution are issues 2. Safety 3. Not all regulators are created equal

Self-Fill Home Oxygen 1. Pt. can fill at home without depending on deliveries of tanks 2. Purity on filled tanks is the same as on stationary concentrators (9095%) 3. Can usually do PD and CF

Liquid Oxygen Systems 1. 99% purity 2. Lightweight 3. Lasts longer than tanks 4. Most DME’s no longer supply because of the cost

POC’s (Portable Oxygen Concentrators)

1. Only portable oxygen that can be used on an airplane 2. Can be plugged in to car, electric, or run on battery 3. Several offer CF & IF capabilities together 4. Purity averages 85-90% 5. Pulse volumes vary widely

Product Variability Bolus Volume Trigger Sensitivity Trigger Response Time DIFFERENCES MAY BE RELEVANT

Respiratory Rate Impacts Oxygen Dose  Exercise compounds device shortfalls, some devices deliver less oxygen as RR increased  Delivery method is as critical as volume of dose, measuring patients during exercise is key to accurate titration

Oxygen Prescription “Titrate as you Migrate” Source Mode and Method of Delivery Duration of use Rest, Sleep, and Exertion (activity out of chair) LPM with CF Numbered Setting With OCD

Travel Considerations

Device Related Saturation Shortfalls Uncovered Gaps between titration settings at discharge vs titration on home device with 65 patients: 1.

60% did not meet 90% saturation goal

2.

20% needed setting adjusted upwards

3.

40% could not meet goal at any setting and required a different device

Assessing Patients  What are the patient’s respiratory mechanics?  What is the prescribed liter flow?  How severe is the patient’s disease state?  Does the patient travel?  Can they walk or exercise on IF setting?  What if any physical limitations does the patient have?

Case Study 72 year old gentleman with Bronchiectasis/COPD during 6MWT on CF 4 LPM is able to walk 1000 ft without stopping and lowest 02 sat is 91%. Pt uses an Inova Activox at a setting of 3 for portable system. Walked pt. on Activiox PD 3 and sat decreased to 87%. Reviewed POC’s and pt. requested an Inogen that went to a PD of 5. Pt. was unable to keep sats >than 90% with exercise and activity. Pt. plans to exercise at home but does not wish to give up POC.

Solution Pt. can rent E tanks from DME for $10/tank Assessed pt. on treadmill and nu-step with E tank and Smart Dose @ a pulse of 5 Lowest sat was 93% and pt. only used 300-400 PSIG

Case Study 35 year old female with pulmonary complications from systemic lupus and Sjorgen’s disease. Pt is ordered for 2 LPM and is using a D cylinder with PD 2. Pt. works full time, is getting married and has a 5 year old son. 6MWT pt. was able to ambulate 1120 ft and on NC 2 LPM lowest sat was 94%. Walked pt. on her portable oxygen at PD 2 and lowest sat was 92%.

Solution Pt. O2 needs are low. Pt. needs a lighter portable system. Pt. would benefit from a POC that she can plug in when she goes to work. Assessed pt. on RA @ rest and sats > 90% Contacted MD and pt. is waiting on a POC to be delivered.

Case Study Pt. is a 79 year old male with GOLD Stage IV COPD and severe hypoxemia. Pt. recently was diagnosed with pulmonary hypertension. Requires 10 LPM Oxy-mask during seated aerobic activities. Ambulation needs are > 6 LPM. DME limiting amount of tanks being delivered.

Solution High Flow stationary concentrator at home Reservoir Cannula Ability to have high flow continuous during ambulation and lowest PD when resting. Double stroller with 2 E cylinders- one for CF the other PD

Helping our Patients be More Mobile

Breathe Technologies-NIOV

6th Oxygen Consensus Conference

 Measurement of baseline oxygen tension and/or oxygen saturation is essential before oxygen therapy is begun.  Measurements of oxygen saturation also should be made to determine appropriate oxygen flow or PDOD/DDOS setting for ambulation, exercise, or sleep.  STANDARDS should be further developed to support clinical practice guidelines.  LTOT should be incorporated into disease management.  Patients with intermittent devices should be assessed and settings should be titrated.

Recommendations from the 6th Oxygen Consensus Conference on LTOT, Respiratory Care 2006;51(5)519-522

Goals of LTOT - Summary

Maintain proper oxygen saturation at all activity levels 1. Rest, exercise, sleep 2. Travel, work, social Prevent 1. Exacerbations, hospital visits, physician visits 2. Equipment related complications Efficiency 1. Provide the best therapy at the lowest cost Cardiopulmonary Rehab should incorporate assessment of patient’s portable oxygen systems and work with patients physician and DME to ensure appropriate setting and device.

Helpful Web Sites  LTOT Network - http://www.ltotnet.org/index.htm  Portable Oxygen a Users Perspective http://www.portableoxygen.org/  CMS Competitive Bidding – http://www.dmecompetitivebid.com/palmetto/cbic.nsf/CB AMap o http://www.aarc.org//app/uploads/2014/08/portable_oxyg en_concentrators_guide.pdf

Questions?