RE: BY CATHERINE S. JONES, RN, MSN/ANP-C. Choosing the best type of oxygen therapy Oxygen is one of the most important treatments available to patients with cardiopulmonary disease. Here's an updated guide to the equipment. i s primary-care providers have become The mos ommany A nereasingly adept at recognizing pa- aprdinelliel ad tients with lung disease, and pube eee cal Cennuta,.g, _ oXimetry has simplified the detection of hypox- ‘emia, the use of long-term oxygen therapy for adults has been on the rise. In the appropriate clinical setting, oxygen administration may be ‘one of the most beneficial therapies available to patients with cardiopulmonary disease. Nurse practitioners and physician assistants are the ideal patient advocates for directing oxygen therapy for those with hypoxemia. Long-term oxygen therapy has been shown to improve survival among patients with severe hypoxemia, Other proven benefits include im- provement in quality of life, cognitive fanction, and exercise capacity. A reduction in the fre- quency of hospitalizations for hypoxemic pa- tients with chronic obstructive pulmonary disease (COPD) has also been noted with oxy: gen therapy. Many patients welcome measures directed at improving cognitive function oF memory. Obviously, the merits of lon, oxygen therapy outweigh the negative effects, and clinicians should not let the intrusive tech- nologies interfere with prescription of oxygen in appropriate patients. ‘The most common chronic diseases requiring term assessment of oxygenation and consideration of oxygen prescription include COPD, interstitial lung disease (pulmonary fibrosis), cystic fibrosis, bronchiectasis, and pulmonary neoplasms. Other diseases that may present with hypoxemia in- clude pulmonary hypertension, obstructive sleep {©.GARO | PHOTO RESEARCHERS INC 60 THE CLINICAL ADVISOR + FEBRUARY 2008OXYGEN THERAPY It is important to remember that oxygen therapy relieves hypoxemia and prevents the complications associated with chronic tissue hypoxia. apnea, and congestive heart failure. Practitioners should be awvare of the chronic disease states that may present with hy- poxemia and monitor them accordingly It is important for clinicians and patients alike to remember that oxygen therapy relieves hypoxemia and prevents the complications associated with chronic tissue hypoxia. How- ever, symptoms of breathlessness and dyspnea do not go hand in hand with hypoxemia, The mechanisms of dyspnea ae litle related to oxygen levels. Patients can have significant hypox- ‘emia without major dyspnea, or conversely, they may have se~ vere dyspnea with completely normal oxygenation. Patients should be aware that they cannot judge their need for oxygen simply by shortness of breath— they require guidance from measurements of oxygenation. Diagnosing hypoxia Making the diagnosis of hypoxemia is relatively easy. Either pulse oximetry or arterial blood gas analysis is sufficient. Pulse ‘oximetry is markedly easier on the patientand can provide ad~ equate data to diagnose hypoxemia. If you suspect that a pa~ tient may have hypercarbia (high carbon dioxide in the blood stream) an arterial blood gasis the only option for analysis, Pulse oximetry measures the light absorption of the hemo- globin in the RBCs, with the absorption changingas the oxy- hemoglobin content changes. If pulse oximetry is measured by light absorption through fingernail beds, there should be ‘no nail polish. Nail polish (especially red) can falsely elevate saturation measurements. However, rotating the oximeter clip 90° sideways on the finger obviates the need to remove nail polish to measure the correct saturation. ‘Also be mindful that cold hands can throw off results—a situation easily remedied by gently warming the hands prior to measurement. Low cardiac output states may also make it difficul to obtain an adequate saturation level Individuals with suspected hypoxemia can be tested in vari- ous ways. During routine office vist, you can measure pulse oximetry when the patient is either at rest or walking. A pa- tient who has a normal oxygen saturation at rest may have hypoxemia with exertion; this patient may benefit from oxy- gen administration during exercise. Patients can also have oxygen saturation measured during exercise at pulmonary or cardiac rehabilitation Finally, if you suspect that your patient needs supplemental oxygen, testing oxygen saturation at night may be helpful. Frequently, nocturnal hypoxemia can be documented with simple nocturnal oximetry. If your office or clinical practice does not have this device, some durable medical equipment (DME) companies offer the service.A formal sleep study will not be needed unless you suspect a sleep-related breathing disorder, such as obstructive sleep apnea. Nocturnal oxygen, therapy is usually a more accepted form of oxygen to patients, since the embarrassment of wearing oxygen equipment in public is avoided. The Medicare indications for long-term oxygen therapy are shown in Table 1 Administering oxygen The most common delivery device for oxygen therapy is a nasal cannula. This device is usually well tolerated by patients and delivers oxygen at prescribed levels. Patients who breathe through their mouths may worry about receiving adequate oxygen. You can reassure these patients that adequate oxygen levels are achieved with the cannula in the nose.As a breath is taken through the mouth, the inspiratory effort pulls the oxy- gen from the nares into the oropharynx and into the rest of the respiratory system. Those with severe hypoxemia can eat, drink, and even shower with a nasal cannula in place. ‘Remind patients to prevent their nasal cannula from becom~ ing stiffand uncomfortable by replacing it routinely. There are even glasses (with or without prescription lenses) that incor porate a nasal cannula without calling attention to this deliv- ery device (for more information, visit www.oxyview.com).. Nasal dryness isa common problem associated with the use of nasal cannulas.The first solution is to add a water bottle hu- midifier to the oxygen source at home. Patients should be carefil to keep this humidifier clean and refill tas needed. An other helpful approach isto moisturize the nasal passages with an OTC balanced sine nasal spray Patients may use this spray as often as necessary without the worry of its interacting with other medications. ‘Continues on page 64 TABLE |. Medicare indications for long-term oxygen therapy (24 hours/day) + Avrest arterial blood gases showing Pig, 55%) THE CLINICAL ADVISOR + FEBRUARY 2008 63OXYGEN THERAPY Nonadherence is common. You can increase patient compliance by being knowledgeable about oxygen therapy and what devices are available. A subset of patients need high-flow oxygen or may be un= able to tolerate long-term oxygen therapy via nasal cannula foran extended length of time. A transtracheal catheter is one option for these individuals. A minor surgical procedure to insert a transtracheal catheter can be performed by a qualified physician. After the site has healed, the patient or caregiver is taught how to clean and change the catheter daily. This mini- mally invasive technique is underutilized After you have identified the at-risk patient and diagnosed hypoxemia, how do you prescribe oxygen therapy? Currently, a certification of medical necessity needs to be completed (only a physician can sign this form). Important aspects to consider when prescribing oxygen therapy are how the pa~ tient will be utilizing the oxygen (continuous, with exercise only, nocturnal only), the required flow rate in liters, and the type of delivery device that will be prescribed. Nonadherence to oxygen therapy is common. Clinicians can increase adherence (and the benefits of preventing hypox- emia) by being knowledgeable about oxygen therapy and the delivery devices available, Simple changes in oxygen devices can greatly improve your patients’ quality of ife. The three forms of oxygen Oxygen can be delivered in three basic ways: via concentra- tor, compressed oxygen gas, and liquid oxygen. The least ex- pensive and most efficient method to deliver oxygen therapy at home is via an oxygen concentrator. This device uses elec~ tricity to extract nitrogen from room air and delivers oxygen that is 95%-96% pure. Concentrators are reliable and rarely require service (except for cleaning the filter). Extended cords for the nasal cannula can be added to allow the patient to use this device throughout the home.At times, concentra- tors can be loud, so the patient may want to put the device in room other than the bedroom ifit disturbs sleep. Electrical power outage is a potential drawback. Patients frequently keep a tank of compressed oxygen at their home for emer gency use, Some concentrator units allow patients to fill their ‘own portable oxygen tanks. Alternatively, portable oxygen tanks can be home-delivered by the DME company. Some patients have only a large gas cylinder for their primary oxy- gen source at home, which must be replaced by the DME company as necessary. Liquid-oxygen systems operate by cooling oxygen to 183°C and forcibly compressing it so it becomes a liquid.A lange liquid-oxygen container is required, which the DME 64, THE CLINICAL ADVISOR + FEBRUARY 2008 company refills on a scheduled basis. From this large contain er,a liquid portable system can be filled by the patient or fam- ily member. All oxygen-delivery systems are reliable;insurance coverage and personal preference guide the selection and prescription. DME companies can only provide what is prescribed: this is when knowledge about the different oxygen systems be- ccomesso important. Portable systems Portable systems are critical for maintaining independence and «quality of life for hypoxemic patients. Several good options are available, such as portable gas cylinders or liquid-oxygen sys- tems, By using pulses of oxygen rather than continuous flow, conserving devices on portable systems make oxygen supplies last longer. Pulse devices deliver oxygen on every breath or on. alternate breaths at a fixed volume, By comparison, demand devices deliver oxygen only with each inhalation. Demand de- vices vary delivery with the patient's inspiratory effort and du- ration, whereas pulse devices deliver at a preset volume and rate, Conserving units may be pneumatically driven or require batteries for delivery. Before selecting one of these devices, ‘make sure the patient’ inspiratory effort is sufficient to trigger the demand valve Demand for oxygen varies with activity. Test the oxygen saturation at rest, with exercise, and during sleep to ensure adequate oxygenation, For example, a patient may require oxygen at 1 L/minute at rest, 3 L/minute with exercise, and 2 L/minute at night. A desirable oxygen saturation level is usually in the low 90s or higher. How long portable oxygen tanks with conserving devices will ast depends on the patient's prescribed flow rate and the ATA GLANCE ‘© Long-term oxygen therapy has been shown to improve survival among those with severe hypoxemia. ‘© The most common diseases for which one should consider ‘oxygen are COPD, interstitial lung disease, cystic fibrosis, bronchiectasis, and pulmonary neoplasms. ‘© Pulse oximetry is markedly easier on the patient than arterial blood gas analysis. (© Oxygen can be delivered in three basic ways: via concentra tor, compressed gas, oF liquid.(olopatadine aday/\ ophthalmic solution) 0.2% wean Ao sce PRULN ner ee eae ack uy meas eg cnr couranoxanons Poway a cnconns ef Psp ova cdr anon at eto ale rrcaumons ‘ors orate ‘may se pet ctype! ea so ashe an at ‘arn ees ueuang aos wore ore le tle. pee Dh ad we Ix Paes sl be ans eta ef ee. PRADA apa oto cp saa) 2% ap be do al cia ee ‘eax he eset RO Docahonum Ce ma be bere Catt ss Pats eo woe ad whee ee ele. 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Atan Cones etn Lt cine efi of ae tie ane ‘i eta am tg re Alcon sic LABORATORES, Ne Fer fxs OXYGEN THERAPY size of the tank. The optimum tank should be lightweight with a conserving device and fit into a shoulder bag for portability Patient outings and oxygen consumption should be planned for accordingly. ‘There are several liquid-oxygen systems available, but two stand outabove the rest. Both have been praised by patients for case of use and facilitating independence. ‘The Helios system (wwwheliooxygen.com) offers two models: the Helios Plus and the Helios Marathon. The He~ lios Plus is only 10 inches tall, weighs 3.6 Ib when filled, and lasts approximately 10 hours on demand flow. The Helios Marathon is 15 inches tal, weighs 5.6 Ib when full, and can, last up to 20 hours. Each model provides either continuous or demand flow depending on the patient’ needs. Both come with a bele clip or can be carried by backpack or shoulder bag. ‘The EasyMate, manufactured by Precision Medical (wwwprecisionmedical.com), is 8.2 inches high, weighs 3.6 Ib when filled, and lasts approximately eight hours. Its quite durable and also comes witha form-fitting carrying bag. Portable oxygen concentrators are now commercially available. The three units available at this time are the Inogen One (www.nogenone.com), the EverGo by Respironics, and the SEQUAL Eclipse by SeQual: These portable devices run on batteries, or they can be plugged into an electrical wall outlet or DC car adapter. The Inogen portable concen trator weighs 9.8 Ib, and the rechargeable battery lasts for three hours. ‘These units are fairly expensive and may not be covered by insurance. One of the biggest advantages of a portable con- centratoris that itcan be used for travel,including on mostair- lines. By federal law, if an airline allows oxygen in flight, a portable concentrator may be utilized by the hypoxemic indi- vidual. Currently, patients cannot use or carry portable tanks or liquid oxygen systems on flights. All arrangements for oxy- gen therapy must be approved by the airline well before the flight; additional costs are paid by the patient. Several DME, companies rent portable oxygen systems for travel and other special situations, Oxygen therapy clearly improves quality of life for hypox- mic individuals. To optimize therapy, clinicians must partici- pate in designing the most appropriate system for each individual patient. ‘Ms Jones is a COPD course leader and trainer with the National Respiratory Training Center and has an ofce-based acuteare practice _foradult pulmonary patent in Bedford, Te.