Annals of Tropical Paediatrics (2010) 30, 87–101

Oxygen concentrators: a practical guide for clinicians and

technicians in developing countries

T. DUKE*{, D. PEEL*{, S. GRAHAM*1, S. HOWIE**, P. M. ENARSON1 &

R. JACOBSON{{

*Centre for International Child Health, University of Melbourne Department of Paediatrics, MCRI, Royal
Children’s Hospital, Parkville, Victoria, Australia, {School of Medicine & Health Sciences, University of
Papua New Guinea, {Ashdown Consultants, United Kingdom, 1International Union Against Tuberculosis &
Lung Disease, **Medical Research Council Laboratories, The Gambia and {{AirSep Corporation, Buffalo,
New York, USA

(Accepted February 2010)

Abstract Hypoxaemia is a common problem causing child deaths in developing countries, but the cost-effective
ways to address hypoxaemia are ignored by current global strategies. Improving oxygen supplies and the detection
of hypoxaemia has been shown to reduce death rates from childhood pneumonia by up to 35%, and to be cheaper
per life saved than other effective initiatives such as conjugate pneumococcal vaccines. Oxygen concentrators
provide the cheapest and most consistent source of oxygen in health facilities where power supplies are reliable. To
implement and sustain oxygen concentrators requires strengthening of health systems, with clinicians, teachers,
administrators and technicians working together. Programmes built around the use of pulse oximetry and oxygen
concentrators are an entry point for improving quality of care, and are a unique example of successful integration of
appropriate technology into clinical care. This paper is a practical and up-to-date guide for all involved in
purchasing, using and maintaining oygen concentrators in developing countries.

Introduction Therefore, it is likely that there are at least

Every year nearly 2 million children die from
pneumonia or other acute respiratory infec-
tions.1 Hypoxaemia is the major fatal
complication of pneumonia and is a major
risk factor for death. The global burden of
hypoxaemia is very large. It is estimated that
at least 13% of children with severe pneu-
monia requiring hospital admission have
hypoxaemia.2 It is also estimated that,
annually, 11–20 million children are
admitted to hospital with pneumonia.3
Reprint requests to: Professor Trevor Duke, Centre for
International Child Health, University of Melbourne
Department of Paediatrics, Parkville, Victoria,
Australia. Fax: z61 39 345 6667; email: trevor.duke
@rch.org.au
# W. S. Maney & Son Ltd 2010
DOI: 10.1179/146532810X12637745452356
1.5–2.7 million cases of hypoxaemic pneu-
monia each year. Furthermore, 40% of the
almost 9 million annual child deaths result
from neonatal conditions such as birth
asphyxia, sepsis and low birthweight,4 and
all of these are commonly associated with
hypoxaemia.
Despite the huge global burden of hypox-
aemia in sick children, treatment for hypox-
aemia, i.e. oxygen, is not available to a large
proportion of patients admitted to hospital
in developing countries. This is particularly
true for children with pneumonia present-
ing to peripheral health centres and small
district hospitals. A recent study from Papua
New Guinea reported a 35% reduction in
pneumonia-related case-fatality rate in
infants and children (2–59 months of age)
88 T. Duke et al.
following the introduction of pulse oximetry
to detect hypoxaemia and oxygen concen-
trators as a reliable source of oxygen.5
Oxygen concentrators were first devel-
oped for military use in the 1950s. In
developed countries in the 1970s, they
began to be used to provide long-term home
oxygen therapy for adults with chronic lung
disease. Their use has been extended over
the past 35 years; concentrators are now
successfully supplying oxygen needs in
hospitals in developing countries through-
out the world, including Egypt,6 Malawi,7
Papua New Guinea,8,9 The Gambia,10
Nigeria11 and Nepal.12 Concentrators have
been used successfully to supply oxygen to
anaesthetic machines.13–15
This article reviews oxygen concentrators
and their use in paediatric care in develop-
ing countries: how they work, the various
types which are available, installation and
maintenance requirements, difficulties
encountered when using concentrators,
and what has been necessary to sustain their
use over many years. Some solutions to the
problem of using concentrators in hospitals
FIG. 1. Delivery of oxygen from a portable oxygen concentrator to two children at once.
with unreliable power supplies are dis-
cussed. Some of the published experiences
in different countries are outlined in the
Appendix.
How Does an Oxygen Concentrator
Work?
Air is 21% oxygen, 78% nitrogen and 1%
other gases. Oxygen concentrators take air
from the environment and separate the
oxygen and nitrogen by means of a
pressure swing adsorption (PSA) process.
Room air is passed through a sieve bed or
column filled with a regenerative, synthetic
zeolite molecular sieve which is a beaded,
inert, ceramic material. This sieve material
allows the oxygen to pass through freely
while the nitrogen is retained under pres-
sure. The cycle alternates typically between
two sieve beds (some concentrators have
more sieve beds), allowing one bed to make
oxygen while the other is depressurised,
freeing the nitrogen to exit the system
through the exhaust muffler. The oxygen
 Oxygen concentrators 89

is collected while the bed is pressurised. oxygen to multiple patients, depending on

Nitrogen is released through the exhaust
muffler when the bed is depressurised,
allowing the sieve bed to regenerate. The
cycle of alternating pressure allows the
continuous production of oxygen. The
system has four main components: an air
compressor, valve(s), sieve bed(s) and
circuit board. Most concentrators supply
oxygen at a concentration of 90–96%,
although .85% is quite adequate for
clinical requirements.
Bedside Oxygen Concentrators
The concentrators most commonly used in
developing countries weigh about 25 kg and
produce oxygen at a rate ranging from 5 to
10 L/min (Fig. 1). They provide a reliable
source of oxygen for many years with
minimal service and maintenance. With
appropriate mechanisms to divide the flow
from the concentrator, they can supply
patient size and oxygen requirements.
Appropriate technical specifications are
listed in Textbox 1. A recent survey docu-
mented the available models suitable for
bedside use in tropical countries.13
Oxygen concentrators are available in a
variety of voltages and frequencies to match
the power supplies of the countries in which
they are to be operated. Power incompat-
ibility renders concentrators unusable very
quickly.14 Voltage transformers alone will
not render power supplies compatible if a
frequency difference remains. Concen-
trators require a continuous AC power
source, most commonly a reliable mains
electricity source and a back-up generator in
case of power failure. The economics of
various systems, including sizes, costs and
payment can be discussed with the manu-
facturer of the oxygen concentrator and
local suppliers of alternative power sources.
Solar power systems will need to include
solar panels, batteries, a charge controller

TEXTBOX 1. Key technical points and specifications for oxygen concentrators suited for use in a district hospital ward.
N The concentrator should achieve .85% oxygen concentration at a flow rate of up to 10 L/min.
N The concentrator should operate at a voltage and frequency suitable for the local power supply; this differs
between countries.
N For energy efficiency the power requirements should be close to 350 W for units providing 5 L/min, 410 W for
8-L/min units, and 600 W for 10-L/min units.
N The concentrator should have one or two outlets with individual flow controls and flow indicators.
N Outlet pressure should be no less than 55 kPa for units providing 5 L/min and 138 kPa for 8- and 10-L/min
units.
N Weight should not exceed 25 kg.
N An hour meter should record total hours of unit operation.
N Maximum operating altitude should be not less than 2000 m, with not less than 85% oxygen concentration at
maximum flow.
N Maximum operating temperature should be not less than 40uC.
N Maximum operating humidity should be not less than 95% relative humidity.
N A list of all spare or replacement parts and their costs for 40,000 hours of operation (e.g. compressor, sieve beds
and valve spares kits) should be provided.
N The concentrator should comply with ISO 8359:199620 and IEC 60601-121 and carry a CE marking.
N The concentrator should be fitted with an oxygen monitor which gives an audible/visual alarm when the product
gas is below 82% oxygen concentration
N A user manual intended for hospital use and a service manual with a troubleshooting guide should be provided.
N There should be a 60-month parts warranty at a defined cost.
N The unit should include either a 4-way flow splitter, together with all nozzles and blanking plugs, which can
deliver flows of 0.5, 1.0 and 2.0 L/min (Fig. 4), OR a flow meter stand (Fig. 2). Each flow meter should be
continuously adjustable with an accurate low flow scale acceptable for patient care, such as from 0.1 to 2 L/min (or
higher flow as appropriate).
90 T. Duke et al.
and an inverter. Their capital costs are
high but they are cheap to run and can
be cost-effective if properly designed and
maintained.
Limitations of Oxygen Concentrators
Absence of a reliable power supply is a
common reason for failure of oxygen con-
centrators. In the Solomon Islands, limita-
tions in power meant that effective use of
oxygen concentrators was possible only in
hospitals in the major centres.15 In Sierra
Leone, where concentrators were the only
oxygen source, supply was frequently inter-
rupted by lack of mains power and by the
high cost of fuel for generators.16
In The Gambia, because of power limita-
tions, only two of 12 hospitals surveyed were
suitable for concentrators; in these settings,
oxygen cylinders were preferred.10 In one
remote rural hospital in The Gambia,
concentrators were run using solar power.17
However, there are important limitations to
current solar technology. Recent estimates
are that the capital cost of solar panels is
$25,000, plus the cost of batteries, charger
and inverter, merely to run a concentrator
which costs less than $1000.
The use of batteries to supply 24-hour
power to a concentrator from only 4 hours
of mains electricity supply is currently being
explored (Bradley et al., unpublished data,
personal communication, David Peel). This
would be sufficient for the majority of
district hospitals throughout the world,
which typically have some mains power.
Many details of a battery system are still to
be evaluated but initial testing is encoura-
ging.
A universal power supply (UPS) can be
useful in settings where power surges are
common and interruptions of power brief.
However, it is important to note that UPS
provides power for only a few minutes after
mains power goes off. UPS may buy time to
switch to an alternative power source, such
as a generator, but is not in itself an effective
alternative source of power, and they are
expensive.
Installation and Maintenance of
Bedside Oxygen Concentrators
Oxygen concentrators are usually supplied
with user manuals and maintenance infor-
mation explaining how the apparatus works,
its limits of performance and what regular
maintenance is required. There will be
instructions on how to unpack and install
the concentrator. It is important to check
that the voltage shown on the packing list is
correct for the power supply and that the
plug fits the mains power socket.
A concentrator should be positioned close
to a mains power outlet in a cool part of the
ward, not in direct sunlight, with a good air
supply. The ward should be well ventilated
and there must be good air circulation
around the concentrator itself: clearance
on all sides should be in accordance with
the manufacturer’s instructions. The con-
centrator should be in the shade and at least
1.5 m away from any source of heat.
Dividing Flow to Multiple Patients
There are two ways to divide the flow from a
bedside concentrator to multiple patients. In
the past, most concentrators used a flow
splitter, which allows a fixed flow of oxygen
(0.5 or 1 L/min) through fixed-size orifices.
If not used properly, however, they are liable
to deliver extremely low flows to patients.
If a flow splitter is to be used, it must be
ensured that all four ports have either
oxygen tubing or a blanking plug so that
oxygen does not escape through unused
nozzles. It is important that a blanking plug
be applied to any unused port of the flow
splitter to avoid wasting oxygen and to
ensure that the correct flow is delivered.
At least one manufacturer of concentra-
tors now has a flow meter stand as an
 Oxygen concentrators 91

FIG. 2. A flow stand which provides oxygen to up to five patients at once.

alternative to a flow splitter. This has the With the oxygen-delivery system in place,
advantage of being more familiar to clinical the power supply cable should be connected
staff who are used to using flow meters on to the concentrator and then plugged into
cylinders. The flow is simply dialled up for the main power socket. An extension cable
each patient, as long as the aggregate flow should not be used. After the concentrator is
does not exceed the flow from the concen- switched on, it is normal for a continuous
trator. A concentrator can deliver oxygen to alarm to sound for up to 1 minute. If there is
one or more patients requiring low flow at a no power supply or other problems arise, an
time if it is equipped with a flow meter alarm will sound; in such cases, the user
stand (Fig. 2). Table 1 shows the equip- manual should be consulted.
ment needed to administer oxygen from an Once the concentrator is running, the flow
oxygen concentrator to up to five patients. rate should be adjusted to the required L/min
flow range by turning the control knob of the
TABLE 1. Equipment for the administration of oxygen flow meter anti-clockwise. Flow-rate mark-
to multiple patients from an oxygen concentrator.
ings are read at the centre of the ball. In flow
Description Quantity meters equipped with backlines, the proper
viewing angle is achieved when the two lines
Oxygen concentrator 1 appear as one. It can take up to 5 minutes for
Flow meter stand or 1 the concentrator to stabilize at or above the
flow splitter specified minimal performance of 85% O2.
Nozzles of 0.5 and 1 4 each
L/min if using flow spitter
There is no harm in using the unit while it is
Blanking plugs if using 3 building concentration, and most units reach
flow splitter therapeutic levels in less than 2 minutes.
Plastic tubing, 5-mm Up to 15 m64
internal diameter
Conduit to mount plastic Up to 15 m64
tubing on wall Testing After Installation
Non-crush plastic oxygen 8m
delivery tubing After all delivery tubing has been attached,
Prongs (or catheters) 4 the concentrator should be tested for flow
Back-up cylinder with 1
regulator and flow controller delivery and monitored for the oxygen
concentration produced.
92 T. Duke et al.

FIG. 3. Simple flow testing for an oxygen concentrator.

The flow is tested (a) by submerging the
oxygen catheter in water, or (b) by using an
in-line flow indicator. Assessing flow under
water is a simple bedside test. Nasal prongs
are attached to each tubing outlet and the
flow from the prongs is checked by immer-
sing the tube under water. The difference in
bubbling rate should be observed when the
flow is adjusted to between 0.5 and 1 L/min
(Fig. 3). In-line indicators test flow from
each concentrator orifice, but are rarely
used.

FIG. 4. An oxygen concentration status indicator or oxygen monitor. Note: The lights indicate adequate or below
normal oxygen concentration; a flow meter is shown to the left.

Monitoring the Function of an Oxygen
Concentrator
It is vital that concentrators are fitted with
an oxygen concentrator status indicator
(OCSI, or what some manufacturers call
an ‘oxygen monitor’). The oxygen monitor
is the most important indicator of function
and is particularly important where engi-
neering support is poor. An oxygen monitor
or OCSI is required to meet ISO 8359
specifications ‘to indicate by visual and/or
audible alarm when the oxygen produced is
at low concentration’. One example is a
coloured light display (Fig. 4). The indica-
tor shows a green light to indicate normal
operation and a concentration of oxygen
greater than 85% by volume. A yellow light
indicates that the oxygen concentration is
between 70% and 85% by volume. A red
light indicates that the oxygen concentration
is below 70% by volume in which case a
continuous alarm will sound. The most
usual causes of low oxygen product con-
centration and the appropriate remedies are
listed in Table 2.
There are differences in the alert limits
and indicators provided by different manu-
facturers for the oxygen monitoring device,
e.g. coloured lights, digital display indicat-
ing concentration. Unfortunately, some
manufacturers sell concentrators without
any form of oxygen monitor; although
these are cheaper than other models, they
are not up to standard and are not recom-
mended.
TABLE 2. Causes of low oxygen concentration delivered by a concentrator (as indicated by the oxygen monitor)
and their remedies.
Cause
Dirty filters
Low voltage
Flow exceeding maximum
capacity (depending on concentrator specifications)
High ambient or operating temperatures
Oxygen concentrators 93
For more precise measurement of oxygen
concentration, an oxygen analyser can be
used. However, these do not come with the
concentrator and cost about US$150–400;
they are therefore mostly used by biomedi-
cal engineers.
Other Types of Concentrator
Very lightweight portable oxygen concentrators
There is now a class of smaller portable
oxygen concentrators, known as POCs.
These miniaturised oxygen concentrators
have been available since 2002. Because of
their small size, they enhance ambulation
and travel for oxygen-dependent patients.
POCs can weigh less than 2 kg and operate
on multiple power sources: internal battery,
external battery, AC or DC power. When
the unit operates on mains power, its battery
is recharged. These devices utilise a built-in
oxygen conserving device which allows a
measured amount of oxygen to flow only
during the beginning of the patient’s inhala-
tion phase. They are much more expensive
than bedside portable oxygen concentrators
and because they cannot deliver oxygen to
multiple patients at the same time are
unsuitable for use in hospitals in developing
countries.
Large oxygen generators
Larger concentrators are often referred to as
oxygen generators and work on the same
Remedy
Wash or change filters
Use a voltage regulator
Reduce flow if safe to do so
Improve airflow around the unit,
reduce ambient temperatures, or reduce flow
94 T. Duke et al.

principle as bedside concentrators. They

provide higher capacities of both oxygen
output and oxygen outlet pressure: up to
450 kPa (65 psi). They can have several
uses: supplying oxygen to anaesthesia
machines, ventilators and other medical
devices; supplying an
entire hospital; or refilling oxygen cylinders.
Large oxygen generators can be custom-
designed to supply all or part of a hospital’s
oxygen requirements when connected to the
medical oxygen pipeline. However, the capi-
tal cost of pipelines is considerable and they
need maintenance. If the pipeline is not
maintained, much of the gas will leak;
leakages of 50–75% have been recorded from
poorly maintained pipelines. The main
source of leak is at the wall outlets, which
have a spring-loaded connection sealed with
a rubber O-ring. With time and friction of FIG. 5. The external, large-pore filter on a concen-
screwing and unscrewing oxygen flow-meters trator which should be removed and cleaned each
from the wall outlets, the O-rings wear out. week.
These have to be checked regularly and
replaced when worn. Leakages can also occur
2 m of the device or any of the oxygen-
at the manifold, if such a system is used.
carrying accessories. Oil, grease and petro-
Oxygen generators can also be used to
leum-based products should not be used on
refill oxygen cylinders. These systems can
or near the unit. The unit should be
fill 2–200 cylinders per day, to 15,000 kPA,
positioned away from curtains or drapes,
with additional oxygen compressors. This
hot air registers, heaters and fireplaces
may be of some value if a central hospital
and should be placed so that all sides are
supplies oxygen cylinders for small health
at least 30 cm away from a wall or other
centres without power.
Typically, the power consumption for obstruction.
oxygen generators is approximately 1 kilo- When not in use, nasal catheters or
watt hour to produce 1000 litres of oxygen. prongs should not be left in contact with
Hospital administrators, engineers and bed sheets or blankets; this is an infection
equipment suppliers should review the hazard and also a fire hazard if the con-
requirements of the facility to properly select centrator is turned on as the oxygen will
or construct an economical oxygen system. make the bedding material inflammable.
Where an oxygen generator is selected as a The concentrator power switch should be
source, the size and the design of the oxygen set to ‘off’ when not in use. Firebreak
system should meet the guidelines of ISO connectors are recommended to stop the
standard 10083.18 oxygen flow in the event of fire.
To avoid nosocomial infection, face
masks, nasal prongs and oxygen tubing
Safety Procedures should be cleaned with soap and water,
soaked in dilute bleach solution, rinsed in
Oxygen can promote fire. Smoking and water to remove chlorine residues, and
naked flames are not permitted within allowed to dry before re-use.

Maintenance
Weekly maintenance by clinical staff
Most portable oxygen concentrators have an
external, coarse, cabinet air filter over the air
inlet which is often at the back of free-
standing or portable concentrators (Fig. 5).
As this filter becomes dirty, less air can pass
through it. If the filter is left to occlude,
oxygen production can be reduced and the
unit may eventually shut down as a result of
elevated internal temperatures. This filter
must be washed in detergent at least once a
week, rinsed in clean water, dried and
replaced. A spare filter should be inserted
if the concentrator continues to run during
cleaning.
The exterior of the oxygen concentrator
should be cleaned with a mild disinfecting
cleaning agent or a diluted solution of
bleach (5.25% sodium hypochlorite). A
solution in the range of 1 : 100 to 1 : 10 of
bleach to water can be used effectively,
depending on the amount of organic mate-
rial present. Allow the solution to remain on
the surface for 10 minutes and then rinse off
and dry.
Maintenance by the hospital engineer or service
technician
Oxygen concentrators have an alarm to
signal power failures. Where a battery is
used for alarm activation, it should be tested
and maintained every 6 months, or as
necessary. Testing involves disconnecting
the oxygen concentrator from its power
source and turning the power switch to
‘on’. For models which use a capacitor to
power the alarm, the unit may need to be
operated for a period of time to provide a
charge to the capacitor.
The oxygen concentrator should be tested
at regular intervals to confirm that the
oxygen concentration is within specifica-
tions. If humidification is used, the humidi-
fier should first be removed from the line
and a calibrated oxygen analyser connected
Oxygen concentrators 95
to the outlet. The flow meter should be
turned to the maximum capacity of the
concentrator and allowed to operate for a
period of at least 5 minutes for the unit to
stabilise before readings are taken. If the
unit’s oxygen monitor is indicating a low
oxygen concentration, an independent test
such as the above is valuable to determine if
the monitor has failed or the oxygen con-
centrator is in need of service. If the unit is
performing below the manufacturer’s speci-
fications, service is required.
All oxygen concentrators have an internal
fine particle filter. These should be
inspected and replaced at intervals accord-
ing to the manufacturer’s instructions.
When dirty, some internal filters can cause
the unit to perform below specifications
because of diminished airflow to the com-
pressor and a resultant decrease in oxygen
production.
Oxygen concentrators commonly have
four major components, outlined below.
An understanding of each of these and their
function greatly enhances the technician’s
ability to properly maintain, diagnose and
repair a concentrator. A log-book should be
kept to record all maintenance activities for
each concentrator, including weekly filter
changes by clinical staff.
The compressor
The compressor is the ‘pump’ within the
oxygen concentrator that pushes room air
into the sieve beds and allows oxygen to flow
out. The two aspects of the compressor
which can cause concern are output and
noise levels. Output is how much com-
pressed air the compressor can produce and
depends on the model, its stroke size, bore
size and cup seal condition. The cup seals
form the seal between the piston and the
cylinder wall. As the cup seals wear, the
compressor’s output gradually decreases
and there is a slight increase in sound
caused by air leaking around the seal. This
reduced output means less air is sent into
96 T. Duke et al.
the sieve beds and less oxygen produced.
When there is a measurable decrease in the
unit’s oxygen production or the operating
system pressure, the compressor will require
rebuilding or replacement.
The condition of the compressor’s bear-
ings also determines sound level. There are
four bearings in the compressor which allow
the inner components to rotate. As the
bearings become worn, the noise level
increases noticeably and service is required.
Valves
The valves, or valving system, control the
PSA process within the oxygen concentra-
tor. They control the pathway of the
compressed air which feeds and pressurises
one sieve bed while the other sieve bed is
allowed to depressurise and purge the
nitrogen through the exhaust muffler.
Many types of valves (4-way, 3-way, 2-
way, rotary, spool and sleeve, diaphragm,
and poppet) are found within different
models of oxygen concentrators. Some
valves can be opened and serviced, but
others are sealed. The type of valve in the
concentrator will directly influence the
need for filtration. Owing to particulates,
dust, dirt, smoke and surface corrosion
caused by humidity, highly sensitive valves
with extremely small tolerances are very
susceptible to sticking. They therefore
require a high degree of filtration. Two-
way poppet valves have been designed and
demonstrated to operate reliably in very
humid climates with elevated tempera-
tures. It is important that the oxygen
concentrator has a valving system proven
to be suitable to the conditions in which the
unit is to be operated.
Sieve beds
The sieve beds hold the molecular sieve
material where gas separation takes place.
The material is regenerative and stores
nitrogen under pressure while allowing
oxygen and argon to pass through freely.
As well as nitrogen, the sieve material has an
attraction for water molecules. Water in the
feed air is contained within a water zone of
the sieve bed and, on depressurisation,
is released along with the nitrogen as part
of the purge gas. A controlled amount of
sieve is intentionally exposed and allowed
to ‘contaminate’ with water molecules form-
ing the water zone. In a well designed
and properly operating PSA system, the
water zone remains constant even when
exposed to high humidity and ambient
temperatures.
Sieve material within the sieve bed can
become contaminated in a number of ways.
A leak in the system, especially on the
product side, allows water molecules in
room air to come in contact with and
contaminate the sieve material. The sieve
material needs to be tightly packed and
contained within the sieve bed. Most
manufacturers use a spring-loaded piston
design which keeps pressure on the sieve to
prevent it from shifting. If the material
moves or migrates, the contaminated sieve
in the water zone will move throughout
the bed.
If the alternating PSA cycle of feeding
and purging the beds is interrupted,
the beds can become contaminated. A
failure to cycle could be caused by a
defective valve or printed circuit board
(PCB) which controls the valves. This could
result in one bed being fed room air
continuously. This introduces more water
molecules than the water zone can contain,
expanding the water zone into the active
part of the bed. Care should be taken to
thoroughly leak-test a unit and repair any
leaks which can result in sieve bed failure.
To detect leaks, a solution of soapy water
should be sprayed or applied to all fittings
and connections, from the air compressor to
the oxygen outlet.
Argon, along with the oxygen, passes
freely through the sieve material and is
allowed to concentrate, so the maximum
oxygen concentration obtainable will be
 Oxygen concentrators 97

TABLE 3. Troubleshooting guide for the hospital engineer or service technician.

Problem Probable cause(s) and solution(s)

Oxygen concentrator No mains power

does not turn on
Oxygen concentrator operates but the
compressor shuts down intermittently
Oxygen concentrator’s
compressor does not turn on
Oxygen concentration is within
specifications but flow fluctuates
Oxygen concentration is
within specifications
but the oxygen monitor
indicates low concentration
Oxygen concentrator runs but
oxygen concentration is low
Inspect and check power cord, electrical connections,
circuit breaker (if equipped), internal fuse (if equipped,
sometimes located on the PCB), on/off switch, PCB
Check cabinet filter, cabinet fan, capacitor for the
compressor, cabinet thermal switch (if equipped), valve(s), PCB
Compressor may have a faulty thermal switch
Inspect and check electrical connections to the
compressor, capacitor, PCB, valve(s), compressor
Pressure regulator needs to be adjusted, repaired, or replaced
Tubing to oxygen monitor is kinked,
faulty oxygen monitor
For these situations it is very useful to test the system’s operating
cycle pressures for determining which component is in need of repair
or replacement; refer to service manual for instructions on
how to test system pressure
Low system pressure can indicate a restriction to the
intake of the compressor, a leak, a worn compressor, valve, PCB
High system pressure can indicate contaminated sieve beds,
restriction in the exhaust muffler, valve, PCB

PCB, printed circuit board.

95.5%, the remainder being argon and a
small amount of nitrogen.
Printed circuit board (PCB)
The PCB is the electronic control for
operating the valve(s) and alarm system. If
it fails, the unit may not cycle properly or
may not operate at all. Some systems have a
lighting and diagnostic system on the PCB
to aid troubleshooting.
Table 3 provides a guide to troubleshoot-
ing some of the more common problems
with oxygen concentrators. Consult the ser-
vice manual for additional troubleshooting
suggestions.
Regular contact with the manufacturer’s
technical support department should be
maintained. This can be done via email
and will allow receipt of updates on equip-
ment and service manuals. Technical sup-
port offers troubleshooting assistance and
recommends spare parts inventories, based
on historical reliability data. Many manu-
facturers provide technical training, either at
their facility or on-site.
To be able to properly support the oxygen
concentrators in a facility, an inventory of
spare parts needs to be maintained and
should include the major components,
components which wear and most, if
not all, electrical components. Items to
consider include compressors, compressor
mounts, sieve beds, valves, PCBs, on/off
power switches, power cords, hour meters,
circuit breakers, fuses, cabinet fans and
tubing, fittings and filters. This inventory
of parts should be adjusted according to
the number of concentrators being sup-
ported. This is where the manufacturer can
be of great assistance in recommending
quantities and parts commonly used.
These parts should be included in the initial
purchase contract. Concentrators will not
run without regular maintenance and repla-
cement of parts.
98 T. Duke et al.
Regulatory Requirements to Support
Oxygen Concentrators
Regulatory requirements need to be brought
into line with rational clinical needs. In
some countries, companies selling bottled
gas have promoted regulations requiring
99% oxygen for hospital use. The cost of
making a concentrator which produces 99%
oxygen is markedly increased. They are
available but require an additional PSA
separation system which uses black carbon
sieve material to remove argon (the major
gas remaining, apart from oxygen, when
nitrogen is removed from air). Processes to
remove argon greatly increase the overall
cost of the system and the power require-
ments. 85% oxygen is perfectly adequate for
patient care. Such regulations increase the
costs of PSA systems and make them less
viable. This is to the detriment of efforts to
make appropriate technology available in
developing countries at an affordable price.
The WHO Essential Medicines programme
lists oxygen as an essential drug.19 WHO
should specify the concentration to be 85%
or more, and national regulations should
reflect this to ensure that concentrators
remain an option for providing oxygen in
all health facilities.
Future Trends in Oxygen Concentrator
Technology
There continue to be improvements in the
design and manufacture of oxygen con-
centrators, resulting in smaller, lighter,
quieter, more power-efficient and less
expensive models. New models of oxygen
concentrators appear every year. However,
within a hospital or health service, stan-
dardising to one model helps ensure
continuity of spare parts, maintenance
and training.
A challenge for oxygen concentrators is in
the use of alternative, renewable or hybrid
sources of power to solve the problem of
running concentrators and other electricity-
dependent medical equipment in health
facilities with no mains or unreliable power.
Another challenge likely to be met in the
near future is concentrators which require
minimal maintenance for an extended per-
iod of time, such as 5 years.
Acknowledgments
We thank David Woodroffe, David
Woodroffe Digital Illustration for Figs 1,
2, 3 and 5. The Centre for International
Child Health is a World Health
Organization Collaborating Centre for
Research and Training in Child and
Neonatal Health, and is supported by
AusAID as part of the Knowledge Hubs
for Women’s and Children’s Health, and by
the R. E. Ross Trust (Victoria).
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6 Dobson M, Peel D, Khallaf N. Field trial of oxygen
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7 Enarson P, La Vincente S, Gie R, Maganga E,
Chokani C. Implementation of an oxygen concen-
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8 Duke T, Wandi F, Jonathan M, et al. Improved
oxygen systems for childhood pneumonia: a multi-
hospital effectiveness study in Papua New Guinea.
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9 Matai S, Peel D, Jonathan M, Wandi F, Subhi R,
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needs in Africa: an options analysis from the
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11 Mokuola OA, Ajayi OA. Use of an oxygen
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12 Litch JA, Bishop RA. Oxygen concentrators for the
delivery of supplemental oxygen in remote high-
altitude areas. Wilderness Environ Med 2000;
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in tropical countries: a survey. J Clin Engineering
2009; Oct/Dec:205–9.
14 Howie SRC, Hill SE, Peel D, et al. Beyond good
intentions: lessons on equipment donation from an
African hospital. Bull WHO 2008; 86:52–6.
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Hospital services for children in Solomon Islands:
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16 Kingham TP, Kamara TB, Cherian MN, et al.
Quantifying surgical capacity in Sierra Leone. Arch
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17 Schneider G. Oxygen supply in rural Africa: a
personal experience. Int J Tuberc Lung Dis 2003;
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18 International Organization for Standardization. ISO
10083: Oxygen Concentrator Supply Systems for Use
with Medical Gas Pipeline Systems, 2006. http://
www.iso.org/iso/iso_catalogue/catalogue_tc/catalo-
gue_detail.htm?csnumber532061. Accessed De-
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of Essential Medicines, 16th edn. http://www
who int/selection_medicines/committees/expert/17/
sixteenth_adult_list_en Accessed December 2009.
20 International Organization for Standardization. ISO
8359: Oxygen Concentrators for Medical Use – Safety
Requirements, 1996. http://www iso org/iso/iso_cata-
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Oxygen concentrators 99
APPENDIX. Various countries’ experiences
of oxygen concentrators.
Egypt
The earliest large-scale field trial
In 1993, a project was set up to introduce
oxygen concentrators in upper Egypt.6 This
involved installing oxygen concentrators in
district hospitals, training technicians in
installation and maintenance, making reg-
ular inspections, servicing and repairing the
equipment and setting up a reporting system
that would closely inspect the performance
and usefulness of the machines. A team and
an overall co-ordinator were appointed to
carry this out. One year after installation,
two concentrators of a total 22 had faults
and both were repaired. The training of staff
was successful and the day-to-day running
of the programme was predominantly done
by the local team.
Papua New Guinea
Proving effectiveness: impact of better detection
of hypoxaemia and improved oxygen supply
After studies showed that hypoxaemia was a
major child health problem and that the
supply of oxygen was a major problem in
Papua New Guinea,22,23 pulse oximeters and
oxygen concentrators were introduced in five
hospitals in 2005. Nurses, doctors and hospi-
tal technicians were provided with training in
the use, maintenance and repair of the
equipment. The technology, training and
ongoing monitoring and support formed the
oxygen programme in Papua New Guinea.9
In the following 2.5 years, there was a
highly significant reduction in hospital mor-
tality rates for pneumonia. In the years before
the system was introduced, there were 356
deaths from 7161 admissions for pneumonia
(case fatality rate 4.97%). In the 2.5 years
after the system was introduced, there were
115 deaths from 3538 admissions (case
fatality rate 3.2%). The risk of a child with
100 T. Duke et al.
pneumonia dying in the hospitals after the
system was introduced was 35% lower than
before (risk ratio 0.65, 95% confidence
interval 0.53–0.80, p,0.0001).5 The cost of
the programme was estimated to be $51/child
treated, $50 per DALY averted, and $1670/
additional life saved. The programme has
now been extended to 17 hospitals.
Malawi
A large national Child Lung Health programme
Malawi was one of the first countries with
limited resources to implement a national
oxygen programme, beginning in 2002. This
was part of a highly successful National Child
Lung Health Project. Case fatality rates from
pneumonia have consistently fallen since the
introduction of the programme. In 2007, an
evaluation of 15 hospitals using oxygen
concentrators showed that this technology
had been successful in reducing hospital
mortality for pneumonia. Many units of one
particular model which claimed to comply
with international standards were not work-
ing. This emphasised that cheaper equip-
ment is not always the most cost-effective in
the long term, and that manufacturers claims
need to be tested in the field. One challenge
was high staff turnover which made it
difficult to sustain adequate staff skill levels.
Another challenge to optimal success was
user fees; making hospital care free for
children in one hospital markedly increased
demand and access compared with hospitals
where fees were charged.7
Nigeria
Oxygen concentrators in a neonatal unit
Oxygen concentrators were introduced to a
neonatal unit in Nigeria in 1993 to over-
come the limitations of cylinder oxygen.11 A
model that met international standards was
purchased and installed. It ran for 18 hours
a day for 3 years without breaking down,
despite high daily temperatures (30–32uC)
and very dusty conditions. The cost of
treating one patient for 1 year using the
concentrator was 27% that of using cylin-
ders. Greater savings could have been
achieved by using a flow splitter on the
concentrator in order to treat several
patients at once. The use of the concen-
trator was limited by interruptions to the
power supply. During power cuts, a portable
generator was used to power the concen-
trator.
Nepal
Oxygen concentrators at high altitude
Oxygen demands are high at Kunde
Hospital, located near Mount Everest,
3900 m above sea level. Oxygen is required
for childbirth, neonatal resuscitation, surgi-
cal procedures and management of cardio-
pulmonary illness and altitude sickness (e.g.
high altitude pulmonary or cerebral
oedema). It is a 10-day walk from the
nearest road, and transport of cylinders is
difficult. In 1997, oxygen concentrators
were installed and connected to power
supplied by a hydro-electric system with a
petrol generator as back-up.12 An additional
two concentrators are kept as back-up. No
equipment failures occurred over 3 years
and the concentrators have replaced oxygen
cylinders and portable hyperbaric chambers.
The Gambia
Donations and options where power is limited
In 2000, a teaching hospital in The Gambia
received a donation of oxygen concentra-
tors.14 Unfortunately, all the equipment
very quickly stopped working. The main
problem was lack of compatibility of fre-
quency: machines constructed for use with
110 V 60 Hz electrical supply did not
function with the 230 V 50 Hz local elec-
trical supply. The concentrators were sec-
ond-hand and, although they had been
serviced before donation, there was not the

expertise in The Gambia to maintain the
equipment and the donor did not assess
whether the electrical frequency was com-
patible. This emphasises the need for better
planning, management and local participa-
tion around donations of equipment to
developing countries. It is also important
to ensure that any new equipment, either
given or bought, is supported by sufficient
technical expertise. Following this experi-
ence, the hospital organised a committee to
oversee all donations, working with a non-
government organization partner.
Oxygen concentrators 101
In remote district hospitals without reg-
ular electricity, oxygen concentrators have
a limited role.10 In one such hospital in
The Gambia, oxygen concentrators were
run successfully on solar power. Despite
a high initial outlay, running costs were
small. Such a set-up requires a high level of
technical expertise.17 In The Gambia, the
use of batteries to supply 24-hour power
to a concentrator from only 4 hours of
mains electricity supply is currently being
developed (B. Bradley, et al., unpublished
data, personal communication, David Peel).