Oxygen is a drug and must be prescribed appropriately and used correctly. Ensuring compliance means using the best modality

A major piece of the current long term oxygen therapy (LTOT) puzzle is the overwhelming fact that most physicians, including pulmonologists, overlook the fact that oxygen is a drug. Just as with antibiotics, steroids, or inhalers, the drug must be prescribed appropriately and used correctly by their patients to gain results. Once oxygen is ordered, the physicians fully expect the home care provider to set up the LTOT equipment correctly and their patients to take their medicine as ordered, and yet the physicians do little or nothing to ensure their patients receive oxygen at a dose to maintain proper blood oxygen at all activity levels.

One possible reason for this is that most physicians think oxygen is something you put “on” a patient, rather than “in” a patient. We talk about putting on a nasal cannula or mask to administer oxygen. Compliance is almost totally left to the patient, and monitoring of the patient’s oxygen needs is rarely done at all activity levels. There is occasionally a pep talk from the physician or home care provider to try to encourage the patient to wear their oxygen 24 hours per day, yet compliance is typically overlooked and rarely emphasized. Long term oxygen therapy is for all practical purposes an “out of sight, out of mind” therapy.

Oxygen Modalities
Oxygen delivered in the home is either a packaged gas that needs to be replenished periodically or oxygen that is produced in the home. There are multiple modalities that are becoming available due to the increased demands of LTOT patients and the constant pressure from payors to reduce the costs associated with LTOT. These oxygen modalities must provide oxygen at a level that meets the patient’s clinical needs, be easily used by the patient at all activity levels, and be cost-effective for all parties involved in the use of the oxygen. If the balance of these three priorities is not well understood, LTOT therapy may be assumed, yet not provided.

Oxygen concentrators have become the standard for therapy in the home. Concentrators are effective in providing continuous oxygen, cost efficiently. Portable oxygen cylinders were available for mobility since traditional concentrators were not portable or designed for more than stationary use. Several new concentrators have been introduced that fill cylinders to allow for a virtually unlimited mobility since the cylinders can be filled from the concentrator as needed. This addresses the issue of access to ambulation and costs associated with delivering portable cylinders. One manufacturer is introducing a concentrator that can fill liquid oxygen portables (LOX), which will allow for a lighter portable system compared to the cylinder (compressed gas) source.

Portable oxygen concentrators (POC) that will allow the patient to have the ability to generate oxygen wherever there is an electrical source have recently been introduced. These concentrators operate on battery, weigh approximately 10 pounds, and allow the patient to take the concentrator wherever they want to go. These new systems will need to establish a reliability track record and address the clinical issues of sleeping while receiving oxygen from the POC and maximum oxygen delivery capability with activity. One manufacturer has tested their POC with 10 sleeping patients with positive results. If the patient can sleep and exercise on the POC, it has the potential of becoming a single source oxygen modality for the patient.

Liquid oxygen became a popular modality in the early 1970s by providing a lightweight, long-lasting portable system. Prior to LOX, a standard portable oxygen system was a steel E-size cylinder with a brass regulator and steel cart, all weighing approximately 22 pounds. A 10-pound LOX portable would operate twice as long as the E cylinder on the same flow setting and could be refilled by the patient as needed. LOX is a packaged gas that requires the base unit to be filled periodically, adding to the distribution costs. This has caused LOX to become unpopular for HME providers as reimbursement continues to drop. New four-pound LOX portables have become available and have caught the eye of patients that see the units in public. These very light systems are preferred by patients, who have created a pull-through effect by requesting the products rather than accepting what is delivered by home care providers. This is the first time patients have been aware of options and demanded the products they prefer. Four pounds has become a new unofficial standard for portable oxygen from the patient’s standpoint, and a very well-known physician/oxygen patient is calling on industry to create a two-pound portable LOX system.

Oxygen conserving devices (OCD) have become a standard for portable oxygen systems due to the patient’s demands for lightweight, long-lasting ambulatory oxygen. OCDs can efficiently dose oxygen when the patient needs it and eliminate waste from oxygen flowing when the patient is not breathing. All OCDs operate differently, and the patient must be titrated on the system they will be using at activity. Oxygen savings or saving ratio is secondary to proper patient oxygenation. If the patient cannot maintain proper oxygen saturation, it does not matter how long the oxygen system lasts.

Oxygen must be delivered from the oxygen source to the patient. Comfort has become an issue for patients, and the delivery system must be comfortable as well as effective. Traditionally, oxygen has been delivered by nasal cannula for LTOT patients. Manufacturers have several options for cannula, including material used, length of the cannula, and molding for comfort. New information indicates that the type of cannula used can have an impact on the performance of an OCD. All OCDs operate differently, and if the cannula is changed, the patient should be titrated again on the new system.

Informed patients are looking for more than just the traditional oxygen delivery options, and several are available. Oxygen can be delivered by transtracheal catheter, which can hide the tubing on the face, improve comfort, and add to oxygen conservation by reducing dead space. This method has been available for years, but the cost is higher than with traditional cannula. Patients who ask for transtracheal usually receive it, yet it typically is not offered by home care providers and most physicians are not aware of the option or benefits. New glasses that run the oxygen tubing through the frames is another option for patients to gain comfort and improve cosmetic appearance. These glasses are readily available, can have prescriptions filled by a local eyeglass company, and are priced similar to regular glass frames. Again, the informed patients usually prefer this option to standard cannula when they know their options. One manufacturer uses silicone for the cannula material that is more comfortable than plastic, yet can be easily kinked and shut off oxygen flow.

Patients and payors are becoming more aware of the different modalities available for oxygen delivery. Each modality has different costs and benefits, yet the number one issue is whether these systems meet the patient’s needs, clinically, at all activity levels. There is no value in providing and paying for a system that does not oxygenate the patient or is not accessible to the patient.

Conclusion
In spite of the fact that, based on the British Medical Research Council (BMRC)¹ and the nocturnal oxygen therapy (NOTT)² studies, oxygen has been proven to be the only “drug” that has the ability to increase survival, many physicians outside of the pulmonary specialty are not aware of the intimate relationship between chronic hypoxemia and right-sided heart failure. Providing oxygen that does not maintain proper oxygenation will have a long-term effect and cost for the LTOT patient and payor.

The importance and significance of the BMRC and NOTT studies will continue to diminish until they end up on the famous pile of “ex-famous” publications. This loss is actually more important than most clinicians think, given the fact that the first wave of retiring Baby Boomers is now reaching retirement age. Many fail to remember that the first Surgeon General’s report on the adverse effect of smoking was in 1963. No one really believed the first one anyway, and so the percentage of the population that continued to smoke remained relatively constant until the weight of the evidence became overwhelming many years later. The smokers of the 60s and 70s will be the COPD and oxygen-dependent patients of the new millennium and beyond.

New oxygen modalities that are targeted at meeting the patient’s needs and reducing overall oxygen delivery costs are entering the market. Most of these new modalities have little to no clinical research to document their applications, benefits, and outcomes. The first objective of LTOT is to get oxygen in the patients—not on the patients—and maintain proper saturation at all activity levels. We need to take the focus off the equipment and put more on the outcomes of LTOT. This is a big change in thought process, yet it needs to begin. If it is true that every journey begins with the first step, let’s take it!

John Goodman, RRT, is a respiratory care educator and lecturer, both nationally and internationally; Robert McCoy, RRT, is managing director, Valley Inspired Products Inc, Apple Valley, Minn.

References
1. Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical trial. Nocturnal Oxygen Therapy Trial Group. Ann Intern Med. 1980;93(3):391-8.
2. Long term domicilliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema. Report of the Medical Research Council Working Party. Lancet. 1981;1(8222):681-6.