Mark Rollason CNC
Helen Antcliffe OT
Prince of Wales Hospital
Randwick
Educational objectives
 Medical Criteria for Long Term Oxygen
Therapy
 Enable requirements for government funding
 Patient considerations for LTOT
 Re-settling patients at home with LTOT
 Minimizing Risks for patients
 Enabling community access
 Maximizing patient Safety, Independence
and Quality of Life
Diseases and Conditions
• Chronic Obstructive Pulmonary Disease
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(COPD)
Bronchiectasis
Pulmonary Fibrosis
Interstitial Lung Disease (ILD)
Pulmonary Hypertension
Cystic Fibrosis
Cancer
Cardiac Failure
Congenital Cardiac Disease
Signs and Symptoms of
Chronic Hypoxia
 Decreased SpO2 at
rest (Often 90-91%
Room air)
 Tolerant to lower
O2 levels
 Shortness of breath
on exertion with
decrease in Sp02
 Dry cough (ILD)
Appearance
Thin, pale, poor skin color
and condition
Clubbed fingers
Poor peripheral
circulation
Coarse finger/toe nails
Types of Home Oxygen Therapy
 Short Term Oxygen Therapy (STOT)
 Long Term Oxygen Therapy (LTOT)
 Palliative Care
Short Term Oxygen Therapy
(Continuous: >16hrs)
Provided for patients:
• In hospital and near discharge or
• Recently discharged from hospital (< 48hrs) with
– PaO2 (ABG): <55 mmHg or
– PaO2 (ABG): 56-59 mmHg (with evidence of end
organ damage due to hypoxia)
• Pulmonary Hypertension
• Right Heart Failure
• Polycthaemia
*Normal PaO2: 80-100mmHg **PaO2 of 50mmHg= SaO2
of 84%
Short Term Oxygen Therapy
(Nocturnal: > 6hrs)
Provided for patients:
 Sleep study or nocturnal oximetry indicating
SpO2 <88% for more than 33% of sleep
OR
 SpO2 <80% for more than 10% of sleep
* May be used as primary therapy or in
conjunction with CPAP/BiPAP
Long Term Oxygen Therapy
 Continuous Oxygen (>16hrs)
 Same criteria as STOT
 Nocturnal Oxygen (>6hrs per night)
 In addition to the criteria for STOT:
Significant nocturnal hypoxemia and
 Objective evidence of improvement
(SaO2) and
 Investigations performed >4 weeks post
acute event

Ambulatory / Portable Oxygen
(Continuous Therapy: 24hrs)
Provided for patients:
 Currently use LTOT via concentrator
(24hrs)
 Clinical justification for the need
 Client agrees to partially fund therapy (i.e
cylinder refills)
 Satisfactory compliance with therapy
Ambulatory / Portable Oxygen
Patients requiring >16hrs of therapy
 In addition to criteria for Portable (24hrs)
 Evidence of desaturation during exercise
(<88% on 6MWT) and improvement of
>30% on oxygen
Patients requiring <16hrs of therapy
 In addition to criteria for Portable (24hrs)
 Demonstration of use for >12mths and
evidence of daily usage requirements.
Palliative Care
 Funding provided by the discharging
institution or community palliative care
service.
 Needs to be approved by Palliative Care
medical team
Contra-indications for Oxygen
Will not be prescribed to patients who:
 Have a PaO2 > 60mmHg (88%SpO2)
 Have no secondary effects of chronic
hypoxia
 Continue to smoke
 Are not adequately treated for condition
 Will not comply with prescription or safety
guidelines
Important - Oxygen may be harmful to:
• CO2 retainers
• Left ventricular or Heart failure
• Obesity hypoventilation syndrome
(OSA)
• Severe neuromuscular insufficiency
Discharge Process for Home O2
 ABGs in A&E
 Nursing obs. at rest if O2
<90%Sp02
 Physio Ax on mobility if
<90%SpO2
 OT Ax with Pulse Oximetry
- during functional mobility &
ADLs
- titration of O2 to
>90%SpO2 during exertion of
mobility / ADLs
 Contributes to Medical decision for ABGs &
Home O2
Short Term O2 >16hrs
Mrs B 68 yrs COPD
 Physio / OT Ax with Pulse Oximetry:
 81%SpO2 mobility / ADLs
 84%SPO2 with energy conservation
 required 2L/mO2 >90%SpO2 on exertion
 Dr prescribed CPAP and Home O2
at 2L/m for 1 month …hospital funded
& Enable paperwork done by CNC
• OT functional Ax & education in safe & effective
use of concentrator, tubing,cylinder & conserving
device & Patient Booklet on O2
Fridge Flyer
>16hrs Oxygen
Based on an
individual
assessment of
daily activities by
OT so patient uses
oxygen effectively
Mrs B – OT at Home
 Home resettlement: O.T. Car & cylinder O2
 O2 concentrator sited centrally in lounge
- 9m + 3m extra tubing required to reach for
ADLs
 Double adaptor changed for power board
- new power point arranged for Concentrator
 Falls risk reduced by coiling, etc
 Fire risk reduced by 2m clearance from gas
heater in lounge and kitchen stove gas hot
plates
Oxygen and Fire Risk
Cooking and Oxygen
- an explosive recipe!
 “The dangers of home oxygen can be
minimized by careful patient selection,
education and ongoing monitoring”
Burns et al. 2001
Mrs B - OT at Home
 O2 tubing 9m + 3m reaches
kitchen, laundry, bed / bathrooms
long house
 O2 pressure 1.5L so dial to 2.5L
for 2L/m O2 by gauge
 Explained to Mrs B, daughter, Dr,
RN, aware of CO2 retention
 Energy conservation seating equipment
installed:
- shower stool in the bathroom
- stool at kitchen stove...no O2
- dressing chair in bedroom
Accessing the Community
 “Continued exercise among patients with
COPD is associated with maintenance of
physical, cognitive and psychological
functioning” Emery et al. 2003
 …“in patients with COPD, a higher level of
physical activity reduces the number of
hospital admissions due to exacerbations as
well as…respiratory mortality”. Garcia-Alymerich et al,
Chest 2009
Portable / Ambulatory O2
Mrs B – Community access
 Taught use of medium size
cylinder & conserving
device
 Physio rec. wheeled
walker/ seat/ hand brakes/
O2 to walk / shop
 Upgrade daily walk in
street
•8 wks Pulmonary Rehab. then support of ”Pink
Panters” club
•RCCP support of RN and PT to prevent readmission with OT / SW / Pharm./ Diet. if needed
Ambulatory Oxygen; why do
COPD pts not use their portable
systems as prescribed?
Arnold E et al, BMJ Pul. Med, 11;9 2011
...“no instruction; uncertain of the benefits;
were afraid the system would run out...; were
embarrassed at being seen with system in
public; and were unable to carry the system
because of the weight. The essential role of
Carers...highlighted.”
Mrs B – Community access
 Drive with O2, slightly open
window & cylinder in carry
bag strapped to back of
passenger seat or under sea.
Mobile, NRMA
 Arrange ahead for a scooter
at the shopping centre to sit or
use a Four wheel-walker or
shopping trolley to carry the
cylinder
•Transport concentrator upright in car boot
or back seat belt to stay away from home,
or hire + cylinders in a new area
•Book wheelchair to / from plane / train,
use O2 from cylinder/conserving device in
flight carry bag or plug-in portable
concentrator, as per flight assessment
flow-rate and order ahead for concentrator /
cylinder refills from depot at new destination
Long Term Oxygen Therapy
 “…under-prescription of LTOT is a risk
factor for re-admission to hospital and
appropriate use of this therapy may
therefore reduce the burden of
exacerbation.”
Hurst JR, Wedzicha JA. 2004
Long Term O2 Therapy >16hrs
Case Study 2; Mr W 53yrs Builder
Interstitial Lung Disease
 Home with OT; oxygen
funded by Hospital for 1
month.
 App to Dust Diseases
Board
•Site concentrator
central to ADL areas
for sleeping,
showering, eating,
watching TV and
gardening
•Tubing lengthened
by 1m so used Flow
gauge to check O2
still 3L/m
Case Study 2: Mr W 53yrs
OT… Energy Conservation
Planning, Positioning
 Equipment…sit / lean uses
less muscles & eliminates
gravity
 Home Modifications…lean on
rails,ramp or remove steps /
hob for wheels
 Aids…long handles, not bend,
stretch
Pausing, Pacing
•Techniques… deep breaths before exertion,
to recover & continue
•Timing… ADLs, walking before meals & in
temperate time of day
•Home Oxygen Ax (cognition/hands/eyes) &
Education for safe, effective use of O2
Concentrator / tubing and the Portable
Concentrator or cylinder/ conserver
Mr W & wife
taught safe use of
electrical
Concentrator
including cleaning
filter weekly.
Taught to move
Concentrator to give
greater range for 9m
tubing rather than
further extend it.
Enclosed sunroom is
perfect for walking for
exercise and for
gardening at waist
height
Ambulatory O2 Therapy
 “…(there is)…consensus on the use of ambulatory O2
to increase exercise tolerance exercise tolerance. The
mechanism for this apparent reduction in dyspnoea is
postulated as the reduced work of breathing when
hypoxia is prevented or reduced in severity.” Lane R, 1987
cited by Roberts CM, 2007
 “Three physiologic effects of supplementary O2 have
the potential to increase exercise tolerance of the
hypoxic pt with COPD; hypoxic stimulation of the
carotid bodies is reduced, the pulmonary circulation
vasodilators and arterial O2 content
increases…providing O2 to exercising muscles and
reducing carotid stimulation by lactic acid.”
O’Donnell D, Webb KA. 2007
Stairs & Oxygen
•If a 2 story house or unit up 2 / 3
flights of stairs & no lift
•Position concentrator near the top
or bottom of stairs allows 9m
tubing to assist the pt up & down. Carer assists with tubing.
•Internal stairs can be avoided by
moving the pt’s bed downstairs
• Otherwise some Carers can
manage to carry a cylinder for pt
Case Study 2;
Mr W Community access:
 Community Access
training along footpath for
exercise route, to shops
 Cylinder or Portable
Concentrator?
- advice on use in train,
plane.
 Consider Electric
scooter
•Home Appointment to select appropriate
Portable Concentrator and train for
community access
…once funding by Dust Board
•Assess on mobility & titrate O2 to
maintain >90%SpO2
- NB 1,2,3 not L/m
•Teach to secure in car. Plug into car
lighter socket…power / batteries
Portable Concentrators:
Prescription is
3L/O2 to >90%
SpO2 1,2,3
buttons do not
equate to L/m so
titrate oxygen for
each patient
Mr W is a ‘mouth
breather’ & requires
a sensitive
Conserving device &
continuous flow for
use when sleeping
Benefits of Home oxygen
 “In
COPD, domiciliary oxygen is the only
therapy shown to reduce mortality
(E1)…alleviates ® heart failure caused by Cor
pulmonale, enhances neuropsychological
function and improves exercise performance
and capacity to undertake activities of daily
living” (E2)
TSANZ Guidelines. 2005
MJA (2006), Vol. 182.621-626
Case Study 3- Mr J 47 yrs COPD,CRF
Fire Risk
 O2 off if cooking on
gas stove and sit on
stool to use pan or stir
saucepan, etc.
 Can now assist his
parents more, ie
microwave or cook
meals & carry on tray
on 4WW to them or to
make tea.
Lives with Father 85
yrs & mother 78 yrs,
both frail
Falls Risk
Taught to coil tubing off
floor
Kept to same side of
hall & not across
walkways or hooked
above them for
parents’ safety
Case Study 3 - Mr J.
Community access:
No longer drives a car
O2 cylinder secured in scooter
basket or bracket
+ Mobile phone + NRMA
Spare cylinder on its side
Drive to Chemist / O2 supplier to exchange for
a full cylinder is $12 or +$23 home delivery
Can do the shopping and get out to socialize
Short Term Oxygen Therapy
(Nocturnal:>6hrs) Case Study 4:Mrs S
Diagnosis; Respiratory
Infection, OSA, Cellulitis
Obese 160kgs.
•Ward Monitored continuously
•Stops breathing when asleep
if not on BiPap, if neck
unsupported and de-saturates
to 85%SpO2, then alarms go &
she wakes in a panic.
• Frightened to go to sleep.
Case Study 4 - Mrs S
•Previously sat day and night in upright chair
leaning against kitchen bench
•Could not sleep flat in bed, could not cover
herself / poor bed mobility
•OT intervention:
•Trial of ELP Orth./Recliner chair & foot stool
successful +Leg lifter and Seating Clinic made a
neck pillow
•Enable Bariatric shower stool, OTA, hand
shower, pick-up stick
OT Action;
 Bed ‘set up’ with pillows to sleep in a
reclining position & light cover
 O2 with BiPap
on table near bed
 Application to ENABLE
for a Bariatric
electric Chair with Lift assist to stand… &
Recliner with head support/wings (sleeping) &
foot raise (for swollen legs)
Positioning
nocturnal SpO2
 “…between 28% and 58% of pts (with CHF)
needed to sleep with many pillows or sitting
up in a chair at night because of shortness of
breath” Barnes et al 2005
 “Changing the sleep position from supine to
non-supine is a simple but effective treatment
for some patients with sleep apnea
syndrome…” Kitamura et al. 2008
Nocturnal O2 re-settlement
 Site concentrator next to the bed
 Sometimes attached to the BiPAP
machine...small nipple for O2 tubing to push
onto...(Ax vision/hands/cog)
 Need smaller length of tubing...especially if
not wanting pt to use it otherwise ie daytime
 Realistically if pt has O2 Concentrator they
will use O2 when SOBOE when unwell,
when SOBOE & for ADLs
eg Mrs S ...forgetful and loves cooking,
use stool
 Set up for safety of Fire risk and Falls
risk if pt uses O2 for ADLs...eventually
may need to use longer
Benefits of Long Term Oxygen
 Improves sleep
 Improves activity and mobility tolerance
 Reduces anxiety due to SOB
 Energy to feed/eat, gain weight
 Limits organ deterioration e.g. heart, brain, kidneys
 Limits cognitive deterioration, less forgetful
 Prolongs the life of end-stage patients
 Improves quality of life
 Relieves distressing symptoms of palliative
patients
Palliative Patients & Oxygen
 Palliative Oxygen is provided free for 3 months by
Concentrator. Cylinder not funded.
 Patients who are mobile require the same home
set-up to minimize fire / falls risks
 Patients with limited mobility requiring wheelchair
or mobile commode or hospital bed, require more
assistance from a Carer to manage the tubing so
both are educated for safe use of O2
 Also medication and techniques to relieve
distress &/or breathlessness eg energy
conservation, fan air to complement the O2
Summary of Team Role- to meet the
needs of our patients
 To comprehensively educate and re-settle
patients with Home Oxygen to optimize
performance of functional mobility & ADLs at home
 To facilitate mobility/driving for Community
access and for Work & Leisure with the latest
portable Oxygen Systems for traveling by car,
train and plane within the local and wider
community
 To assist patients regain self efficacy to maintain
the challenge to their life imposed by their
conditions
References:
1. McDonald CF, Crockett AJ & Young IH. Adult Domiciliary
Oxygen Therapy. Position statement on the Thoracic
Society of Australia and New Zealand. Medical Journal of
Australia 2005. Vol 182 (12); pp 621-626.
2. Health Support Services - EnableNSW. Adult Home
Oxygen Prescription and Provision Guidelines. June 2011