Home Respiratory Care and Mechanical Ventilation
I Overall Goals of Home Respiratory Care
C Reduce morbidity associated with disease
D Arrest the progress of chronic diseases
E Improve overall physiologic and psychological function
F Provide an environment to enhance individual potential
II Home Care Coverage: Financial Considerations
A Federal programs such as Medicare Part B DME provision, Veterans Administration, Social Service Block Grants, or Medicare Hospice
B State programs such as Medicaid
C Local community organizations and chapter affiliates of large organizations such as American Cancer Society, National Easter Seal Society, Amyotrophic Lateral Sclerosis Association
D Private third-party payers, which include commercial health insurance companies, health maintenance organizations (HMOs), managed care organizations (MCOs), participating provider organizations (PPOs), and worker’s compensation
E Payment directly by patient and/or family, which may satisfy deductible, copayment, or total payment for uninsured or uncovered services
III Primary Forms of Home Respiratory Care
A Indication: Any cardiopulmonary disease resulting in significant, chronic hypoxemia in the patient’s chronic stable state.
B Chronic hypoxemia in the home care setting is defined by Health Care Financing Administration (HCFA) reimbursement criteria and is scientifically supported by the Nocturnal Oxygen Therapy Trial (NOTT study) and the British Medical Research Council Working Party study.
C Reimbursement criteria include each of the following
2. PO2: 56 to 59 mm Hg (group II) with
a. Dependent edema suggestive of congestive heart failure
b. Pulmonary hypertension or cor pulmonale determined by measurement of the pulmonary artery pressure, gated blood pool scan/echocardiogram, or “P” pulmonale on the electrocardiogram (ECG), or
3. Hemoglobin saturation: ≤88% (group I)
4. Hemoglobin saturation: 89% (group II), and
a. Dependent edema suggestive of congestive heart failure
b. Pulmonary hypertension or cor pulmonale determined by measurement of the pulmonary artery pressure, gated blood pool scan/echocardiogram, or “P’ pulmonale on the ECG, or
5. Criteria for activity-based oxygen desaturation
a. PO2 of ≤55 mm Hg or hemoglobin saturation of ≤88%
b. Taken during activity for a patient who demonstrates an arterial PO2 of ≥56 mm Hg or an arterial oxygen saturation of ≥89% during the day while at rest
c. In this case supplemental oxygen is provided for use during exercise if it is documented that the use of oxygen improves the hypoxemia that was demonstrated during exercise when the patient was breathing room air.
6. Criteria for sleep-induced oxygen desaturation
a. PO2 of ≤55 mm Hg or an arterial saturation of ≤88% taken during sleep for a patient who demonstrates an arterial PO2 of ≥56 mm Hg or an arterial oxygen saturation of ≥89% while awake, or
b. A greater than normal decrease in oxygen level during sleep (a decrease in arterial PO2 >10 mm Hg or a decrease in arterial oxygen saturation >5%) associated with “P” pulmonale on ECG, documented pulmonary hypertension, and erythrocytosis.
c. In either of these cases coverage is provided only for nocturnal use of oxygen.
D Because the relationship between PO2 and hemoglobin saturation is variable and affected by a number of factors, criteria for home oxygen therapy generally should be based on PO2, not on HbO2%, as depicted in Figure 32-1, where some nonqualifying HbO2% are a result of qualifying PO2.
E Physiologic effects of long-term oxygen therapy
1. Increased exercise capacity
2. Decreased work of the myocardium
3. Decreased work of breathing
4. Decreased pulmonary hypertension
5. Normalization of the hemoglobin level
F Oxygen containment systems used in the home (see Chapter 34 for details)
1. System choice is commonly based more on cost versus reimbursement issues than on clinical efficacy; nonetheless the system chosen for a specific patient should satisfy the domicilary and mobility needs. Each system has major advantages and disadvantages (Table 32-1).
TABLE 32-1
Advantages Versus Disadvantages of Various Oxygen Delivery Systems
| Advantages | Disadvantages | |
| Cylinder oxygen | Fixed finite source of oxygen | Heavy/bulky |
| May be stored indefinitely | Represents the smallest content | |
| Large liter flows transiently available | Requires frequent redeliveries | |
| 100% oxygen source | High pressure 2000-3000 psi | |
| Quiet oxygen delivery | Represents weight and high-pressure danger | |
| Liquid oxygen | Patient can transfill portable | Evaporation/flash loss |
| Large content 860 times compressed | Requires frequent redeliveries | |
| Liter flow limited to 8-10 L/min | May freeze, interrupting O2 flow indefinitely | |
| Low pressure <20 psi | Represents thermal hazard | |
| 100% oxygen source | Requires backup cylinder O2 | |
| Quiet oxygen delivery | ||
| Concentrator oxygen | Infinite source of oxygen | Consumes patient electricity |
| Simplicity of operation | Noisy | |
| Least supplier intrusion | Potential of mechanical failure | |
| Requires patient/supplier maintenance | ||
| Liter flow limited to 5-6 L/min | ||
| Requires backup cylinder O2 | ||
| 85-98% O2 dependent on liter flow | ||
| Represents electric shock hazard |
2. Oxygen concentrators are most commonly used when the patient is essentially homebound for the majority of time. This system provides an infinite amount of oxygen supply with proper maintenance. However, being electrically powered, concentrators should have a backup source of oxygen for power and/or equipment failures. Oxygen cylinders typically provide backup oxygen in the amount to cover three times the supplier’s average response time. With the concentrator there exists the additional cost of electricity, which is incurred by the patient and can be substantial. Specialty concentrators are manufactured that allow the user to slowly transfill aluminum portable cylinders. Portable concentrators with internal battery power and integral oxygen conservers also have recently been introduced. Further a single manufacturer has brought a concentrator capable of delivering 10 L/min to market.
3. Liquid oxygen systems are especially useful for travel, work, and patients with consistent out-of-the-home mobility needs. Liquid oxygen systems represent a large finite source of oxygen with features allowing patient transfilling of portable units. Liquid oxygen units should have a backup source of oxygen for equipment failures or complete depletion of the liquid oxygen contents. Oxygen cylinders typically provide backup oxygen in the amount to cover three times the supplier’s average response time. This finite source of oxygen, which is continuously being consumed, requires weekly (or more often) replenishment by the oxygen supplier.
4. Oxygen cylinders are the least commonly used, are the most labor intensive, and are the most expensive. However, cylinders represent a small finite source of oxygen that can be stored indefinitely, hence making them ideal backup sources of oxygen for the home care patient. Smaller cylinders are commonly used to satisfy the periodic mobility needs of patients using an oxygen concentrator for their primary oxygen source. Cylinders made of composite light-weight resin material that may be filled to 150% the normal filling pressure (3000 psi) are available and represent a significant increase in duration and portability (Table 32-2).
TABLE 32-2
Comparison of Available Portable Oxygen Delivery Systems
| Portable Device | Weight | Gas Contents | Duration† |
| Aluminum M-6 or “B” cylinder* | 2.2 lb | 164 L | 42 min |
| Aluminum M-9 or “C” cylinder* | 3.7 lb | 255 L | 2 hr 7 min |
| Aluminum M-15 or “D” cylinder* | 5.3 lb | 425 L | 3 hr 30 min |
| Aluminum M-22 or “E” cylinder* | 7.9 lb | 680 L | 5 hr 40 min |
| Composite 3000 psi M-9 “B” cylinder size* | 1.7 lb | 246 L | 2 hr 3 min |
| Composite 3000 psi M-15 “C” cylinder size* | 2.6 lb | 410 L | 3 hr 23 min |
| Composite 3000 psi M-22 “D” cylinder size* | 3.2 lb | 640 L | 5 hr 20 min |
| Small representative LOX portable | 5.5 lb | 542 L | 4 hr 31 min |
| Large representative LOX portable | 8.5 lb | 1058 L | 8 hr 50 min |
*Require cylinder valve stem and regulator weighing 1.75 lb.
5. Some patients use a combination of oxygen concentrator for their stationary oxygen source and a portable liquid oxygen unit (transfilled from a stationary liquid oxygen reservoir) for their portable oxygen needs. Note that third-party payers will only pay for one stationary oxygen source under most circumstances.
G Oxygen therapy equipment (see Chapter 34)
1. The simple cannula is most common; however, smaller-sized, low-flow cannulas have been used by long-term users of oxygen because of their comfort and inconspicuous appearance. Such cannulas are reserved for liter flows of ≤2 L/min.
2. The simple cannula is usually supplemented with a 25- to 50-foot oxygen extension to provide mobility from the stationary oxygen source. The 50-foot extension is the longest recommended by oxygen equipment manufacturers.
3. Oxygen-conserving devices are used for normal mobility, long-distance travel, or high oxygen demand.
a. Oxygen reservoir systems function by increasing the anatomic reservoir available for oxygen accumulation.
b. Pulse dose or demand systems deliver a predetermined dose of oxygen at the initial portion of inspiration on every- or multiple-breath variations. Such devices are either independent or integral to the oxygen equipment.
(1) Independent devices are commonly electronically controlled sensors or fluidic switches that are connected in series between the patient and the oxygen source. These may be used with a variety of portable or stationary oxygen sources (e.g., cylinders or liquid oxygen units).
(2) Integral devices are incorporated directly by the oxygen manufacturer and are typically found on small liquid oxygen portable units that provide for extraordinarily small size and light weight without compromise in duration of oxygen provision.
c. Transtracheal oxygen is useful in continued work or other activities away from home or for those with hypoxemia refractory to conventional home oxygen system limits.
H Monitoring home oxygen therapy
1. Patients who meet the criteria for oxygen therapy at discharge frequently do not require oxygen after a few months as a result of
2. Monthly monitoring of status should occur in the home.
a. Pulse oximetry: After the need is established with PO2 criteria, HbO2% is concurrently determined with and without oxygen to establish an HbO2% baseline. Oximetry should also be performed with the patient performing the most strenuous activity of his or her normal day to ensure adequacy of the oxygen prescription. These data are to be used as the baseline for future home monitoring.
b. Sequential monitoring of HbO2% will provide screening for need to assess PO2 by arterial blood gas.
c. Adequacy of PO2 coupled with medical optimization should guide the physician’s decision to maintain or discontinue home oxygen.
3. Office follow-up evaluation: Frequency depends on the severity of the overall disease process.
I Complications/safety considerations
1. Fire hazard is increased in the presence of increased concentrations of oxygen. Generally oxygen should be kept a minimum of 5 feet away from any source of spark and/or flame.
2. Unsecured cylinders present a physical hazard, as does thermal (cold) burn from mishandling liquid oxygen and electric shock from ungrounded oxygen concentrators.
3. Fall secondary to oxygen extension tubing clutter.
4. Complications may occur from the oxygen appliance (e.g., cannula or transtracheal device).
A Patients with an intact airway and thick, tenacious secretions (e.g., cystic fibrosis, bronchiectasis) may require intermittent administration of aerosol therapy via pneumatic nebulizer.
B Patients with permanent artificial airways
1. Most patients are capable of acclimating to artificial airways without the need for continuous aerosol therapy other than the use of artificial noses or heat and moisture exchangers.
2. Many require nocturnal aerosol therapy. Whether heated or unheated, with or without oxygen, depends on the patient’s medical status and tolerance. Note that use of oxygen as a convenient vehicle of aerosol delivery, as is commonly used in the hospital setting, is normally not done in the home care setting. This is a result of home care equipment limitations and third-party payer (reimbursement) constraints.
3. Occasionally the direct instillation of 3 to 5 ml of sterile 0.9% NaCl into the tracheostomy tube on an intermittent or before suction basis is used to thin secretions and/or induce cough.
4. Systemic hydration remains the cornerstone of maintaining normal viscosity of pulmonary secretions.
C Small-volume aerosolized drug therapy (see Chapters 17 and 35) is typically delivered via metered dose inhaler (MDI) or small volume nebulizers (SVNs) with a compressor.
1. Many nontracheostomized, nonmechanically ventilated patients are capable of coordinating the use of an MDI with a spacer, and delivery of medication is best served in that fashion for convenience and cost.
2. However, in those who have psychomotor and/or cognitive impairments precluding the coordinated ventilatory act required of the MDI, the use of pneumatically operated SVNs is warranted. Young pediatric patients unable to grasp verbal instruction also commonly use such devices. These devices are typically AC powered, but variations with rechargeable self-contained batteries and/or cigarette lighter adapters are manufactured.
3. Most common drugs delivered by aerosol in the home include
D Complications/safety considerations
1. Aerosol provides the perfect vehicle for droplet nuclei transmission of contaminants to the lower airway; therefore
a. Proper hand washing should be used before handling equipment.
b. Equipment should undergo regular mechanical cleaning with liquid detergent and water.
c. Equipment should be disinfected periodically with weak acetic acid solution, quaternary ammonium compound, glutaraldehyde, or boiled per equipment manufacturer’s recommendations.
2. By ensuring that the patient and/or caregiver understand the prescription dosage, diluent, and frequency and can physically prepare medication for aerosolized delivery, improper medication dosing is minimized. Unit dose preparations often provide the greatest insurance of proper dosing for those experiencing problems.
VI Bronchial Hygiene Techniques Used in Home Care (Box 32-1)
A Postural drainage, percussion, and vibration (see Chapter 36)
1. Postural drainage uses bodily positioning along with gravity to drain secretions from specific targeted segments of the lung to larger, central airways.
2. Chest percussion is used to dislodge secretions and is performed on inspiration and exhalation using the cupped-hand technique, a palm-held, molded rubber cup-shaped device, or alternatively an electric- or pneumatic-powered percussor. Mechanical percussors are generally a nonreimbursed item.
