Home Respiratory Care and Mechanical Ventilation

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Home Respiratory Care and Mechanical Ventilation

Overall Goals of Home Respiratory Care

II Home Care Coverage: Financial Considerations

III Primary Forms of Home Respiratory Care

IV Oxygen Therapy

Indication: Any cardiopulmonary disease resulting in significant, chronic hypoxemia in the patient’s chronic stable state.

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.

Reimbursement criteria include each of the following

1. PO2: ≤55 mm Hg (group I)

2. PO2: 56 to 59 mm Hg (group II) with

3. Hemoglobin saturation: ≤88% (group I)

4. Hemoglobin saturation: 89% (group II), and

5. Criteria for activity-based oxygen desaturation

6. Criteria for sleep-induced oxygen desaturation

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.

Physiologic effects of long-term oxygen therapy

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

image

*Require cylinder valve stem and regulator weighing 1.75 lb.

@ 2 L/min liter flow.

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.

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.

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.

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.

3. Office follow-up evaluation: Frequency depends on the severity of the overall disease process.

Complications/safety considerations

Aerosol Therapy

Patients with an intact airway and thick, tenacious secretions (e.g., cystic fibrosis, bronchiectasis) may require intermittent administration of aerosol therapy via pneumatic nebulizer.

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.

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

Complications/safety considerations

VI Bronchial Hygiene Techniques Used in Home Care (Box 32-1)