Appendix 3

Long term oxygen therapy (McDonald et al., 2005)

Initiating oxygen therapy

• Before introducing oxygen therapy, ensure optimal treat­ment of the pulmonary disorder while monitoring improve­ment with objective tests such as FEV₁ and FVC. Treatment may include maximum therapy for airway obstruction, attention to nutrition and bodyweight, an exercise rehabili­tation program, control of infection, and treatment of cor pulmonale.
• In patients selected for oxygen therapy, assess the ade­quacy of relief of hypoxaemia (Pao2 > 60 mmHg, or 8 kPa; Spo2 > 90%) and/or improvement in exercise capacity or nocturnal arterial oxygen saturation while using a practical oxygen delivery system.

What the patient needs to know

• Patients receiving oxygen therapy in the home, and their carers, should have the use clearly explained. That is, hours of use and flow rate, and any need to vary flow rates at given times. The equipment and its care, including how to obtain servicing or replacements, needs to be explained. The dangers of open flames (especially cigarettes, gas heaters and cookers) need to be emphasised.
• Flow should be set at the lowest rate needed to maintain a resting Pao2 of 60 mmHg (8kPa) or Spo2 > 88%. For patients with COPD, 0.5-2.0 L/min is usually sufficient. Flow rate should be increased by 1 L/min during exercise.
• Humidifiers are generally not needed at oxygen flow rates below 4 L/min.
• Extrasoft nasal prongs are recommended for continuous oxygen use, but may become uncomfortable at flow rates over 2-3 L/min and in the long term. Facemasks may be preferred for at least some of the time, although there are dangers of rebreathing exhaled CO2 at flow rates below 4 L/min.
• In some patients needing 24-hour oxygen therapy, trans­tracheal delivery systems may have advantages.

Review

• Reassess 4-8 weeks after starting continuous or noctur­nal oxygen therapy, both clinically and by measurement of Pao2 and Paco2, with and without supplementary oxygen. A decision can then be made as to whether the treatment has been properly applied and whether it should be contin­ued or abandoned.
• Patients on intermittent oxygen therapy should also be reassessed periodically. The review can be undertaken by appropriately trained staff using a pulse oximeter to confirm hypoxaemia (Spo2 < 88%) at rest or during daily activities. They should also check compliance with therapy and smok­ing status.
• Review at least annually, or more often according to the clinical situation.

Dangers

• Supplementary oxygen in patients with increased arterial Paco2 may depress ventilation, increase physiological dead space, and further increase arterial Paco2. This is suggested by the development of somnolence, headache and disorien­tation.
• In long-term oxygen therapy, the increase in arterial Paco2 is usually small and well tolerated. However, serious hypercapnia may occasionally develop, making continued oxygen therapy impractical. Risk appears greater during acute exacerbations of disease or if the flow of oxygen is increased inappropriately.
• Sedatives (particularly benzodiazepines), narcotics, alco­hol and other drugs that impair the central regulation of breathing should not be used in patients with hypercapnia receiving oxygen therapy.

Choosing the right method

Domiciliary oxygen therapy can be delivered by three systems:

• Cylinders: These contain compressed oxygen gas and deliver 100% oxygen at the outlet. Portable lightweight cylinders are available. Electronic conservation devices trig­ger oxygen supply on demand, resulting in up to fourfold reduction in oxygen consumption. Reservoir-style conserv­ers are a cost-effective alternative.
• Oxygen concentrators: These extract the nitrogen from room air by means of molecular sieves, delivering 90%-95% oxygen at a flow rate of 2 L/min. The percentage falls to about 78% oxygen at a flow of 5 L/min, depending on the model. All units currently available in Australia are imported. A back-up standard D-size oxygen cylinder may be added in case of concentrator breakdown or power failure, but adds to the cost and is rarely necessary. Users may claim a rebate on their electricity account.
• Liquid oxygen systems: These systems conserve space by storing oxygen in liquid form. The oxygen is delivered through coils, where it vaporises. Two tanks are needed: a large storage tank, which is filled by the supplier as required (eg, one unit has a 25 800 L gaseous capacity, equivalent to seven E-size cylinders), and a portable unit is filled from the larger tank for ambulatory use.

The prescription should always specify:

• the source of supplemental oxygen (gas or liquid);
• method of delivery;
• duration of use; and
• flow rate at rest, during exercise and during sleep.

There is no significant difference in the quality of oxygen delivery among the above methods. However:

• Concentrators are cheaper than cylinders if use is equiva­lent to or more than three E-size cylinders per month.
• Concentrators can be wheeled around the home but are heavy (about 21–26 kg) and are difficult to move up stairs and in and out of cars.
• Concentrators cannot be used for nebulisation, as the pressure delivered is too low (35–63 kPa, compared with 140 kPa for nebuliser pumps).
• If the anticipated need is for longer than three years, it is cheaper to buy than to rent a unit. The units usually have a five-year guarantee. However, public funding is available for pensioners and Health Care Card holders, subject to means testing.