Presentation by Dr. Hetan Shah on the topic- Home based oxygen therapy" at the Cardiology Society of India conference in Mumbai.

1. 1
Home based oxygen therapy
For Severe Pulmonary
Hypertension
Dr Hetan C Shah
Assoc Professor of cardiology
Sheth G S Medical College
KEM Hospital,Mumbai
Consultant Interventional
Cardiologist
Jaslok Hospital

2. Outline
• Introduction
• Historical aspects
• Clinical Effects of O2 Therapy
• Indications in pulmonary Hypertension
• Oxygen Delivering Devices
• Techniques of administration
2

3. Introduction
“Who can tell but that in time this pure air
may become a fashionable article of luxury”
Joseph
Priestly
3

4. History
• Joseph Priestly, Wilhelm Scheele and Antoine
Lavoisiere discovered oxygen independently in
eighteenth century
• Lavoisiere named it oxyge'ne
• John Cotes and Alvan Barach- First administered
oxygen to patients with COPD to relieve dyspnea
and improve exercise capacity
• Campbell - Controlled Oxygen Therapy for safe
continuous treatment
4

5. Home based Oxygen
therapy
5
• Long-term oxygen therapy (LTOT)
• Nocturnal oxygen therapy (NOT)
• Ambulatory oxygen therapy (AOT)
• Palliative oxygen therapy (POT)
• Short burst oxygen therapy (SBOT).

6. LONG-TERM OXYGEN
THERAPY
LTOT can be defined as oxygen used for at
least 15 h per day in chronically hypoxaemic
patients.
Chronic hyperaemia is defined as a PaO2
7.3 kPa or, in certain clinical situations,≤
PaO2 8.0 kPa.≤
6

7. Clinical effects of domiciliary
Oxygen treatment
• Improves the function of all Hypoxia sensitive
cells
• Effects on-
1. Survival
2. Neuropsychiatric function and Quality of Life
3. Pulmonary Circulation
4. Erythropoietic System
7

8. Effect Of O2 on
Survival
• Studied in detail in patients with COPD
• Hypoxemia and Pulmonary hypertension -
increase airflow limitation- Decrease
survival
• Continous O2 delivery decreases mortality
from 71% to 30% in patients of COPD with
cor pulmonate
8
Petty et al 1960

9. NOTT Study
• 12 hrs/day O2 vs 24 hrs/day O2 in patients
of COPD
• % of patients surviving at 12, 24,and 36
months was higher in 24hrs/day group
(p<0.01)
9
Nocturnal oxygen Trial Therapy Group, Ann Intern Med 1980;93:391

10. Survival in patients of COPD on
LongTerm Oxygen therapy
10
Nocturnal oxygen Trial Therapy Group, Ann Intern Med 1980;93:391

11. MRC Study
• 15 hrs/day O2 Vs No O2 in COPD pts with
Cor pulmonale
• Survival notably higher in patients receiving
Long Term O2
11
Report of the Medical Research Council Working Party,
Lancet 1981; 1: 681

12. Survival in patients of COPD on
LongTerm Oxygen therapy
12
Report of the Medical Research Council Working Party, Lancet 1981; 1: 681

13. Individuals with less severe hypoxemia may not
derive survival benefit from LTOT.
Trials with
Survival Benefit
Trials with No
survival benefit
PaO2
<60mmHg
(7.98kPa)
<69mmHg
(9.18kPa)

14. Effect on Neuropsychiatric
function
• Brain represents only 2% of adult body mass , but receives
20 % of cardiac output
• Chronic hypoxia leads to
Cognitive impairment (Perceptual learning, Problem
solving , memory and simpler motor skills) and
Emotional disorders (High level of anxiety, stress and
Depression)
• Treatment with continuous O2 improved Cognitive function (
Recent Memory and speed of Work)
14
Krop et al, Borak et al

15. Effects of LTOT on sleep
• Ventilation–perfusion mismatch during sleep can
lead to-
Nocturnal hypoxemia,
Decreased functional capacity
Nocturnal hypoventilation particularly pronounced during
REM sleep
• This in turn can lead to poor sleep quality with
sleep fragmentation.
• Use of LTOT corrects nocturnal SaO2, decreases
sleep latency and improves sleep quality
evaluated by EEG.
15

16. Improved quality of life
Demonstrated in a prospective study that measured health
related quality of life (using the St. Georges Respiratory
Questionnaire [SGRQ]) before and after six months of LTOT
delivered via a concentrator.
Prior to therapy, health related quality of life was worse among
the patients with COPD who had hypoxemia (and had already
been receiving LTOT for at least six months via a cylinder),
compared to patients with COPD who were not hypoxemic.
After six months of LTOT, health-related quality of life had
improved and was similar in both groups.
16

17. Effects on Pulmonary
Hypertension
• Alveolar Hypoxia is a potent pulmonary
vasoconstrictor and leads to increased
PAH
• It is generally considered important to
maintain oxygen saturations at 90% at all
times.
• The use of supplemental oxygen may
decrease the need for phlebotomy, and
reduce the incidence of neurologic
dysfunction and complications.
17

18. • The effect of LTOT on PAP are small.
• NOTT trial, survival after 8 years was related to the
decrease in mean PAP during the first 6 months of
treatment.This subgroup analysis also showed
improvement in PAP and stroke volume in patients with 24 h
of oxygen therapy per day compared to those given only 12
h of oxygen per day.
• MRC trial, LTOT prevented a rise in PAP of 0.4
kPa (3 mm Hg), seen in the control group, although
a fall in PAP was not found.
18

19. Predictors of LongTerm response to
Continuous Supplemental OxygenTherapy
• Decrease of the mean PAP greater than 5
mmHg after 24 hours of 28 % oxygen
therapy
• High peak oxygen consumption (VO2) after
symptom-limited exercise (>6.5 cc/kg per
min as determined by a 30 second
collection of expired gas in an airtight
collection bag)
19
Ashutosh K, Dunsky M. Noninvasive tests for responsiveness of pulmonary
hypertension to oxygen. Prediction of survival in patients with chronic obstructive lung
disease and cor pulmonale. Chest 1987; 92:393.

20. Effect on Erythropoietic
system
Supplemental oxygen therapy reduces
secondary polycythaemia,as seen by a fall in
haematocrit and red cell mass.
LTOT in patients with a low haematocrit have
worse survival than patients with high
hematocrits (>0.55).
20

21. 21
Pulmonary hypertension may occur in a number of
pulmonary vascular disorders which can all
predispose to
hypoxaemia.
There is no evidence of the effectiveness of LTOT in
RCTs in patients with pulmonary hypertension, with
the
exception of those patients who develop pulmonary
hypertension as a complication of their COPD.
LTOT in patients with
pulmonary hypertension

22. Evidence statement
▸ The use of LTOT in patients with pulmonary
hypertension may improve tissue oxygenation and
prevent complications associated with hypoxaemia
rather than lead to a specific survival benefit.
Evidence level 4
Recommendation
▸ LTOT should be ordered for patients with
pulmonary hypertension, including idiopathic
pulmonary hypertension, when the PaO2 is 8 kPa.≤
(Grade D)
22
The BTS Guideline for Home Oxygen Use in
Adults, Thorax, 2015 July

23. Evidence statement For Hypercapnia
during O2Treatment
• Patients with baseline hypercapnia can undergo
LTOT assessment without adverse outcome but
require monitoring of pH and PCO2 levels during
and at the end of assessment. Evidence level 4
Recommendation
• Patients with baseline hypercapnia should be
monitored for the development of respiratory
acidosis and worsening hypercapnia using ABGs
after each titration of flow rate, as well as ABG
sampling after oxygen titration is complete. (Grade
D)
23
The BTS Guideline for Home Oxygen Use in
Adults, Thorax, 2015 July

24. Evidence statements for flow
titration
24
• Patients for whom LTOT is ordered at a single
flow rate suffi- cient to achieve PaO2 >8 kPa (60
mm Hg) at rest demon- strate a survival benefit
from LTOT. Evidence level 1+
• LTOT ordered at a single flow rate to provide
adequate oxygenation at rest may offer
inadequate oxygenation during exercise and/or
sleep. Evidence level 3
• LTOT ordered for patients at different flow rates
for use during sleep and exercise demonstrates a
survival benefit from LTOT.Evidence level 1+The BTS Guideline for Home Oxygen Use in Adults, Thorax,
2015 July

25. 25
▸Patients eligible for LTOT should be initiated on a flow
rate of 1 L/min and titrated up in 1 L/min increments until
SpO2 >90%.
▸An ABG should then be performed to confirm that a
target PaO2 8 kPa (60 mm Hg) at rest has been≥
achieved. (Grade B)
▸Non-hypercapnic patients initiated on LTOT should
increase their flow rate by 1 L/min during sleep in the
absence of any contraindications. (Grade B)
▸ Patients initiated on LTOT who are active outdoors
should receive an ambulatory oxygen assessment to
assess whether their flow rate needs to increase during
exercise. (Grade B) The BTS Guideline for Home Oxygen Use in Adults,
Thorax, 2015 July
Recommendations

26. EQUIPMENT FOR HOME
OXYGENTHERAPY
The equipment for home oxygen therapy can be
divided into three categories:
oxygen source (concentrators, cylinders and
liquid oxygen)
oxygen delivery (cannulae, masks, conservers
and tracheal devices) and
supplementary equipment (humidifiers
and equipment to carry oxygen).
26

27. Portable oxygen systems
• Lightweight compressed gas cylinders
• Liquid oxygen systems
• Portable Oxygen concentrators
27

28. Portable oxygen sources
Heavy, Cumbersome, and Limited in the duration of
oxygen supply,
Oxygen conserving devices
Oxygen therapy more efficient,
More portable
Less intrusive

29. Continous Flow Nasal Canula
Continuous flow oxygen delivery through nasal cannula is the
usual prescription for LTOT in hypoxemic patients and, thus, is
the standard against which all oxygen-conserving techniques
should be compared
29
Relation between oxygen flow rate via nasal cannula and the fraction of inspired oxygen (FiO2). Each
additional L/min in oxygen flow increases the FiO2 by about 4 percent (shown as a separate block on

30. Methods of O2 Conservation
In the home setting, oxygen cylinders with limited storage
and oxygen concentrators with limited flow range present
barriers for patients on long-term oxygen.
Modes of O2 Conservation
A.Reservoir cannulas
B.Transtracheal catheters
C.Demand oxygen pulse devices
•Non invasive open ventilator with oxygen
30

31. Reservoir Canula
Reservoir cannulas function by storing oxygen in the reservoir space during
exhalation, making that oxygen available as a bolus upon the onset of the next
inhalation.
Oxygen is conserved because the patient breathes a higher concentration of
oxygen without increasing flow from the oxygen tank or concentrator.
Reservoir cannulas increase the percent of oxygen in the air that the patient
inhales over that delivered by standard nasal cannula and usually enable a
reduction in the oxygen flow setting of approximately 25 to 50 percent while
maintaining the same pulse oxygen saturation.
Reservoir cannulas can help decrease the flow rate needed for patients on low-
flow oxygen, but they are more commonly used to provide a higher concentration
of oxygen to patients who require a flow rate of oxygen 4 L/minute or higher.
31

32. Moustache
Configuration
(Oxymizer)
32
Top panel: During exhalation, the membrane in the Oxymizer
reservoir cannula is thrust forward, creating a 20 mL
chamber. Bottom panel: When the patient is ready to inhale,
he/she receives the stored oxygen in addition to the supply
oxygen. This allows the patient to become adequately
oxygenated at lower supply flows.
Pendant
Configuration
(Oximizer Pendant)
Fluidic
Reservoir
canula
The fluidic reservoir cannula
is designed to be oxygen
conserving across a range of
oxygen flow rates. Unlike the
Oxymizer mustache cannula,
the device does not have an
inner membrane.

33. Use Of Nasal Reservoir Canula
33
The reservoir cannulas (Oxymizer and Pendant) set at 0.5 L/min will achieve an oxygen saturation measured by
oximetry (SpO2) equivalent to continuous flow at 2.0 L/min - an efficency of 4:1. Similarly, 2.0 L/min will achieve an
SpO2 equivalent to continuous flow at 4.0 L/min - an efficiency of 2:1.
Tiep BL. Reservoir cannulas. In: Portable Oxygen Therapy: Including
Oxygen Conserving Methodology, Tiep BL (Ed), Futura Publishing, Mt
Kisco, New York, 1991.

34. Delivers oxygen directly into the trachea through a
small opening in the neck
34
Transtracheal catheters
Physiologic
benefit
Mechanism
Decrease in
dead space
O2 from catheter enters the trachea lower in
the airways, decreasing dead space.
Decrease in
total inspired
minute
ventilation
Due to flow from the catheter, less gas is
inspired at the mouth, reducing work of
breathing.
Increase in
CO2
elimination
efficiency
Fresh gas flowing from the catheter flushes
the area proximal to the catheter tip during
expiration, reducing the amount of CO2 that
returns to the alveoli with the next
inspiratory cycle. In addition, gas exiting the
catheter tip at high velocity generates
turbulence that enhances gas mixing distal
to the catheter tip, increasing CO2 washout.
As a consequence, PaCO2 remains
unchanged despite a decrease in total
inspired minute ventilation.

35. Demand Oxygen Pulse therapy
35
The demand module is interposed between the pressurized oxygen source and the patient.
As the patient inhales, inspiratory airflow is detected by pressure changes in the nasal
cannula. A solenoid in the module is rapidly opened and closed, enabling a pulse of oxygen
to be delivered at the beginning of inhalation Tiep BL. Electronic pulse oxygen. In: Portable Oxygen Therapy: Including
Oxygen Conserving Methodology, Tiep BL (Ed), Futura Publishing, Mt Kisco,
New York, 1991.

36. Methods Of O2 Conservation
36
Reservoir Demand pulse
Noninvasive
open
ventilator with
oxygen
Transtracheal
catheter
(placed
surgically)
Mechanism Stores
oxygen during
exhalation
Delivery during
early inspiration
Delivers 50 to
250 mL pulses
Store, bypass
dead-space
Efficiency 2:1 to 4:1 3:1 to 7:1 Not available 2:1 to 3:1
High-flow 16 L/m Not applicable Larger pulses 16 L/m
Comfort Adequate Adequate Adequate Good after
insertion;
requires daily
cleaning
Cosmetics Obtrusive Adequate Adequate Excellent
Complications Rare Mechanical
failure
Mechanical
failure
Mucous plug,
bleeding,
malposition
Porszasz J, Cao R, Morishige R, et al. Physiologic effects of an ambulatory ventilation system
in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2013; 188:334.

37. Responsibilities of physicians
prescribing long-term oxygen
therapy (LTOT)
37
Document the need for LTOT in the medical record*
Select a qualified oxygen equipment supplier
Complete certificate of medical necessity form and specify:
1. Oxygen flow at rest, during exercise, and during sleep, where appropriate
2. Oxygen delivery systems, including:
A. Stationary unit
B. Portable or ambulatory equipment
C. Oxygen-conserving device, if desired
D. Nasal cannula or transtracheal catheter
3. Justification for portable or ambulatory oxygen, if requested
4. Verify that the supplier has correctly restated the prescription before signing
Monitor use and environment (with home oxygen supplier)
Reevaluate for possible changes in the prescription
Renew LTOT, as required

38. Thank You
38