On the Move with Home Oxygen
On the Move with Home Oxygen
Conservation Devices Provide Alternatives for Active Patients
By James Stegmaier, RRT, RFPT, CCM
Whether they’re sinking a putt on the golf course or strolling through the mall, oxygen therapy patients are enjoying a more active lifestyle than ever before. But providing adequate portability for ambulatory patients outside their residences several times per week while keeping costs in check is a challenge.
Oxygen therapy reimbursement has decreased over the past two years due to the Balanced Budget Act for Medicare patients. At the same time, managed care organizations have aggressively worked to get oxygen therapy reimbursement in many areas significantly lower than the current Medicare reimbursement level. In order for a home durable medical equipment provider to adequately serve the patient’s portability demands and be able to work within the reimbursement structure, the provider must look at alternatives available today.
One of these alternatives is the use of an oxygen conservation device with the oxygen portable system. The theory behind oxygen conservation devices is not new. The typical COPD patient spends approximately 60 percent to 70 percent of his respiratory cycle in exhalation. During exhalation, oxygen from a continuous flow oxygen system is wasted into the atmosphere. Conservation devices either store oxygen or only provide oxygen flow on inhalation to conserve the oxygen in the portable system.
The first oxygen conservation devices seen in the early 1980s included the transtracheal catheter, which used the patient’s trachea as a reservoir allowing for a decrease in oxygen liter flow. Today, two other types of conservation devices are available to the respiratory care manager: reservoir and intermittent flow.
The reservoir system of oxygen conservation is basic and works off the theory behind standard oxygen therapy delivery devices. Every oxygen therapy delivery device relies on either an anatomical or mechanical reservoir to provide the FIO2 to the patient. The reservoir collects and stores oxygen during the expiratory phase of breathing, allowing the patient to inhale a specific stored amount of oxygen from the reservoir upon inspiration.
For example, the reservoir style nasal cannula uses the anatomical reservoir of the nasopharynx and an external reservoir to increase the concentration of oxygen on inhalation. Another option is a nonrebreather mask, which uses a reservoir bag to collect oxygen for the patient to inhale from to increase the oxygen concentration. Some reservoirs have a built-in membrane to aid in emptying the oxygen from the reservoir on inspiration.
Reservoir devices allow the practitioner to decrease the overall oxygen liter flow (2:1 when compared to continuous therapy), thereby saving oxygen and increasing portability. Patients can use smaller and lighter oxygen cylinders. No additional equipment is required other than the reservoir cannula, they’re easy to operate and they can be used with either portable liquid or compressed gas. However, reservoir systems need to be changed at regular intervals, and some patients find them unsightly.
Intermittent flow style of conservation devices provide between 3:1 and 7:1 conservation of oxygen ratio, depending on liter flow, respiratory rate and actual type of conservation device.
The first type is the pulse system; oxygen flow is initiated with an inspiratory effort, and a preset pulse of oxygen is delivered. The theory of this style device is that the gas at the start of inhalation ultimately reaches the alveoli, whereas the gas at the second half of the inhalation remains in the patient’s airways and is dead space. The second style is the demand type, which provides oxygen flow with the start of inhalation and terminates the flow with the start of exhalation
The intermittent flow style conservation devices are manufactured for compressed gas cylinders and liquid oxygen systems, but unlike the reservoir system, some of the devices are not interchangeable between liquid and compressed gas. Other disadvantages include higher cost and the chance for mechanical failure.
Conservation devices can be very economical if they are matched with the durable medical equipment provider’s philosophy on the type(s) of stationary oxygen systems that they use to service their patients. If an organization is using largely oxygen concentrators and compressed gas cylinders, then either the reservoir style or the intermittent style can be appropriate. If an organization has a large number of liquid oxygen patients, then the liquid oxygen conservers can be cost-effective as well.
The respiratory care manager must remember that Medicare and most insurance carriers are product-neutral in regards to reimbursement for oxygen therapy. They paid for oxygen therapy and its related services, not for a specific type of system, and the cost of the oxygen conservation device is not covered.
When looking at the finances of providing home oxygen therapy, the major operating cost is the delivery. If the cost of the stationary system is depreciated over a five-year period, one delivery to the patient’s home will cost the provider more than the one-month allocation expense of the depreciation. Therefore, oxygen conservation can work to the durable medical equipment provider’s advantage by allowing the provider to deliver to the patient on a less frequent basis or decrease the number of cylinders needed.
The final step to using oxygen conservation devices is that a patient assessment must be performed to determine his or her portability requirements. Does this patient leave home for large periods of time, or are all trips short in nature?
Also, the patient must be assessed on the conservation device while performing some form of exercise. Most patients use the same liter flow for the conservation device, if the device is intermittent, as on their continuous system. However, a few patients may require more or less oxygen. This cannot be determined in any fashion other than assessing the patient’s oxygen saturation with activity. The reservoir style systems have a basic chart to determine a starting point where the oxygen liter flow should be set to begin assessing the patient with activity, but this must be titrated to a final liter flow that is appropriate for the patient.
Oxygen conservation devices can offer a win-win situation. They increase the patient’s portability and satisfaction, while decreasing the provider’s costs.
Burton G, editor. Respiratory Care, A Guide To Clinical Practice. Philadelphia: J.B. Lippincott; 1991. p. 336-7.
McCoy R. Oxygen-Conserving Techniques and Devices. Respiratory Care 2000;45:95.
Stegmaier J, Lewarski J, Frate-Mikus G. Oxygen Conservation Devices Improve Portability and Reduce the Cost of Care for Ambulatory Home Oxygen Therapy Patients. Respiratory Care 1999;44:1223.
Stegmaier is director of clinical services at Hytech Homecare, Mentor, Ohio.