New lightweight concentrators give new
freedom to patients dependent on oxygen.
Oxygen. Don’t leave home without it.” That is
what home care clinicians have been advising patients for
decades. We know that using portable oxygen makes a
fundamental difference for patients, but ensuring compliance
with prescribed regimes has been a constant challenge. To that
end, manufacturers of home oxygen equipment have poured
enormous resources into research of better ways to help
patients live comfortably with supplemental oxygen. Initially,
oxygen concentrators replaced bulky banks of H tanks. Aluminum
E tanks replaced steel for reduced weight. Cryogenic (LOX)
systems brought the advantages of liquid oxygen into the home
care setting. More recently, oxygen conserving devices (OCDs)
have facilitated use of much lighter portable oxygen units
without compromising the hours of available use.
Amazingly, the cost of all this
progress has been absorbed by manufacturers competing to build
a better mousetrap, and by respiratory home care providers
committed to improving the quality of life for the patients
they serve. Reimbursement has consistently decreased, even as
we have provided increasingly more sophisticated portable
oxygen options.
Recent innovations are breaking the rules and
limitations we once accepted for both oxygen concentrators and
cryogenic systems. Since the beginning, respiratory home care
providers have accepted the generality that a concentrator
delivering five liters of continuous flow would weigh nearly
50 pounds. A three-liter machine would weigh close to 30
pounds. Oxygen concentrators require a pair of sieve beds to
process the air into oxygen, and a compressor to push the air
through the system. This produces heat, so a cooling fan was
also necessary. All that adds up to considerable weight, and
draws considerable current.
But a new generation of truly portable oxygen
concentrators, using improved sieve bed technology combined
with OCDs, promise to deliver a level of innovation and
convenience that was previously unimaginable. At least three
companies now have (or will soon have available for sale)
oxygen concentrators that weigh less than 10 pounds and can
operate on AC, 12V DC, or up to 3 hours on a battery pack. The
maximum equivalent flow rate, using OCD technology, is a five
setting. In a business that is constantly operating on a fixed
income due to Medicare payment caps and the specter of
competitive bidding, the new technology has implications for
the continued health of respiratory home care businesses.
Cryogenic oxygen systems are also offering
equally innovative technology. At least one company has
received approval from the US Food and Drug Administration for
an oxygen concentrator that, in addition to providing
continuous flow home oxygen, actually produces its own liquid
oxygen, eliminating the need for costly refills from the home
care provider. The president of the company explains that the
system takes “feed flow from an oxygen concentrator and sends
a portion of it through a cryogenic cooling device that chills
it to the temperature at which oxygen condenses [into liquid].
The liquid oxygen is stored until it’s ready to be transfilled
into a portable, 4.2-pound unit that can give a typical
patient 6 to 8 hours’ worth of oxygen. This basically gives
the patient an unlimited supply of liquid O2,” he says. The
product will begin shipping in 2006.
As a respiratory therapist and vice president of
operations and compliance for Premier Medical, Denver, Dave
Empey, MBA, RRT, understands the importance of nurturing the
health of his company as well as the health of his patients.
“It’s pretty mind-boggling,” he says, when discussing the
emerging technology. At this time, his company is not using
the breakthrough technology because it is relatively
expensive. “But cost is supposed to decrease as production
increases,” he says, and it is his understanding that Medicare
will allow billing as both a stationary and a portable,
because the machines serve both functions. He cautions that
the portable concentrators necessarily employ OCDs, which are
not appropriate for all of the people all of the time. Some
patients simply require a constant flow.
After years of lobbying by the AARC and other
organizations interested in easing travel restrictions for
patients on oxygen therapy, the Federal Aviation
Administration (FAA) published its final rule, allowing
patients to take their portable oxygen concentrators where no
concentrator has ever gone before—on board commercial
airlines. “Airlines can write their own specific rules, so it
won’t necessarily be consistent—some may, for example, require
the passenger to have a fully charged backup battery,” Empey
points out. But the new ruling is a major breakthrough for
patients traveling with oxygen.
Most airlines charge a hefty fee for providing
in-flight oxygen for each leg of the journey. A round trip
with two legs each way, for example, could add $400 to the
price of a ticket. At least one major airline does not make
in-flight oxygen available at any price. Armando Rodriguez,
RRT, is a flight attendant for a major airline and has
simultaneously continued to work as a respiratory therapist
for 30 years. He has seen first hand the hardships many
oxygen-dependent patients must endure. “They [the airlines]
charge them a fortune, and they have to be in specific seats.
If they had a battery-powered concentrator, they could sit
anywhere.” He mentions that cabins are pressurized to 6,000
feet, so patients may need a higher liter flow than what they
required at sea level. In addition, they may be stressed and
dehydrated, further increasing their oxygen requirements.
Although some battery packs last up to 3 hours,
and the patient could conceivably carry an extra battery pack,
using the AC or 12V DC mode would be the most attractive
option while in transit. Rodriguez sees that as a problem
right now, but one that may not last for long. “The only 12V
capacity on the planes I fly is in first class and business
class, and in some planes it’s been disconnected because they
were having heat problems in some of the older planes,” he
says. This will not be a problem as newer planes replace aging
fleets. “The new air-liners are going to have power in every
cabin, and they are going to redo all the entertainment (and
power) options. I’ll be surprised if they don’t have Ethernet
ports for everybody.”
Bonnie Piel, RRT, is a pulmonary rehabilitation
patient care manager at North Colorado Medical Center,
Greeley, Colo, and has experience working with patients who
enjoy travel. After it is determined whether they are
candidates for an oxygen conserving device, major factors for
her patients are portability and weight. She emphasizes the
critical importance of titrating the patients’ oxygen level to
their activity level. Before planning plane trips, she loans
her patients a pulse oximeter and has them take a drive to
nearby Estes Park (altitude 7,500 feet), and monitor their
oxygen saturations during rest and with activity. “We find
that if they can maintain oxygen saturations of 92% to 96%,
they demonstrate better stamina and reserve,” she says. “On a
cruise ship, for example, we found that with saturations of
88% to 90%, patients began to poop out after walking about 100
feet. But if we could maintain 92% to 96% by increasing their
flow rates during activity, they had relatively unlimited
stamina and reserve. And we often find they have to increase
their oxygen level by about one liter or more when they gain
altitude.”
Rodriguez likes the idea of allowing patients to
bring their own portable oxygen systems on board aircraft. “If
a patient is oxygen dependent and can control their own
oxygen, it’s much better for us, and much better for the
patient,” he says.
Regina Carbone, RRT, has worked in the home
oxygen field for more than 20 years. “When I saw the portable
concentrators for the first time, I asked, ‘Where are the
sieve beds?’ They’re in a little tube, they’re not in big
containers… and ‘Where is the compressor?’ They have it
fine-tuned and it is all miniaturized,” she says. “It is
expensive, but I think it’s a great innovation, and now they
are allowing it on the airplanes.” She adds a cautionary note,
saying, “Medicare reimbursement is so low, I don’t think home
care companies will be able to provide it for their routine
patients. It might make sense for long-distance rural patients
(where it takes a half day of staff time to service one
patient). I think companies will buy a handful to loan out to
patients for travel. I also see a lot of very savvy oxygen
users that are on the Internet, that read journals, and will
be purchasing them themselves. There is quite a bit of
disposable income in some of the senior population, and I have
patients that want to buy the best. They want to buy it, and
own it outright.”
Innovation costs money, and product
manufacturers, home care providers, and patients all continue
to work together to find ways to do much more with much less.
“Oxygen continues to represent 75% to 80% of our revenue,”
says Empey. “I think Medicare will continue to ratchet down
oxygen reimbursement and competitive bidding will be a factor
limiting income, but there is also potential for respiratory
therapists to pursue new opportunities. We may finally begin
to be reimbursed for patient care services (like pulmonary
rehab) that could be provided in the home.” Creative managers
continue to find ways of offering more and an ever wider
variety of home oxygen options for their patients, while
maintaining fiscal health. For manufacturers and providers to
continue making these strides in the face of rising costs and
sinking revenue is a remarkable achievement and testimony to
their creativity and determination. Improved patient
compliance and quality of life can continue to coexist in an
ever challenging economic environment.
John A. Wolfe, RRT, CPFT, is a clinical
specialist, North Colorado Medical Center, Greeley, Colo.