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 the patients who
need it, 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
and development 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 entirely
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 in at 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 for business, the new technology has
implications for the continued health of respiratory home care
businesses as well as the patients they serve.
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, and get
up and use the bathroom on their own.” 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 potential 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 considerable experience working with patients who
enjoy travel adventures. 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. “I think it’s a wonderful thing.”
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 of them to loan out to
their 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.”
Innovative solutions, providing improved portability and
enhanced quality of life for respiratory home care patients,
continue to thrive, in spite of the fact that there are no
direct financial incentives to fuel the research and
development fires. 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 home care
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, and a member of RT’s
editorial board.