Vol. 20 •Issue 20 • Page 22
Various Guidelines Govern Oxygen Delivered at Home
Did you know that the preferred way to deliver oxygen was via a nasogastric tube intermittently for 10 minutes every 4 to 6 hours? OK, that was along time ago. Other methods, including intra-abdominal, intravenous, rectal and subcutaneous delivery, were also popular in the early 1900s.
If these delivery methods aren’t a good reason we need guidelines for the appropriate use of oxygen therapy, nothing is.
Fortunately, we have come a long way in the past 100 years. Recently the American Association for Respiratory Care (AARC) updated its guidelines for oxygen in the home and for alternate site health care facilities. The revamped guidelines stress the need for appropriate assessment of need and patient outcomes.
Need must be documented prior to the initiation of therapy and on an ongoing basis. This does not mean monthly arterial blood gases are required. In fact, they are discouraged. Re-evaluation should be done to follow the course of patients’ diseases or assess/document changes in their clinical status if changes in the oxygen prescription are needed.
Evaluation may be done by either invasive or non-invasive means whenever there is a change in the patient’s clinical status that may be cardiopulmonary-related. Outcomes are assessed to establish the adequacy of the patient’s response to therapy. In other words: Is it helping them? AARC guidelines lay out the indications for long-term oxygen therapy (LTOT) use. Rather than identifying specific disease states, the guidelines note LTOT is primarily used for the treatment of hypoxemia. This is different from some other guidelines.
The World Health Organization (WHO), for example, has several sets of recommendations that apply to a variety of disease states. WHO guidelines also treat hypoxemia, though they are tied to various disease states like infections in pediatric patients, avian influenza, sickle cell disease or newborns in distress. The difference in these guidelines is they address oxygen therapy in the context of the specific illness and do not present long-term management criteria/information.
In the United Kingdom, LTOT practices have undergone recent revisions. In 2005, the British Thoracic Society convened a working group to study the situation. That group developed recommendations for an integrated oxygen service. These recommendations apply to home oxygen, including LTOT, ambulatory oxygen therapy and short-burst therapy. Their term “short burst” is defined as the intermittent use of supplemental oxygen at home, usually for periods of about 10 to 20 minutes at a time.
It is important for practitioners to differentiate short-burst therapy from continuous oxygen therapy needed for exercise/exertion. In the British system, the later is known as ambulatory oxygen therapy.
Interestingly, U.K. caregivers stratify their LTOT patients into three grades. Grade 1 patients are primarily housebound and do not leave the home without assistance. They need an oxygen cylinder only for occasional use. They are allotted a cylinder calculated at the same oxygen flow rate as they use for LTOT. The average estimated time of use for their cylinder will be approximately one hour per day but may vary with individual patients.
Grade 2 patients require referral to specialist care for full assessment of their ambulatory oxygen needs. It is expected that most patients in this group will be provided with ambulatory oxygen starting at a usage of two hours daily and they will be asked to monitor their daily usage. The patients should be reassessed after two months. These assessments, in most cases, must be conducted at designated assessment centers.
Grade 3 patients are known as “Exercise Desaturators.” This category is not as clearly defined. These patients must be seen by a specialist in order to quality for ambulatory oxygen.
Closer to home, Canada’s home oxygen system is a bit more decentralized than that in the U.K. The Canadian Home Oxygen Program offers financial assistance to cover the costs of oxygen and related equipment for people who require LTOT. Canadian guidelines are disease-state specific.
What do all these different guidelines mean? For U.S. caregivers, the guidelines are recommendations under which they should operate. Beyond that, RTs need to be aware other guidelines can provide some new perspectives and insights to care.
Medicine is not delivered cookbook-style, but U.S. guidelines do not permit case-by-case management options. I do strongly encourage you to get a second opinion if you are presented with an order for 10 lpm via a nasogastric tube.
Margaret Clark is a Georgia practitioner.