Home oxygen prescribing the brave new world

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Home oxygen prescribing-the brave new world

• Rob Primhak

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Overview

• Why prescribe home oxygen?
• Oxygen and target SaO2 in babies
• New prescribing arrangements

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General principles

• What is the objective?
• Prevent pulmonary hypertension
• Prolong life
• Improve symptoms
• What is the likely impact on lifestyle?
• Does it need monitoring?

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Who needs it?

• Chronic illness which should improve (e.g. CLDN)
• Chronic progressive illness (e.g. CF)
• Terminal care

• Maintain normoxaemia- prevent PH
• Palliate symptoms- ? Bridge to transplant
• Symptomatic relief only (SaO2 unnecessary)

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Chronic Lung Disease of prematurity
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Normal oxygen levels

• Healthy term infants lower limit of normal
• 93-97
• Fetus- typical in utero
• 70-75 ( paO2 3.2 kPa)
• What is normal for a preterm baby?

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Assessment of oxygenation-Variables

• Oximeter
• Data storage
• Duration of study
• Awake vs asleep
• Mean/median vs lower limit?

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What is normoxaemia in healthy infants?

• Evidence
• 90 infants on first day of life
• median baseline 98.3 in first 24 hrs
• 64 infants longitudinally 2 wks to 6 mths.
• Median baseline 97.3

O'Brien L. Arch Dis Child FN 200083F35-8.
Hunt CE. J Pediatrics1999135(5)580-586.
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VLBW studies

• STOP-ROP 89-94 vs 96-99
• BOOST 91-94 vs 95-98
• Suggestion of worse outcome with high oxygen
• Started in preterm period.

Askie LM. N Engl J Med 2003349959-967.
STOP-ROP. Pediatrics 2000105(2)295-310
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Conclusions?

• Dont give excessive oxygen to ELBW babies!
• (But we knew that already)

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But normal(ish) oxygen is good for you!

• Evidence
• Pulmonary hypertension occurs lt 90

Weitzenblum ERJ 200118251-3.
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But normal(ish) oxygen is good for you!

• Evidence
• Pulmonary hypertension occurs lt 90
• Levels lt 90 associated with ALTE

Iles R. Arch Dis Child 199674304-308
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But normal(ish) oxygen is good for you!

• Evidence
• Pulmonary hypertension occurs lt 90
• Levels lt 90 associated with ALTE
• Growth / survival better if minimum gt 92

Moyer-Mileur LJ. Pediatrics 199698779-83.
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Squaring the circle

• High oxygen targets (gt95) appear to be
  disadvantageous in babies lt36 weeks PMA- ? Result
  in ? lung injury..
• Low oxygen levels (lt91) appear to be
  disadvantageous in babiesgt40 weeks PMA.
• Oxygen targets need to change during life!

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Oxygen therapyGuidelines on current evidence

• NB. Applies to established CLD, post 36 weeks
• Spot checks inadequate- needs recording awake and
  asleep
• Aim at mean ? 93-95
• Avoid values lt90 (no more than 5 of recording)

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Home oxygen

• The brave new world

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Why change?

• Mainly adult-driven
• Decisions about home O2 mainly in 2o care
• Prescribing only from GP (except Scotland)
• Concentrator (regional contracts)
• Cylinders from local chemist
• 2-4 lpm flowmeter/regulator
• Occasional contractor service

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NHS Integrated home oxygen therapy service

• 11 regions in England and Wales
• 1 contractor for each region
• The Contractor is responsible for providing home
  / ambulatory oxygen to meet the clinical needs of
  the patient as set out in the order issued
• In place- Autumn 2005

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Factors taken into account

• Patients oxygen needs
• Long term O2 therapy
• Ambulatory O2 therapy
• (Short burst oxygen)
• Palliative Care
• Children and Young Adults
• Oxygen flow rates and usage

• GP Prescribing
• Hospital Discharge arrangements
• Emergency and Out of Hours arrangements
• Oxygen equipment
• Information for Patients and Carers
• Patient follow-up and review
• Discontinuing oxygen therapy

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Children

• Recognised as different!
• Lower flows
• Mandatory ambulatory oxygen
• Need for fixation to buggies etc.

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Advice to parents/patients from clinicians

• Explanation of why and how.
• Assessment of individual needs and abilities
• Dangers of smoking / fires Advice to inform fire
  brigade
• Contact telephone numbers for the clinical team
• Advice on travel
• Assess parents ability to cope
• Resuscitation training

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Contractors obligations

• Written instruction, supported by appropriate
  training, in the safe and effective use of the
  oxygen equipment provided, (esp smoking and open
  and gas fires)
• Inform fire brigade
• Advice on the use of any instruction manual(s) or
  other service information provided
• A manned 24 hour/7days a week freephone contact
  number

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Other points

• Cylinders will be with integral
  flowmeter/regulator (after 18 months)
• Weight of portable system lt2.5 kg
• Cannulas etc provided by contractor
• O2 provided within 3 working days of receipt of
  order.
• Contractor pays electricity costs of concentrator

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Guidance- discharge

• Mean 93 but no more than 5 of time below 90
  saturation.
• No apneas for gt 2 weeks
• Low flow meter if 0.1-1.0 lpm
• Home visit and assessed as adequate
• Phone available
• Parents trained in use of O2 and CPR

Balfour-Lynn IM et al. Thorax 20056076-81.
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Domiciliary Oxygen Request

• Patient details
• Consultant and other clinicians involved
• Diagnosis
• Assessment .

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Uncertainties in process

• Exact roles of clinical team vs contractor in
  practice
• Influence of paediatricians on process
• Can we get the PCTs/SHAs to show any interest??
• Change-over of existing patients on to different
  systems

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Uncertainties in guidelines

• Exact optimum O2 level.
• Weaning
• Gradual 24 hour process
• Constant flow and increasing time off
• Mixture of both
• Oximetry
• Spot check vs day vs night vs 24 hr vs
• Mean vs below level vs graph

?
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Potential in new system

• Better for patients
• Improved specifications for home oxygen gear
• Simplification for clinicians
• Much of work taken over by contractors
• Potential for audit and research
• Nationwide ascertainment / standardisation

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Questions?