New perspectives in pulmonology
Long-term oxygen therapy (LTOT) revisited: In defense of non-delivery LTOT technology
Oxigenoterapia de longa duração (OLD) revista: Em defesa da tecnologia OLD sem fornecimento domiciliário
P.J. Dunne
HealthCare Productions, Inc., Fullerton, USA
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Winck, A. Morais" "autores" => array:2 [ 0 => array:2 [ "nombre" => "J.C." "apellidos" => "Winck" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Morais" ] ] ] ] ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0873215912000785?idApp=UINPBA00004E" "url" => "/08732159/0000001800000004/v2_201509041425/S0873215912000785/v2_201509041425/pt/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">New perspectives in pulmonology</span>" "titulo" => "Long-term oxygen therapy (LTOT) revisited: In defense of non-delivery LTOT technology" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "155" "paginaFinal" => "157" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "P.J. Dunne" "autores" => array:1 [ 0 => array:3 [ "nombre" => "P.J." "apellidos" => "Dunne" "email" => array:1 [ 0 => "pjdunne@Sbcglobal.Net" ] ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "HealthCare Productions, Inc., Fullerton, USA" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Oxigenoterapia de longa duração (OLD) revista: Em defesa da tecnologia OLD sem fornecimento domiciliário" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The term “<span class="elsevierStyleItalic">non-delivery LTOT</span>” is used to describe installations of newer home oxygen therapy systems where oxygen concentrator technology is used to provide both stationary and ambulatory oxygen.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The use of non-delivery LTOT equipment obviates the need for oxygen supply companies to make repeat (and costly) home deliveries to replenish depleted gaseous or liquid oxygen contents, the majority of which is most often used during ambulation away from the stationary system.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The evidence base for LTOT supports the use of both stationary and ambulatory oxygen systems to maintain adequate oxygenation at all times and under all conditions of use.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Non-delivery LTOT systems therefore offer hypoxemic COPD patients requiring continuous, uninterrupted supplemental oxygenation, and meaningful, real-time options. With a properly functioning non-delivery system, LTOT users now have the option of spontaneously going where they want to go, when they want to go, and how they want to go, as opposed to constantly waiting (and hoping) that a much needed re-supply delivery will take place as scheduled.</p><p id="par0015" class="elsevierStylePara elsevierViewall">There are three options presently available to provide non-delivery LTOT.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> One method is to use a standard stationary oxygen concentrator, in tandem with a pressure booster, to re-fill small portable cylinders. A second option is the use of a portable oxygen concentrator (POC). The third option, still under development, is a standard oxygen concentrator, used in tandem with a cryogenic liquefier, to re-fill a small canister with liquid oxygen. All three options employ the use of concentrated oxygen (≈93%) as opposed to medical grade oxygen (99.9%).</p><p id="par0020" class="elsevierStylePara elsevierViewall">All of the aforementioned non-delivery systems incorporate the pulse dose delivery of oxygen. With pulse dose delivery, a preset volume (or bolus) of oxygen is administered at some point during the inspiratory phase of a patient's breathing cycle. In this regard, pulse dose delivery devices provide an intermittent flow (IF) of oxygen as opposed to the more ubiquitous continuous flow (CF) delivery. Oxygen administered with an IF device is quantified in milliliters (mL) per breath while the standard for CF is liters per minute (L/min).</p><p id="par0025" class="elsevierStylePara elsevierViewall">In theory, the ability to adjust the size of a delivered pulse volume of oxygen, as well as the speed at which the selected pulse dose volume will be delivered, should facilitate optimum oxygenation. This is especially desirable during the periods of even moderate ambulation when systemic oxygen demand increases.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It should be noted that pulse volume dosing was originally developed to conserve gaseous or liquid contents of smaller portable units.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> While this original oxygen conservation application is still valid when used with home re-filled gaseous or liquid cylinders, when integrated into a POC, the IF function is to prolong battery life. This raises important questions about the accuracy of oxygen dosing when a POC is used as a non-delivery LTOT system, although evidence suggests that similar issues surround the use of traditional oxygen conserving devices.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">There are two classes of POCs – those that can only operate in the pulse dose/IF mode (single-mode POCs), and those capable of operating in both the pulse dose/IF mode <span class="elsevierStyleItalic">and</span> CF mode (dual-mode POCs). On average, single-mode POCs weigh<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>4.5<span class="elsevierStyleHsp" style=""></span>kg, whereas dual-mode POCs weigh slightly more, ≈7.7<span class="elsevierStyleHsp" style=""></span>kg. The trade-off with the lighter weight single-mode POCs is a reduction in the amount of concentrated oxygen that can be produced. Where single-mode POCs produce approximately 700–900<span class="elsevierStyleHsp" style=""></span>mL of concentrated oxygen per minute, dual-mode POCs are capable of producing up to 3000<span class="elsevierStyleHsp" style=""></span>mL per minute. The larger oxygen production capability of dual-mode POCs provides prescribers and home care clinicians more options while individually titrating chronic hypoxemic patients to a target arterial oxygen saturation.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">All POCs (single and dual mode) share the common feature of operating from flexible power sources, i.e. standard household electrical outlet, the external power outlet in motor vehicles and aircraft, or a rechargeable battery. When home oxygen patients first learn about POCs, especially patients using a CF delivery device, they are quickly enamored with the lightweight feature of most single-mode POCs. The most attractive feature is the potential ability to use a 3–4<span class="elsevierStyleHsp" style=""></span>kg, easily carried device that is literally self-contained, allowing the device to be used for both stationary and ambulatory purposes. However, many soon discover that the reduced oxygen production per minute (the trade-off for the device's lighter weight) is insufficient to prevent desaturation at all times and under all conditions, especially during extended ambulation. A recent report also showed the inability of a pulse dose/IF POC to be used in conjunction with noninvasive ventilation to provide supplemental oxygen.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">At the root of the problem is the widely held misperception that a numerical setting on a pulse dose/IF device is equivalent to the corresponding continuous flow – e.g. a numerical setting of 1, 2 or 3 is equal to 1, 2 or 3<span class="elsevierStyleHsp" style=""></span>L/min. This is not the case and often results in unintended sub-optimal dosing. It is intuitive that the exact dose of any medication prescribed for long-term control of a chronic medical condition (e.g. hypertension, hyperlipidemia, hyperglycemia) be known. This truism applies equally when oxygen is used as a controller medication for chronic hypoxemia. Failure to know the dose of any delivered medication is not conducive to attainment of optimum clinical outcomes or sustained symptom control. With respect to sub-optimal LTOT dosing, the inability to correct underlying severe chronic hypoxemia often leads to a worsening of the deadly adverse sequelae of COPD.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Regardless of which type of POC is used, when operating in the pulse dose/IF mode, the amount of the oxygen pulse volume (in mL) must be known for each numerical setting. It is also essential to know the delivered oxygen purity at a particular setting, as well as the effect an increase in the breathing rate would have on the delivered oxygen purity. For example, some single-mode POC models, when set on the device's maximum setting, may well deliver oxygen purity<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>90% at a breathing rate of 12<span class="elsevierStyleHsp" style=""></span>breaths/min, only to have the oxygen purity decrease into the mid 80% range when the breathing rate increases to 20<span class="elsevierStyleHsp" style=""></span>breaths/min or higher. In this all-too common example, the patient's requirements exceed the performance capability of the selected POC. A decrease in oxygen purity typically results in periods of unintended arterial desaturation, and may lead to the incorrect perception that the disease state is deteriorating, when in fact, it is the LTOT equipment that is failing the patient.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Regrettably, not all manufacturers promoting POCs for non-delivery purposes provide detailed information regarding the pulse dose volume (expressed in mL) of a particular delivery device at a specific setting. Equally frustrating is the absence of information on the impact of increased breathing rates on concentrated oxygen purity at each setting. Further, there is no consistency in the number of numerical settings a particular device may have. Some models have three settings (i.e. 1, 2, and 3) whereas others have five settings, and some even six or more. Adding further confusion is the fact that, in most cases, the selected setting does not display the delivered pulse volume. Thus, one model POC will deliver a pulse volume of 27<span class="elsevierStyleHsp" style=""></span>mL at the highest setting of 3, whereas a competing model will deliver a pulse volume of 192<span class="elsevierStyleHsp" style=""></span>mL at the highest setting of 9. The former example is characteristic of single-mode POCs whereas the latter is characteristic of the more robust dual-mode POCs. In the absence of uniform data on performance specifications, especially with single-mode POCs, the only way to ensure adequate oxygenation is to conduct an individualized titration study and equip the patient with a personal pulse oximeter.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">While appealing in concept, because of the aforementioned deficiencies, it must be understood that non-delivery technology is not for every LTOT user. While there may be those who cannot be adequately saturated with one model of single-mode POC, another brand single-mode POC with higher oxygen production capabilities might work. At the same time, there may those patients in whom no single-mode POC will work, but who can attain satisfactory oxygenation with a dual-mode POC. It is therefore incumbent for both prescribers of LTOT and home care clinicians to understand the capabilities and limitations of non-delivery LTOT systems. It is this writer's experience that this is the exception rather than the rule. Accordingly, it is highly recommended that patients having any type of pulse dose/IF device prescribed for any use need a titration study to determine the device's ability to maintain adequate oxygenation under all conditions of intended use.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,12,13</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In summary, when used correctly by knowledgeable prescribers, home care clinicians and properly trained patients, non-delivery LTOT systems can provide a welcome alternative to being tethered to a large, stationary LTOT device, this in spite of the aforementioned performance limitations. Technological advances are sure to result in higher oxygen production capability of POCs even as unit weight decreases. Also on the horizon is the presumable integration of closed-loop, oximetry-driven oxygen delivery technology where oxygen dosing is automatically adjusted to maintain a target arterial saturation.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13-15</span></a> As non-delivery LTOT technology does continues to evolve, one hopes that the appropriate regulatory agencies will establish uniform standards in terms of equipment labeling, dosing representations and performance capabilities to redress the issues and concerns described herein.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">DOI of refers to article: <span class="elsevierStyleInterRef" href="doi:10.1016/j.rppneu.2012.04.003">http://dx.doi.org/10.1016/j.rppneu.2012.04.003</span>.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The clinical impact of new long-term oxygen therapy technology" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "P.J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 6 | 15 |
| 2024 October | 48 | 57 | 105 |
| 2024 September | 68 | 45 | 113 |
| 2024 August | 76 | 33 | 109 |
| 2024 July | 53 | 34 | 87 |
| 2024 June | 53 | 31 | 84 |
| 2024 May | 55 | 28 | 83 |
| 2024 April | 69 | 28 | 97 |
| 2024 March | 52 | 24 | 76 |
| 2024 February | 33 | 18 | 51 |
| 2024 January | 36 | 23 | 59 |
| 2023 December | 45 | 27 | 72 |
| 2023 November | 35 | 34 | 69 |
| 2023 October | 26 | 34 | 60 |
| 2023 September | 28 | 26 | 54 |
| 2023 August | 23 | 25 | 48 |
| 2023 July | 22 | 22 | 44 |
| 2023 June | 27 | 10 | 37 |
| 2023 May | 37 | 22 | 59 |
| 2023 April | 27 | 16 | 43 |
| 2023 March | 65 | 29 | 94 |
| 2023 February | 40 | 19 | 59 |
| 2023 January | 28 | 12 | 40 |
| 2022 December | 54 | 26 | 80 |
| 2022 November | 68 | 36 | 104 |
| 2022 October | 59 | 21 | 80 |
| 2022 September | 29 | 26 | 55 |
| 2022 August | 47 | 45 | 92 |
| 2022 July | 42 | 36 | 78 |
| 2022 June | 29 | 31 | 60 |
| 2022 May | 34 | 37 | 71 |
| 2022 April | 41 | 31 | 72 |
| 2022 March | 40 | 43 | 83 |
| 2022 February | 42 | 29 | 71 |
| 2022 January | 38 | 38 | 76 |
| 2021 December | 35 | 37 | 72 |
| 2021 November | 34 | 34 | 68 |
| 2021 October | 41 | 38 | 79 |
| 2021 September | 36 | 30 | 66 |
| 2021 August | 40 | 19 | 59 |
| 2021 July | 27 | 17 | 44 |
| 2021 June | 28 | 22 | 50 |
| 2021 May | 50 | 40 | 90 |
| 2021 April | 56 | 72 | 128 |
| 2021 March | 129 | 11 | 140 |
| 2021 February | 86 | 15 | 101 |
| 2021 January | 46 | 20 | 66 |
| 2020 December | 48 | 5 | 53 |
| 2020 November | 56 | 19 | 75 |
| 2020 October | 41 | 15 | 56 |
| 2020 September | 91 | 22 | 113 |
| 2020 August | 96 | 23 | 119 |
| 2020 July | 130 | 24 | 154 |
| 2020 June | 117 | 25 | 142 |
| 2020 May | 118 | 23 | 141 |
| 2020 April | 104 | 10 | 114 |
| 2020 March | 73 | 11 | 84 |
| 2020 February | 83 | 11 | 94 |
| 2020 January | 108 | 22 | 130 |
| 2019 December | 87 | 18 | 105 |
| 2019 November | 104 | 18 | 122 |
| 2019 October | 107 | 32 | 139 |
| 2019 September | 89 | 23 | 112 |
| 2019 August | 156 | 19 | 175 |
| 2019 July | 160 | 20 | 180 |
| 2019 June | 136 | 10 | 146 |
| 2019 May | 142 | 17 | 159 |
| 2019 April | 144 | 21 | 165 |
| 2019 March | 187 | 17 | 204 |
| 2019 February | 97 | 8 | 105 |
| 2019 January | 169 | 23 | 192 |
| 2018 December | 90 | 2 | 92 |
| 2018 November | 37 | 3 | 40 |
| 2018 October | 47 | 11 | 58 |
| 2018 September | 29 | 7 | 36 |
| 2018 August | 35 | 27 | 62 |
| 2018 July | 41 | 20 | 61 |
| 2018 June | 56 | 19 | 75 |
| 2018 May | 86 | 19 | 105 |
| 2018 April | 80 | 16 | 96 |
| 2018 March | 148 | 21 | 169 |
| 2018 February | 35 | 17 | 52 |
| 2018 January | 41 | 17 | 58 |
| 2017 December | 30 | 17 | 47 |
| 2017 November | 34 | 23 | 57 |
| 2017 October | 24 | 23 | 47 |
| 2017 September | 25 | 20 | 45 |
| 2017 August | 24 | 23 | 47 |
| 2017 July | 25 | 19 | 44 |
| 2017 June | 34 | 23 | 57 |
| 2017 May | 55 | 24 | 79 |
| 2017 April | 11 | 10 | 21 |
| 2017 March | 12 | 45 | 57 |
| 2017 February | 18 | 9 | 27 |
| 2017 January | 14 | 6 | 20 |
| 2016 December | 19 | 13 | 32 |
| 2016 November | 21 | 7 | 28 |
| 2016 October | 16 | 9 | 25 |
| 2016 September | 13 | 7 | 20 |
| 2016 August | 9 | 2 | 11 |
| 2016 July | 9 | 6 | 15 |
| 2016 June | 7 | 7 | 14 |
| 2016 April | 32 | 4 | 36 |
| 2016 March | 54 | 9 | 63 |
| 2016 February | 58 | 15 | 73 |
| 2016 January | 43 | 16 | 59 |
| 2015 December | 45 | 12 | 57 |
| 2015 November | 46 | 15 | 61 |
| 2015 October | 49 | 13 | 62 |
| 2015 September | 50 | 8 | 58 |
| 2015 August | 40 | 8 | 48 |
| 2015 July | 27 | 6 | 33 |
| 2015 June | 32 | 3 | 35 |
| 2015 May | 60 | 11 | 71 |
| 2015 April | 59 | 10 | 69 |
| 2015 March | 56 | 7 | 63 |
| 2015 February | 69 | 8 | 77 |
| 2015 January | 87 | 11 | 98 |
| 2014 December | 95 | 12 | 107 |
| 2014 November | 96 | 12 | 108 |
| 2014 October | 177 | 14 | 191 |
| 2014 September | 72 | 9 | 81 |
| 2014 August | 69 | 6 | 75 |
| 2014 July | 83 | 13 | 96 |
| 2014 June | 61 | 8 | 69 |
| 2014 May | 67 | 10 | 77 |
| 2014 April | 43 | 9 | 52 |
| 2014 March | 75 | 14 | 89 |
| 2014 February | 49 | 11 | 60 |
| 2014 January | 80 | 10 | 90 |
| 2013 December | 48 | 11 | 59 |
| 2013 November | 74 | 19 | 93 |
| 2013 October | 53 | 11 | 64 |
| 2013 September | 53 | 15 | 68 |
| 2013 August | 60 | 11 | 71 |
| 2013 July | 82 | 24 | 106 |
| 2013 June | 50 | 14 | 64 |
| 2013 May | 59 | 19 | 78 |
| 2013 April | 64 | 27 | 91 |
| 2013 March | 61 | 15 | 76 |
| 2013 February | 69 | 20 | 89 |
| 2013 January | 65 | 31 | 96 |
| 2012 December | 36 | 20 | 56 |
| 2012 November | 50 | 30 | 80 |
| 2012 October | 43 | 17 | 60 |
| 2012 September | 38 | 13 | 51 |
| 2012 January | 95 | 0 | 95 |
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