Spilling the Box of Pearls: All the Tips on Supplemental Oxygen Management

In my recent post on COPD management, I mentioned that there are some really important parts of supplemental oxygen management that you need to be aware of and consider in your practice. If you are assisting patients who utilize supplemental oxygen regularly, you need to keep these things in mind. You also may be working with patients who are new to supplemental oxygen. This may be the case if you are working with someone who has had COVID-19 and is transitioning settings, or if you work with people who may be new to COPD or other lung diseases.

The first exacerbation of a chronic lung disease is always the scariest because the patient doesn’t know what to expect. They come home with all this new equipment and medicines, and they have no idea what to do with themselves. Usually, rehab and nursing can get them straightened out pretty quick, but sometimes you catch this on the fly and have to completely adapt your process.

Remember, for those who are new to oxygen, they may be pretty overwhelmed as it is. Taking in all this safety info and attempting to coordinate any changes to what they came home with will be very difficult for them as their cognitive load is already very high. Many of these things will fall to you to manage for the initial time frame. You’ll be lucky if they remember even half of what they were told as part of their discharge instructions.

So, on to the list of things we mentioned in the previous post on COPD management. I was going to go in to detail on these items in that post but decided it would just be too much and wasn’t necessarily specific to COPD management. These things can really be applied to all cases where supplemental O2 is required. This post is going to be specific to rehab considerations, but if you are looking for information on supplemental O2 delivery systems and devices, you can check out this post. These tips are all my own, and just what I’ve come to find works best in the long run.

Are you ready for this? Here we go…

1. Supplemental oxygen is typically delivered by a static concentrator that utilizes lengths of tubing that deliver oxygen to the patient wherever they are, which means tubing laying on the floor.
   • Tubing on the floor is a tripping hazard for the patient as well as any other people living in the home. This tripping hazard increases when the patient also uses an assistive device as this is one more (at least) point of contact with the floor that must be cleared with each step. The risks and benefits of utilizing this standard delivery method must be weighed and compensated for each patient individually. Here are some considerations:
     • How active is your patient?
     • Is your patient already a significant fall risk?
     • Are there others in the home that are a significant fall risk, for example, a spouse with dementia?
     • Does the patient utilize a wheelchair? Tubing on the floor creates a barrier and could be considered a restraint if the patient cannot wheel over the tubing in their chair.
     • Is there another option for oxygen delivery that would successfully meet the patient’s needs?
     • Is there another option for oxygen delivery that is within the payer scope?
   • And, yes, supplemental oxygen NEEDS to be worn in the shower. Showering takes a lot of energy and time which requires lots of oxygen. Without it, this particular ADL (and pretty much all ADL, if I’m being honest) are not safe.
   • Oxygen is flammable. Keep it away from gas stoves, lighters, cigarettes, and any other source of flame or high heat.
   • Don’t forget that, as a disease progresses, so too will the patient’s oxygen needs. They may require more or less depending on their disease.
     • If they have something chronic and long-term like COPD, they will probably require an increase over time. This is important to monitor closely as they could transition to being a CO2 retainer which would indicate some further work on your part, like reviewing ABGs and contacting the physician for a change in orders.
     • If they have an acute condition like pneumonia, they may be able to wean off of their oxygen over time. I’ve had this happen in patients, also. It’s a really great day when they get to send all that equipment back! But you’ll need to coordinate an overnight oxygen saturation study with the DME provider and perform a functional capacity test (like a 6-minute walk test) to be sure the patient is safe.
       
2. Oxygen needs to be mobile to go with the patient when they go, and where a large static concentrator cannot follow. Therapists need to facilitate equipment setup to achieve this via mobile concentrators or other portable devices. This equipment must also be coordinated with their assistive device if they have one.
   • Mobile oxygen options vary by DME provider. You can have portable oxygen concentrators (or POCs), oxygen conservers, or cryogenic liquid oxygen delivery systems (Helio). All have their advantages and disadvantages and patients may have more than one delivery method depending on their needs.
   • Insurance will typically only cover one type of delivery system, and it is typically the standard concentrator with tubing if the patient is on standard flow orders. High flow orders can necessitate different delivery systems (such as liquid oxygen).
   • When used in conjunction with an assistive device, portable oxygen delivery systems can be attached in many ways.
     • Portable concentrators can go in a walker basket, on the walker seat, in a backpack, or over the shoulder in the carry bag.
     • Liquid oxygen has to be stored in an insulated bag (usually provided to the patient) and requires more equipment. The liquid has to be transformed in to a gas, which requires several steps, before it can be delivered to the patient. These tanks may require mounting brackets to the sides of wheelchairs, walkers, or the inside of the car to keep them safe. There are some that can be carried in carrying bags, but they are heavy (about 10 pounds) and require increased energy expenditure.
     • Small portable tanks with or without conservers (also known as “on demand” regulators) can be placed in a walker basket, carried in the carrying bag over the shoulder or on the walker handle, or can be mounted to a walker using a standard tank mounting bracket.
     • Mobile units will be limited in ability to provide adequate flow as most do not exceed 4 L/min, and will be limited in battery life based on flow needs. They will need to be charged whenever not in use.
   • When a patient is not regularly ambulatory, you may consider changing up their delivery system based on their functional status.
     • If they are in a recliner or bed most of the day with the exception of when you or another caregiver is present, you may consider have a spare small tank and canula to use for activity only, and have them use the concentrator at all other times.
     • If they are more mobile, you may switch them to smaller tanks to be used throughout the day and have them only use the concentrator at night for sleeping. This is a very successful approach in my practice. Patients love that they can be more mobile without tubing on the floor. Some concentrators come with an attachment that allows the concentrator to fill smaller oxygen tanks for exactly this purpose.
     • To make these changes, a physician order is not typically required as long as the flow rate isn’t changing. You can simply call the DME company, explain the safety concerns and ask for what you want.
       
3. Backup oxygen supply is essential should there be an interruption in the power supply or the concentrator malfunctions.
   • All patients on supplemental oxygen should have a kilo tank, helio reservoir, or other backup supply available (maybe a charged portable concentrator) and know how to access it. Having the tank is great, but if their bedroom is upstairs and the tank is in the garage, that isn’t going to be helpful for them.
   • Kilo tanks have large regulators and can be used to fill smaller tanks or can be tapped directly via canula, but there needs to be at least 24 hours of spare oxygen in the home and the patient needs to know how to contact the DME company to let them know of a power supply failure so the DME can get more supply to them before their kilo runs out.
   • This is a step that is frequently missed in long term oxygen management, so remember to ask about it or check for a back up supply. If there isn’t one, call the DME company and get one delivered.
     
4. Patients need to be educated on how to properly store tanks and swap regulators, as well as how to utilize their oxygen through any other delivery device such as their CPAP, a Duet, or a nebulizer.
   • Oxygen is still a drug that requires a physician order for proper use. It should not be used in any way other than how it is prescribed. However, it still remains our job to ensure it is used properly. Just like other drugs, patients can “ration” their supply if they are going to have to pay out of pocket for refills. This leads to hypoxia, cognitive impairments, and serious medical issues.
   • Spare tanks should be stored upright in some type of device that secures them from a fall. I have seen tanks chained to walls or inside of cars, I’ve seen velcro straps used, I’ve seen 2 liter pop bottle holder trays (they hold small tanks perfectly!). The DME company should have a solution for safe storage as part of their service to the patient. Backup supply tanks also need to be secured at they are tall and tipsy. Spare tanks should not be stored with regulators on them to prevent leaking.
   • Swapping regulators is an easy process, don’t be afraid that you are going to make the tank explode. There will be a loud puff of air but nothing more. Teach your patient to do this also.
   • If your patient is dependent upon supplemental oxygen, they also need to be utilizing this oxygen during other respiratory treatments. This includes CPAPs, BiPAPs, Nebulizers, Duets, and Acapellas.
     • CPAPs, BiPAPs, and nebulizers have a special attachment for supplemental oxygen to flow in. The DME providers should be setting this up, but sometimes it gets missed.
     • And if you are implementing a PEP device such as the Acapella or Duet, you need to make sure your patient is still getting their supplemental oxygen during use. Duets can run the oxygen directly through the bottom attachment. Acapellas allow the patient to still run oxygen via a nasal canula, but if that isn’t working, you can place the oxygen at the end of the Acapella so their are still breathing it in.
       
5. Patients need to be educated on when to clean or replace canulas, tubing, masks, connectors, and any other parts of their oxygen delivery system to prevent pneumonia.
   • Canulas and masks should be replaced weekly, tubing biweekly or monthly (depending on the type of tubing). Connectors should be replaced with the parts they are attached to. So, connectors between lengths of tubing should be thrown out with the tubing. Tubing lengths should not exceed 50ft to maintain the proper flow rate.
   • Masks can be cleaned (just like CPAP masks) using vinegar and water, air dry. Tubing shouldn’t be cleaned as it retains too much moisture and can actually increase the risk of pneumonia. If you see moisture in the tubing, run the oxygen through it without having it attached to the patient until it is dry. (Put the patient on another source of oxygen while you do this.)
   • Dirty parts can lead to pneumonia and other respiratory infections. I’ve found that patients tend to have a drawer or box somewhere with all their “spare” tubing and canulas, not realizing that they are supposed to replace this stuff regularly.
   • If tubing or canula pieces become stiff (like from age or body oils), they should be replaced.
     
6. Adaptations are available to make supplemental oxygen delivery more comfortable for the patient.
   • The most common one is a humidifier. It looks like a small cup of water attached to the concentrator. The oxygen creates bubbles in the cup if it is working properly. These typically require distilled water which leads patients to not refill them when they should, and then they don’t get used. They really do make that oxygen much more comfortable and humidifiers also prevent bloody noses and sore throats.
   • Ear padding is available for people who need to wear canulas and glasses or for people who have discomfort on their ears from the canula. I’ve even seen pressure ulcers on ears due to canulas so this is a big concern. The padding is easy to place on the canula, you just have to ask for it.
   • Canula face padding is also available for noses and cheeks to make the canula as comfortable as possible.

And the final tip I have for you about the management of supplemental oxygen is this: Watch your patient change from mobile oxygen to concentrator oxygen and back.

I do this with literally every patient I evaluate that uses oxygen, new or not. I will tell you that in seven years of doing home health care, I’ve only ever had two patients do this properly. I actually time them. No joke. I time how long it takes them to do it. I once timed a patient as they went three and a half minutes without oxygen while they were trying to figure out how to change from static to mobile oxygen sources. They were exhausted, short of breath (go figure), and desaturated to 84%. I intentionally let them go all the way until they were done, under my close supervision.

The most common mistake patients make is they don’t set up their mobile before taking off the canula from the concentrator. It usually goes down like this:

1. I ask them to show me how they switch from concentrator to mobile tank
2. They take off the canula for their concentrator
3. They hunt around the house for their mobile tank
4. They hunt around for a canula
5. They get everything put together
6. They try to figure out how to turn the regulator on (if there is even a regulator on the tank at all)
7. They can’t see the numbers on the regulator so they have to get glasses…

Do you see where I’m going? They spend way too much time without oxygen trying to figure this out. That is why I always ask them to show me how they do it. By moving step 2 in the above process to the last step, they maintain their safety. One simple change, that’s all it takes. Most of the time, when I show people this, they are in awe. It’s like I waved my magic wand.

Now that I’ve rambled on and on about this, I need you all to go out and wave your magic wands. Go make those patients so much safer. Take the reigns of their oxygen management for a time to make sure they are safe and then teach them how to do the same.

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Try out a few of these clinical pearls and let me know how it goes in the comments!

References:

Hardavella, G., Karampinis, I., Frille, A., Sreter, K., & Rousalova, I. (2019). Oxygen devices and delivery systems. Breathe (Sheffield, England), 15(3), e108–e116. https://doi.org/10.1183/20734735.0204-2019

Hillegass, E. (2020). Vital Signs, oxygen, & exercise prescription: How are these impacted by COVID-19? PACER Project. Cardiovascular and Pulmonary sections of the APTA. Retrieved from https://www.youtube.com/watch?v=lj716KWNcig

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