Portable Oxygen: A User's Perspective
Questions & Answers

Medicare Reform and O2 Users

( A reprint of the Letter to the Editor by Peter M. Wilson that appeared in the Fredericksburg Free-Lance Star, 10 December 2003.)
In November 2003, the new Medicare bill passed both the U.S. Senate and the U.S. House. Prescription cost has been the media focus about this bill, so oxygen patients may not know how the changes will affect them.

Beginning in 2005, there will be a reduction in Medicare reimbursements to companies who provide oxygen and oxygen equipment, meaning that these companies will be paid less and be expected to provide the same level of services.

If you live in one of the nation's 100 largest metropolitan areas in 2007, expect your oxygen company to be chosen by competitive bidding. This process will ensure that the lowest bidder will serve you.

I followed the several years of demonstrations of competitive bidding that Medicare conducted in Polk County, Fla. The purpose of the demonstrations was to set aside any fear that oxygen providers or patients might have about competitive bidding.

During the demonstrations, services and the costs of participating Polk County patients were compared with those of nonparticipating patients in nearby Brevard County.

The good news from these comparisons is that the co-pay of Polk County patients was 20 percent lower than that of Brevard County patients. The bad news is that Polk County patients did not receive as many home service calls and were less likely to be issued equipment that would allow them to be mobile.

What troubled me the most about the demonstrations was that none of the companies from the first demonstration participated in the second. Whether they were bought out, changed their names, or packed up and left the county, I do not know.

What you can expect from all this is an oxygen company to serve you with fewer and less well-trained employees. Prepare yourself by fully understanding your medical condition and knowing how to manage oxygen and the equipment that delivers it.

Changing the Impulse Mode

To change mode: 

• Turn conserver off.
• Open the battery compartment and remove battery.
• Locate the white switch in the center of the blue plastic housing.
• Using a very small slotted screwdriver, move the switch to the left for Mode A or the right for Mode B.

Changing the Oxylite 301 to Continuous Flow

This procedure requires you to disconnect the tubing from both sides of the conserver and connect this tubing together. By so doing, the conserver is no longer between the regulator and the oxygen cylinder, so the oxygen flow from the cylinder through the regulator is continuous. I quote the instructions as they appear in the manual: 
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In the unlikely event of operational malfunction or failure, the user will know that the Oxymatic conserver is not delivering the pulse of oxygen in the customary manner.

1. When using a standard cannula, simply disconnect the cannula from the Oxymatic conserver connector, disconnect the oxygen supply tube from the regulator, and attach the cannula tubing directly in the regulator.

2. When using the shorter Oxymatic cannula with the "bayonet" fitting, disconnect both the cannula and the supply tube from the Oxymatic conserver and join the two together with a twist motion as illustrated (fig. 8).

I would suggest that you first turn off the oxygen before following the above steps. The process is very difficult as it is. The presence of oxygen under pressure of 25 psi during the above process makes the above task impossible. If you don't believe me, try it with the oxygen on. 

Practice the above procedure periodically. Practice it as though there was an emergency, with no oxygen flowing. Practice will reduce your stress should an emergency occur, and frequent manipulation of the tubing will keep it from "freezing" at the connections at both the regulator and conserver. 

Remember, a cylinder empties two the five times faster on continuous flow than on puolse flow. It would be helpful for you to know just how quickly. 

Regulators vs. Conservers

Any oxygen system, portable or not, liquid or compressed, may have a device which releases oxygen in pulses. There are many long names for this device with abbreviations such as DOD, OCD and DOC. Most people call it simply a "conserver." 

Some conservers are a separate small box that is placed in the tubing between the regulator and your cannula. Examples of this type are Chad's Oxylite, AirSep's Impulse, and Invacare's Venture. Others combine the regulator and conserver into a single unit which fits over the neck of the cylinder. Examples of this type are AirSep's Impulse Select, DeVilbiss's PulseDose, Mada Medical's Model OCD-2000, VES International Texas's Portamate II, and Mallinckrodt's Companion CR 50. 

Many conservers are battery operated. Some, like the Oxymatic and the Impulse have a switch which controls how often an inhalation will be recognized and oxygen released (from one to four). Most have a switch which controls the volume of oxygen released on an inhalation. The switch on these conservers are numbered, the numbers corresponding to equivalent flow rates (in Lpm) of continuous flow oxygen. 

For more information about conservers, see Portable Oxygen: A User's Perspective.

Concentrator's Electrical Cost

1. Look at the label on your concentrator. It states the number of volts and amps the concentrator uses. My uses 115 volts at 4 amps. I will use these amounts in this example. 

2. Calculate the number of kilowatt (KW) hours per year. 

115 volts x 4 amps = 460 watts (W) 
460 W x .001 KW/W = .46 KW 
. 46 KW x 24 H/day x 365 days/year 
= 4,029.6 KWH/Y 

3. Multiply the above result by the cost per KWH for electricity. I called my electric company and they said 8 cents per kilowatt hour. 

4,029.6 KWH/Y x $0.08/KWY = $322.37

Concentrator maintenance

What you should do.

• Clean the air filters weekly in running water.

• Clean the humidifier as frequently. (If you do not have a humidifier and your flow rate is 3 lpm or higher, you probably should. Besides adding moisture and reducing nasal and sinus dryness, the humidifier also filters out those small particles, such as pollens, which are not captured by the concentrator's filters.)

Make these activities a regular task by setting aside a certain day of the week to clean your filters and humidifier.

• Make certain that your oxygen provider checks your concentrator once a a year if your concentrator has an oxygen sensor, else every three months (1) to certify the flow rate is as indicated, and (2) to verify the oxygen concentration is at 85 percent or greater.
  

• Check the time counter on your concentrator. If its above 20,000 hours, it is time for your oxygen provider to recalled your concentrator and have its compressor rebuilt.

After each maintenance visit by your provider, set up an appointment for the next one, marking your calendar accordingly.

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Transtracheal Oxygen: The "Scoop"

A reader from Colorado wrote asking about the transtracheal delivery of oxygen.

I responded as follows:

Transtracheal oxygen therapy is the delivery of oxygen directly into the lungs by a small, flexible catheter which passes from the lower neck into the trachea or windpipe. The transtracheal delivery of oxygen is not new but has been around for quite a while. It is a well-established method started more than 20 years ago that is used by more than 16,000 oxygen users around the world. Both the surgery and supplies are covered by Medicare.

The manufacturer is Transtracheal Systems, Inc  The system is called transtracheal oxygen (TTO) and it catheter is referred to as the "Scoop." Here is what it looks like from the outside.(image). The most successful candidates for the Scoop are those who manage their health well.Your best source of information is directly from the Transtracheal Systems website.

I have had a Scoop for more than two years. It took me that long to decide to do it. (Unlike many of our youths, I guess I think a long time before I voluntarily have my body pierced.) The surgery is quick and painless, requiring a morning of outpatient work in a hospital. Most of the morning is spent waiting in line for the post operational Xray.

There are two procedures for surgery. If your mother uses the one I had, here is what will happen. For the next six weeks after surgery your mother would return to the hospital once a week to have the Scoop replaced. During these weeks she would clean it in place with a solution and brush. So, plan for weekly trips.

After this "maturity" period, she will be doing the "remove and replace" procedure once or twice a day. Removing one Scoop and replacing it with a clean one is very easy. The only problem with R/R is attaching the chain in the back of the neck--something your mother will be more talented at than I.

The frequency of R/R depends on the individual, and is usually dictated by the accumulation of mucus and plugs. Plugs are the mucus that is dried by the oxygen passing out the the Scoop. They tend to adhere to the Scoop, requiring patience while removing it, particularly when R/R is not done frequent enough. My experience is R/R twice a day with a lung infection and otherwise, once a day.

The surgery is Medicare covered as are all the supplies. She will buy only antibacterial soap. Quarterly, she will receive two Scoops, tubing, and saline solution.

There is one study that shows increased lung infections among Scoop users. It appears as though all doctors remember this study above all the others which praise the device. The device does require regular maintenance and should only be used by someone with good personal hygiene.

It is effective, making use of ALL the oxygen from the source (no blow back around the nose). Gone are the dry and bleeding noses and ears. And, she won't believe how "normal" she looks with only a tube coming out from her waistband.

The surgery procedure is so well written that almost any surgeon can do it, although, as a person who doesn't like to be a barber's first customer, I would suggest someone with experience. The patient instructions, and telephone and email help from the company, are the best done that I have seen.

The only downside are the six weekly trips to the hospital right after surgery. Hopefully, it is closely. If she doesn't like the Scoop, remove it and the surgery will heal in a short time, leaving a small scar.

Another reader asked a series of questions about the Scoop. I responded, imbedding my answers after each question.

Other Questions

Catherine, Martin, Mary and Nick, as indicated below, understand this and are seeking answers, as their messages to the COPD list for October 14th and 15th
indicate. I really appreciate what you four have said. There are many more folks out there who are still working things out in their minds and aren't ready to articulate it yet. 

I hope you won't mind if I respond to your messages here with my own observations. I have no more expertise at these matters than you, it is just I have done more research and talked to more folks.

Catherine in La. wrote, "There really is no difference to amount of 02 that I'm getting on either unit [Helios portable or direct connect to the reservoir] set on # 3. One is click, pause click pause & etc. and other is continuous flow.".

Actually Catherine, there is a difference. Like water over a dam, continuous flow can be measured directly. But, turned into a pulse, it must be measured and calibrated indirectly, through a person or a breathing machine. Here is how, in simplest terms, the calibration marks for pulsating flow get on your conserver. The manufacturer financed a study where 5 to 10 COPD patients sit around with a conserver, continuous flow, and an oximeter. The subjects are given continuous liter flow at one setting (say, 2 Lpm). The oximeter reading is duly noted. The subjects are give a varying pulse sizes (measured in milliliters), which is adjusted until the oximeter reading is the same as continuous flow (here, 2 Lpm). The conserver is "notched" accordingly, and you have on the conserver a setting in ml the "is equivalent to" 2 Lpm of continuous flow. The study continues and other notches are duly noted.

The result you see is your conservers rotating selection switch with numbers 1, 2, 3, 4, 5 and 6 marking pulses in ml which are said to be settings that are "equivalent to" 1, 2, 3, 4, 5, and 6 Lpm of continuous flow. What the actual output is depends on the manufacturer. One manufacturer uses multiples of 10 ml; that is, the settings are for 10,20, 30, 40, 50, and 60 ml. How convenient. Others use multiples of 9.25, 18.5, and 23 ml.

I have talked to some manufacturers about the "equivalence to" numbering and they say if they had this to do over, they would not have tried to equate continuous flow to pulsating flow. They knew all along that dosage was a matter between doctor and patient with help from RTs, but they hoped to make matters simpler for physicians. What they unknowing did was to stress some users--users who believe the world is perfect and the settings must be the same on both, and if they are not, then there is something wrong---with them, with the equipment, their doctor, or their oxygen provider. Such thinking can only lead to a dysfunctional relationship between this user and his/her professionals.

Note that in no instance here have we said which liter flow any of the subjects need, so we go to Martin of Southern California who wrote, "The measuring of the Helios flow is not the same for every user. People breathe differently. This is why the supplier sends a therapist out to measure your 0-2 saturation while wearing the Helios."

Exactly, Martin---and pay no attention if the setting for continuous flow at home is different from the pulsating flow on your conserver. It should be set with consultation with your RT under the circumstances you will use it. Remember, when you go out with a portable, there is greater variability than at home. You walk differently, are dressed differently, and weigh more (oxygen, pocketbook, coat, etc.).

And this leads nicely into what Mary in PA said, "The only problem with this Helios output bit is the medical team doesn't know that much about it."

I like the way that Mary refers to her "medical team" which is what each one of us has who has a chronic illness. If is also good to know the role and, particularly, the limitations of each member, so you know who can give you the best information. I'll bet none of the folks on Mary's team is required to know about portable oxygen systems to perform their jobs. There is some shared expertise among team members, but most of its is focused. Don't ask your provider's delivery person about COPD and don't ask your physician about pulse rates of portable equipment.

And Nick follows up Mary with, "How do I even know that my concentrator, and pulse device on the portable cylinders, are even working right and delivering the right amount of o2. What all should the RT be checking, and how often?"

This is exactly the question you should go with to your oxygen provider's manager. How often is my concentrator/portable equipment checked and for what? Is it periodically replaced? When should I be tested and retested with this equipment? Remember, your provider is a service company (they rent, not sell) and you are a customer, a very, very valued customer. Chronic customers are great because providers can write off the equipment quickly and begin making a profit early on.

 © 2001 Copyright 
Peter M. Wilson, Ph.D.
Founder of PortableOxygen.org