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Sep.30.2021

Oxygen Equipment: Home Education Management (Ambulatory) - CE

ALERT

Use caution in the presence of oxygen. Oxygen is a fire hazard because it lowers the temperature at which materials catch fire in the presence of an ignition source, such as a spark or heat from a light source.undefined#ref4">4

The goal of oxygen use is to treat hypoxemia, but excess oxygen use can cause hyperoxia, causing worse outcomes.3

OVERVIEW

Oxygen is a medication used in a variety of settings. Home oxygen therapy may be short-term or long-term for the patient who is hypoxemic, who has respiratory complications, or who is experiencing activity intolerance. Short-term oxygen therapy may be administered via a nasal cannula or a simple face mask. There are three types of oxygen delivery systems available for home use (Table 1)Table 1: compressed oxygen cylinders, liquid oxygen systems, and oxygen concentrator systems.2

Compressed oxygen cylinders come in a wide variety of sizes. Ideally, the patient should have the lightest cylinder possible that provides oxygen for the longest time (Figure 1)Figure 1. Compressed oxygen cylinders require a regulator and flowmeter. The size of the cylinder and the oxygen flow rate determine how long the compressed oxygen cylinder will last (Table 2)Table 2. The tanks are replaced on a regular basis by an oxygen supply company.

Liquid oxygen systems store oxygen in a liquid state in a cryogenic storage unit. They are more convenient than oxygen cylinders because they take up less space. The patient uses a small ambulatory liquid oxygen unit that is filled from a home storage unit (Figure 2)Figure 2. The liquid oxygen system’s flow duration depends on the prescribed flow rate (Table 3)Table 3. The storage unit is refilled as needed by an oxygen supply company.

Oxygen concentrator systems extract oxygen from the room air and supply oxygen to the patient at the prescribed flow rate. Oxygen concentrators deliver a lower percentage of oxygen to the patient. As the flow rate of oxygen increases, the patient may need a different concentrator. Portable oxygen cylinders that can be filled from a stationary oxygen concentrator unit are also available. Home delivery of oxygen is not needed with a concentrator unit. The patient, however, should have a backup electrical source in case of a power failure.

Home oxygen equipment is designated as durable medical equipment (DME) in the home health setting. Whenever a patient who relies on oxygen therapy contacts the health care system, the health care team member needs to confirm his or her understand of the system used and if there are outstanding DME needs. A patient who requires home oxygen should be given instructions on how to use oxygen therapy efficiently and safely (Box 1)Box 1. To enhance home safety, an oxygen home risk evaluation should be performed, including evaluating smoking materials, other fire risks, and the functioning of smoke detectors in the home.4

EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Provide teaching and written or pictorial instructions to reinforce previous learning of the teaching plan. Have the patient perform a return demonstration to confirm that learning has occurred.
  • Instruct the patient on how to appropriately clean, disinfect, and maintain all oxygen delivery systems and supplies. Verify instructions using the manufacturer’s and the DME supplier’s instructions for use.
  • Instruct the patient to check the mask and tubing by placing hands or face over the mask or cannula to feel the airflow.
  • Inform the patient that any oxygen delivery device may irritate the skin. Instruct the patient to inspect his or her skin frequently.
  • Instruct the patient to check the mask to ensure that it is not too tight; a tight mask can leave indentations on the skin.
  • Educate the patient on oxygen safety measures related to fire and smoking. Instruct the patient never to smoke when using oxygen.
  • Educate the patient to use the accurate oxygen flow rate when using an oxygen device (Table 4)Table 4.
  • Teach the patient the signs and symptoms of hypoxemia or respiratory tract infection (e.g., fever, increased sputum, change in color of sputum, foul sputum odor) and instruct him or her on when to seek additional care.
  • Discuss emergency plans for power loss, natural disaster, acute respiratory distress, or depleted oxygen administration supply. Instruct the patient when to seek additional care.
  • Instruct the patient on safe home oxygen practices:
    • Place “No Smoking” or “Oxygen in Use” signs at each entrance to the home.
    • Do not allow smoking in the home.
    • Keep oxygen tanks away from heat registers, open flames, and any heat sources.2
    • Store oxygen tanks upright in a location where they will not fall over.
  • Encourage questions and answer them as they arise.

PROCEDURE

  1. Perform hand hygiene.
  2. Introduce yourself to the patient.
  3. Verify the correct patient using two identifiers.
  4. Explain the procedure to the patient and ensure that he or she agrees to treatment.
  5. Ensure that evaluation findings are communicated to the clinical team leader per the organization’s practice.
  6. Ensure that the patient places the oxygen delivery system in a clutter-free environment that is well ventilated, smoke free, away from combustible materials, and away from open flames and heat sources.1
    Stress to the patient that an oxygen concentrator system should not be placed in a closet.
  7. Demonstrate the steps for preparing and initiating oxygen therapy. Refer to the instruction manual for the specific model as needed.
    Rationale: Demonstrating the steps is a reliable technique for teaching psychomotor skills and enables the patient to ask questions.
    1. Compressed oxygen cylinders
      1. To turn the oxygen on, turn the cylinder valve counterclockwise with a wrench until the valve appears loose and oxygen is flowing from the tank.
      2. Check the cylinder by noting the reading on the pressure gauge.
      3. Store the wrench in a convenient place where it will not get lost.
    2. Liquid oxygen systems
      1. Check the liquid system by depressing the button at the lower right corner and reading the dial on the stationary oxygen reservoir or the ambulatory tank.
      2. Collaborate with the DME supplier to provide instructions for refilling the ambulatory tank.
        Fill ambulatory tanks only when they are empty. If cold oxygen from the reservoir mixes with warmer oxygen left in the ambulatory tank, it will malfunction.

        To refill the ambulatory liquid oxygen tank:

        1. Wipe both of the filling connectors with a clean, dry, lint-free cloth.
          Rationale: Wiping the filling connector removes dust and moisture from the system.
        2. Turn off the flow selector on the ambulatory unit.
        3. Attach the ambulatory unit to the stationary reservoir by inserting the female adapter from the ambulatory tank into the male adapter of the stationary reservoir (Figure 3)Figure 3.
        4. Open the fill valve on the ambulatory tank (e.g., lever, button, key) and apply firm pressure to the top of the stationary reservoir by holding the ambulatory tank firmly in place (Figure 4)Figure 4.
          Rationale: Applying firm pressure to the top of the stationary reservoir prevents oxygen from leaking during the filling process. If oxygen leaks during the filling process, the connection between the ambulatory tank and reservoir tank may ice up, causing them to stick together.
        5. Stay with the unit as it is filling; it will make a loud hissing noise.
        6. Disconnect the ambulatory unit from the stationary reservoir when the hissing noise changes and a vapor cloud begins to form from the stationary unit.
          Be aware that overfilling will cause the ambulatory unit to malfunction because of high pressure in the tank.
        7. Disengage the ambulatory unit. If the unit does not separate easily, wait until the valves warm to disengage.
          Rationale: If the unit does not separate easily, it is most likely because the valves from the reservoir and ambulatory unit are frozen together.
          Do not touch any frosted areas because contact with the skin may cause skin damage from frostbite.
        8. Wipe both of the filling connectors with a clean, dry, lint-free cloth.
          Rationale: Ice often forms during the filling process. Wiping the filling connectors removes moisture from the oxygen system.
    3. Oxygen concentrator systems
      1. Plug the concentrator into an appropriate electrical outlet.
      2. Turn on the power switch.
      3. Ensure that an alarm sounds for a few seconds until the desired pressure inside the concentrator is reached.
  8. Connect the oxygen delivery device (e.g., nasal cannula) to the oxygen delivery system (Figure 5)Figure 5.
  9. Document the patient’s oxygen saturation before using the oxygen.
  10. Adjust the oxygen flow rate (L/min) to the prescribed rate.
  11. Place the oxygen delivery device (e.g., nasal cannula) on the patient, ensuring a proper fit.
  12. Instruct the patient not to change the oxygen flow rate without direction from the practitioner. Provide written instructions that indicate when and how much oxygen to use.
    Rationale: The oxygen flow rate provides the prescribed amount of oxygen.
    Instruct the patient that exceeding the prescribed amount of oxygen can be harmful (e.g., if the patient has chronic obstructive pulmonary disease).
  13. Have the patient perform each step with guidance. Provide written material for reinforcement and review the material with the patient.
    Rationale: A return demonstration allows for correction of any errors in technique and a discussion of their implications.
  14. Instruct the patient on the required system cleaning.
  15. Discard supplies and perform hand hygiene.
  16. Document the procedure in the patient’s record.

EXPECTED OUTCOMES

  • Patient demonstrates how to apply the oxygen device and adjust the flow rate of home oxygen.
  • Patient demonstrates how to clean and maintain oxygen system.
  • Patient verbalizes the process for obtaining additional oxygen supplies from the DME company.
  • Patient verbalizes the safety guidelines for oxygen use.
  • Patient verbalizes the emergency plan of care.

UNEXPECTED OUTCOMES

  • Patient is unable to demonstrate how to apply the oxygen device and adjust the flow rate of home oxygen.
  • Patient is unable to demonstrate how to clean and maintain oxygen system and oxygen delivery device.
  • Patient is unable to verbalize process for obtaining additional oxygen supplies from the DME company, the safety guidelines for oxygen use, or the emergency plan of care.

DOCUMENTATION

  • Prescribed oxygen flow rate
  • Type of oxygen delivery system and related supplies
  • Education
  • Validation of patient learning
  • Unexpected outcomes and related interventions
  • Evaluation findings communicated to the clinical team leader per the organization’s practice

PEDIATRIC CONSIDERATIONS

  • Oxygen equipment and matches must be kept out of the reach of any children in the home. Playing with fire and manipulating dials or flowmeters can have disastrous effects.

OLDER ADULT CONSIDERATIONS

  • An older adult has a less-efficient respiratory system and less surface area for gas exchange compared to younger adults, and thus has a higher risk for cerebral hypoxia, which is evidenced by confusion caused by decreased oxygen levels.
  • Older adults may be unable to recognize respiratory problems or problems with the oxygen delivery system.
  • An older adult patient should:
    • Have frequent contact with a designated caregiver.
    • Understand which signs and symptoms require a call to the practitioner.
    • Be able to perform tasks related to home oxygen therapy, such as placing the nasal cannula on his or her face.
    • Be cognitively able to use oxygen safely in the home.

REFERENCES

  1. American Lung Association®. (n.d.). Using oxygen safely. Retrieved July 22, 2021, from (Level VII)
  2. American Thoracic Society (ATS). (2020). Patient education: Oxygen therapy. Retrieved July 22, 2021, from https://www.thoracic.org/patients/patient-resources/resources/oxygen-therapy.pdf
  3. Dugdale, D.C., III. (2020). Oxygen safety. Retrieved on July 22, 2021, from https://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000049.htm (Level VII)
  4. Joint Commission, The. (2021). National Patient Safety Goals® for the home care program. Retrieved July 22, 2021, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2021/npsg_chapter_ome_jan2021.pdf (Level VII)

ADDITIONAL READINGS

American Lung Association. (2021). Supplemental oxygen. Retrieved July 22, 2021, from (Level VII)

Heuer, A. J. (2021). Chapter 57: Respiratory care in alternative settings. In R.M. Kacmarek, J.K. Stoller, A.J. Heuer (Eds.), Egan’s fundamentals of respiratory care (12th ed., pp. 1279-1298). St. Louis: Elsevier.

Elsevier Skills Levels of Evidence

  • Level I - Systematic review of all relevant randomized controlled trials
  • Level II - At least one well-designed randomized controlled trial
  • Level III - Well-designed controlled trials without randomization
  • Level IV - Well-designed case-controlled or cohort studies
  • Level V - Descriptive or qualitative studies
  • Level VI - Single descriptive or qualitative study
  • Level VII - Authority opinion or expert committee reports
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