Starting Oxygen Therapy

 
A Practical Guide for Beginning Oxygen Therapy

Your doctor told you that you need to start oxygen therapy, or that you will need to consider oxygen therapy in the near future. In the Oxygen Therapy article, we answered the most frequently asked patient questions. These include questions about the effect of oxygen therapy on life expectancy, quality of life, and symptoms. 

However, there are many questions that patients do not even think to ask. Those questions are often the ones that, left unanswered, cause patients and their caregivers the most frustration. This guide provides you with a list of questions to ask right from the very beginning to ensure that the process goes as smoothly as possible. 

What are my oxygen needs?

Your doctor determines how much oxygen you need based on the results of tests such as pulse oximetry, the six-minute walk test, and/or an overnight oxygen test.

• Pulse oximetry: A pulse oximeter (often called a “pulse-ox”) is a small device placed on the finger. It has a light source that stays cool to the touch. The light shines through the fingertip, making the fingertip glow red. The device can analyze the light as it shines through the fingertip. Changes in the way the light is absorbed through the finger tissue allow the device to measure oxygen saturation in the blood, with 100% meaning the blood is carrying all the oxygen it possibly can.
• Six-minute walk test: This is a simple fitness test. The object of the test is to walk as far as possible for six minutes. You will walk at your normal pace to a chair or cone, and turn around and walk back. You will continue to walk back and forth for six minutes. You are allowed to slow down, rest or stop. The distance you walk will be compared to what is known to be normal for people in your weight, height, gender and age categories. 
• Overnight oxygen test: This measures your oxygen saturation in the blood during sleep. A pulse oximeter is taped to your finger, and the information on the amount of oxygen in your blood is collected by a small, attached device that is worn all night while you sleep. 

If your oxygen saturation drops below 88% at any time, then you will need oxygen therapy. This is true even if your oxygen saturation comes back up above 88% while you are resting or sitting. 

Once your doctor determines your oxygen needs, they are written up in an oxygen therapy prescription. They are written as liter flow of oxygen per minute, such as 2 liters per minute, or 5 liters per minute (usually written “LPM”). A higher number means more oxygen.

It is important to remember that people with ILDs usually will need more oxygen over time as the disease becomes worse over time. Your oxygen needs at the beginning of therapy will be less than your needs months or years later. Always consider your FUTURE needs when making choices about which oxygen supplier you want to work with and which equipment to buy.

Your doctor may or may not talk to you about your future oxygen needs. It is a good idea to ask directly. You can ask your doctor and your respiratory therapist to discuss this with you. You will need to advocate for yourself to make sure this question gets answered.

What is an oxygen supply company?

Home oxygen supply companies supply medical equipment and supplies to people who use oxygen in their home or while they are out doing daily activities. These companies are also called durable medical equipment providers. There are generally two types: national and local. It is wise to ask your respiratory therapist about which type of oxygen supply company is right for you. There are pros and cons to various companies, and respiratory therapists can often guide you when you make this choice. 

Many patients do not realize they have a choice in which oxygen supply company to use. Their doctor’s office may usually call the same company for all patients, and they may not think to tell you about all your choices. You do have a choice! It is a good idea to ask questions and understand your choices before you sign any paperwork.

Note that if you currently use BiPAP or CPAP, you do NOT have to choose the same company to be your oxygen supplier. 

What does the Medicare “five-year contract” really mean for me?

If you have Medicare and your doctor prescribes oxygen therapy, you will enter a five-year contract with Medicare and your oxygen supplier. This is a complicated contract. (See Medicare.gov for detailed information).

The contract states that the oxygen supplier must provide 1) oxygen equipment, and 2) accessories (tubing, nasal cannulas, etc.) for a total of five years (60 months), as long as you continue to need oxygen therapy. The contract begins the first month that the oxygen supplier bills Medicare for your oxygen.

During the first three years (36 months) of the contract, Medicare pays the oxygen supplier for 80% of the cost of everything – the oxygen equipment rental as well as the accessories. You pay 20%. 

During the last 24 months of the contract, the oxygen supplier is paid less by Medicare. They are paid 80% of only the cost for providing accessories. You pay 20% of the cost for accessories. The oxygen supplier is still required to continue to provide you rental oxygen equipment as well – for no extra cost to Medicare or to you.

During the five years, a supplemental provider plan may cover some or all of the 20% difference you are responsible to pay. Check with your supplemental plan provider if you have one. 

Note that this contract basically locks you into using one oxygen supplier for five years. This happens because the oxygen supplier is paid for oxygen equipment rental for only three years, but must provide you oxygen equipment for five years. If you are unhappy during those five years, you are stuck. Another supplier will not take you on as a patient if you are still in a contract with a different supplier. They would lose too much money on your care.

Once your five-year contract is up, you can switch oxygen suppliers and start a new five-year contract. The new five-year contract will have the same rules as the first one. 

What type of equipment options are there, and which do I need?

Oxygen suppliers will deliver a stationary oxygen concentrator to be used in the home. This plugs into the wall outlet and draws oxygen from the air. There is long tubing that attaches to the concentrator and connects to your nasal cannula or face mask. You may need more than one oxygen concentrator if your house is multiple stories. 

If you need oxygen while moving around outside the home, your doctor will write a prescription for an ambulatory oxygen system. There are two types of ambulatory oxygen systems:

• Portable oxygen concentrator (often called a “POC”): A small electric device that can be worn on the back or wheeled in a carrier. These units draw oxygen out of the surrounding air. They run on regular electricity or a battery and can be recharged from an electrical outlet or from the car. They do not require tanks or filling. These units can be taken onto airplanes. The maximum tubing length for proper delivery of oxygen is 7 feet. 

POCs can be handy, but there are things to keep in mind. First, these units max out at a flow of 3 LPM. Most patients with ILD will need more than 3 LPM over time. Second, most POC devices deliver oxygen in “pulsed dose”. This means that the oxygen is only delivered when you take a breath, instead of all the time (“continuous flow”). Many patients with ILD will eventually need a continuous flow to be comfortable and get enough oxygen. Be sure to ask your respiratory therapist questions about your current and future oxygen needs before you choose to have your oxygen supplier deliver a POC or before buying an expensive POC yourself that insurance or Medicare does not cover. Be aware that the light, small units that are often advertised heavily are will usually not meet your oxygen needs over time. 

• Ambulatory oxygen tanks: These are small, aluminum tanks that are designed to be carried by the patient or wheeled in a carrier. Typically, they are used with an oxygen conserving device (OCD), which delivers pulsed-dose oxygen when you breathe in. The tank may last about 2-6 hours, depending upon how high your oxygen flow is. There are larger oxygen tanks (called “portable” oxygen tanks or “E” tanks) that can be wheeled around. These are used when you need a higher flow of oxygen or continuous flow delivery of oxygen. These are typically the tanks that are given to patients when they come to the hospital or clinic, and they are often given as backups in case of a power outage at home. 

In addition to these items, you will also receive accessories, which may include:

• Oxygen tubing: Tubing connects the oxygen source to your nasal cannula or face mask. There are many different quality levels for tubing. The company will supply basic tubing. You may wish to purchase higher quality tubing that is less prone to kinking or catching on furniture/doorways. The stationary equipment for home use comes with 50-foot tubing, so you can freely move about the house. The ambulatory/portable equipment comes with shorter tubing.
• Nasal cannula: The nasal cannula attaches to the end of the tubing and has prongs that fit into your nose. Again, you may wish to purchase a higher quality cannula than what the oxygen company provides. 
• Oxygen masks: Oxygen masks can also be used for higher-flow oxygen needs. 
• Reservoir tubing: A special type of larger cannula device or a pendant worn around the neck that can increase the amount of oxygen delivered or make the oxygen last longer. These are often used when oxygen flow needs are very high (up to 10 LPM).
• Humidifier bottle: Higher oxygen settings can be drying to the lining of the nose. A humidifier attached to the stationary oxygen equipment can increase your comfort.

Will the equipment I receive be new or refurbished?

Often the stationary oxygen concentrator and the POC (if you have one) will be refurbished. Be aware that the batteries that come in your POC might be years old, even if you have just received the device. It is a good idea to call and ask your oxygen supplier about whether the equipment has been recently serviced and the batteries changed.

Accessories, such as tubing, masks and nasal cannulas, will be new. 

When am I entitled to fresh equipment? Will my oxygen supplier automatically send me fresh equipment at the right time?

You should call your oxygen supplier and ask directly about fresh equipment and supplies. They may not provide supplies automatically. You will need to advocate for yourself, and you may need to be persistent. 

Generally, you should expect to get fresh tubing for at-home use every month. You should expect to get at least 2 new nasal cannulas per month for your at-home system, and 2 new, separate nasal cannulas per month for your ambulatory/portable system. You may need to ask to get the maximum tubing length of 50 feet for at home and 7 feet for ambulatory/portable use. Oxygen suppliers will often supply shorter lengths. Again, you must call and ask. Don’t be afraid to advocate for yourself!

Will my oxygen supplier automatically come out to service my equipment?

Usually they will not. You will likely need to call and ask for service. When you first receive any equipment, write down in a safe place what it is, when you received it, and when the next service should be. Make sure to call and schedule regular service appointments to replace filters, change batteries, and check functionality of your equipment. The longest you should go between service visits is one year. 

Do I need to pay fees to my oxygen supplier?

Yes, sometimes you are responsible for a monthly fee as part of your contract and your insurance company terms. Before you sign any contract with any oxygen supplier, make sure you are very clear about how much your insurance covers and how much you must pay (and when). 

What should I do if my equipment breaks or is not working?

Call your oxygen supplier immediately if you think your equipment is not working.

Who is responsible for managing all these details surrounding oxygen therapy?

Patients are ultimately responsible for managing all the details surrounding their oxygen therapy. The doctor, hospital, clinic, and oxygen supplier will expect you (or your caregivers) to stay on top of contracts, calling for maintenance, calling for supplies, and calling immediately if something is broken. They usually will not do this for you. Do not be afraid of bothering the company or being a difficult customer. When it comes to oxygen therapy, you must advocate for yourself and continue to do so as your oxygen needs change. 

References and further reading

1. American Lung Association. Oxygen therapy.
2. Medicare.gov. Oxygen equipment and accessories.