Supplemental Oxygen Therapy: Tailor to Your Patient's Needs

Medscape

5 days ago

Nothing captivates patient (or physician) imagination quite like oxygen. Its power and necessity are considered self-evident. Also a given is the need for saturation to be 90% or above. It's a nice round number, and we're taught early on it's the tipping point on the sigmoidal hemoglobin curve. No one wants to be caught on the steep portion. So, the floor nurse sneaks a nasal cannula onto your patient at night, and the intern walks them wearing a pulse-ox before discharge. At $2 billion per year for oxygen, we have a problem.
JAMA recently published a 'patient-centered' oxygen review. It's excellent reading. Table 1 summarizes studies of patient and caregiver feedback on oxygen use, and Box 1 provides an individual patient narrative. The described experience and related complaints are painfully familiar to anyone caring for a patient on oxygen. There isn't any 'news' here, and others have called for oxygen reform. The review highlights the evidence — or lack thereof — and is notable for its practical depiction of oxygen devices, durable medical equipment (DME) companies, and overall oxygen logistics.
I regularly receive emails from the American Thoracic Society (ATS) oxygen interest group asking for feedback to help support passage of the Supplemental Oxygen Access Reform Act. I can't speak to the substance of the act, but — per its proponents — it's designed to achieve what the JAMA review advocates: oxygen reimbursement and supply tailored to individual patient needs. Great.
There are things we healthcare providers can do now, though. De-implementation (or deprescribing) is critical to cost efficiency, but it's a distant second to not ordering oxygen at all. Outside of the mortality benefit for those with resting hypoxia, outcomes from oxygen prescriptions range from inconsistent to nonexistent. So, to start, if your patient does not have resting hypoxia, think twice (or perhaps three times) before walking them or doing an exercise test.
This brings us to the walk-of-life prior to hospital discharge. The resulting ambulatory oxygen prescription is meant to be 'short-term,' but it is rarely so. More often, it's a gateway drug, driving long-term prescriptions and patient dependence. This is well recognized, and both the ATS and CHEST College list deprescription as part of the their 'Choosing Wisely' campaign. Therapeutic overconfidence and time constraints, along with psychological patient dependence, conspire to prevent it. Discharge is typically handled by general medicine clinicians, house staff, or advanced practice healthcare providers, none of whom are comfortable withholding therapy from someone who desaturates with ambulation. However, to quote an old adage from The House of God , 'if you don't take a temperature, you can't find a fever.' If you don't walk your patient before discharge…
I'd take the same approach to nocturnal hypoxia. The Centers for Medicare & Medicaid Services (CMS) reimbursement for desaturation at night is a modern-day medical mystery. The data isn't there and there aren't guidelines recommending it. Past reviews have argued against screening or prescribing. Anecdotally, I see this less now; but again, if you eliminate reimbursement. I'm confident it won't be seen at all.
Lastly, there's oxygen education to improve health literacy. This is critical but it's a heavy lift. It takes time and resources, and both are in short supply. The JAMA review recommends an oxygen specialist to shepherd the anaerobe through the DME gauntlet. If only the authors could help me pay for one. Maybe I can negotiate with CMS myself. I'll stop ordering nocturnal and ambulatory oxygen supplementation. With the savings generated, CMS will pay for a respiratory therapist to do deprescription and DME navigation. Now that's choosing wisely.