Long-term oxygen therapy delivery systems.

Three major systems are currently available in most urban settings for the delivery of long-term oxygen therapy. These are compressed oxygen in tanks, liquid oxygen, and oxygen concentrators. Each system has advantages and disadvantages. The choice of system for any individual patient must be based on relative cost, the need for portability, and safety features. The cost of oxygen and regulations governing its reimbursement vary widely throughout the country. Oxygen should be supplied by reputable vendors who meet specific criteria for assuring quality service. In many instances referral to a home care agency for teaching and supervision of the patient is essential. Patient compliance with long-term oxygen therapy is often poor due to factors such as lack of significant subjective improvement, unrealistic fears or embarrassment concerning use of oxygen, and feelings of depression or hopelessness that the patient may experience when told he needs oxygen.     

Long-term oxygen therapy in Australia.

Thoracic physicians in New South Wales, Australia, and conservative in their administration of long-term oxygen therapy. Relatively few patients are being treated with it at present. Those who are use oxygen cylinders and concentrators in their homes. Use of long-term therapy is restricted to two groups: first, well-motivated patients who, after investigation and treatment, continue to have PaO2 values below 60 mm Hg and evidence of complications arising from hypoxia; and second, a few patients who have central apnea and severe desaturation of hemoglobin during sleep.     

Long-term oxygen therapy: conference summary

With Jan's presentation, the conference concluded. In looking back on it, I think it is obvious that the group heard a very comprehensive, state-of-the-art review of this very important topic. Obviously, LTOT has enormous clinical and financial impact for millions of patients around the world. Indeed, LTOT is one of the few therapies available that has clearly been shown in randomized controlled trials to impact mortality. There are many questions that remain, however. To me, the most important of these questions involve the diagnosis and management of patients who do not have resting hypoxemia but who do have NOD and/or XOD. How aggressively should we "screen" for these conditions? If we find them, do we treat continuously or just during the hypoxemic episodes? What is the role of supplemental oxygen during rehabilitative exercises (including usage in patients who don't become hypoxemic)? The answers to these questions will clearly have substantial clinical and financial impact. Other memorable aspects of this conference included the tireless efforts of Ray Masferrer to pull this conference off, the special camaraderie of the participants that made the discussions so productive, and the lovely location that gave the conference an atmosphere of high quality. I'd like to recognize and thank two important groups. First, the American Association for Respiratory Care did a superb job of organizing the conference and providing the journal Respiratory Care as a forum to publish the proceedings. Second, our 3 industry sponsors not only provided critical funding support but also gave the group important perspectives during many of the discussions. These kinds of industry-profession collaborations benefit everyone. Finally, I'd like to extend my congratulations to all the speakers for jobs well done and to thank them for making my job as summarizer an enjoyable one.     

Use of heliox in critical upper airway obstruction. Physical and physiologic considerations in choosing the optimal helium:oxygen mix

Heliox has a lower density than oxygen and nitrogen, and can improve ventilation rapidly in patients with critical upper airway obstruction. The choice of the best helium:oxygen ratio depends on whether the predominant problem is hypercarbia or hypoxia. In the former situation, 80% helium should be used, and in the latter, 100% oxygen is appropriate.     

Prolonged ventilator dependence: economic and ethical considerations.

Patients who receive ventilator treatment tend to be older and sicker than ever before, factors that contribute to the complexity of ventilator weaning. The provision of prolonged ventilator support entails a commitment of expensive hospital resources, yet survival is often poor. Consideration must be given to limiting ventilator treatment in instances when benefit is highly unlikely or when the burdens of treatment outweigh benefits. Decisions to withhold or withdraw mechanical ventilation must be made with full knowledge and understanding of relevant ethical principles. If ventilator support is to be terminated, this should be accomplished according to institutional protocols that take into account these ethical considerations, as well as the medical and legal facts that apply.     

Long-term oxygen therapy vs long-term ventilatory assistance

The use of positive-pressure nasal ventilation in combination with LTOT in stable COPD patients with hypercapnic respiratory failure controls hypoventilation and improves daytime ABGs, sleep, and quality of life. Nasal ventilation in COPD is unlikely to produce benefit unless used with supplemental oxygen therapy at night. The patients who show the greatest reduction in overnight PaCO2 with ventilation are the patients most likely to benefit from long-term ventilatory support. Although there is now evidence for short-term benefit from NPPV in hypercapnic COPD, large multicenter studies with survival, exacerbations, and hospital admissions as the primary end points are required to evaluate longer-term effects of this potentially important intervention.     

Oxygen therapy in emergency medicine Part 2. Paediatric oxygen therapy,special considerations and complications

This is the second of a two part article reviewing oxygen therapy in emergency medicine. The first part covered the physiology of oxygen, measurement of oxygenation and oxygen delivery apparatus. This section reviews oxygen therapy in specific clinical settings including paediatrics, acute medical conditions and shock. Oxygen therapy during patient transport, complications of oxygen therapy and special delivery systems are also reviewed. The emergency physician should possess a thorough knowledge of this therapeutic modality which forms one of the cornerstones of emergency medicine.     

Intravenous therapy: a review of complications and economic considerations of peripheral access

Despite the growing frequency of intravenous (IV) injections, establishing peripheral IV access is challenging, particularly in patients with small or collapsed veins. Therefore, patients often endure failed attempts and eventually become venous depleted. Furthermore, maintaining patients' vascular access throughout treatment is difficult because a number of complications including phlebitis, infiltration, extravasation, and infections can occur. The aim of this article is to review the use of the IV route for administering therapy, identify and analyze key risks and complications associated with achieving and maintaining peripheral IV access, examine measures to reduce these risks, and discuss implications for nurses in clinical practice.     

Oral anticoagulant therapy: practical considerations.

The key to safe and effective oral anticoagulation is to have an understanding of the rationale for dosing guidelines and therapeutic ranges; an appreciation of the imprecision of prothrombin time testing and its standardization; knowledge of the factors influencing prothrombin time response; and awareness of the importance of patient empowerment via ongoing patient education. This review focuses on the routine management of oral anticoagulant therapy to provide these practical insights and to promote safe and effective therapy.     

Urinary tract infection: economic considerations

Urinary tract infection results in significant morbidity and mortality while consuming large amounts of national resources. The prevention, diagnosis, and treatment of urinary tract infection produce both costs and benefits, and economic analysis provides a rational framework for looking at these effects. The goals and methods of economic analysis in medicine are summarized, and strategies to address uncomplicated cystitis, nosocomial urinary tract infection, and pyelonephritis are reviewed, with an emphasis on the economic trade-offs faced by decision makers.     

The impact of economic considerations on clinical decisionmaking: the case of thrombolytic therapy

This study examines the intravenous use of two thrombolytic agents [streptokinase (SK) and tissue plasminogen activator (tPA)] in the acute phase of myocardial infarction (MI). These two agents have very different costs and offer an excellent opportunity to study both the impact of economic factors on clinical decisionmaking and the potential for cost savings by limiting the use of expensive new therapeutic agents. A nationwide survey of the 5,792 acute care general hospitals listed in the American Hospital Association's 1988 data file was responded to by 2,651 hospitals (46%) and revealed that 2,384 of these responding hospitals (90%) were using thrombolytic therapy. For 2,200 of these 2,384 hospitals (92%), the respondent was a physician who primarily used one of the two drugs. Eight hundred eighty-six of these 2,200 physicians (40%) primarily used SK while 1,314 (60%) primarily used tPA. SK users were more concentrated in federal public hospitals (69% used SK) than in nonfederal public hospitals (47% used SK), and were least concentrated in private hospitals (36% used SK). There was no difference between the rate of SK vs tPA use in investor-owned and not-for-profit private hospitals. SK users most often (62%) cited various economic factors as the reason for their choice. The users of tPA primarily (73%) cited clinical preferability as the reason for their choice even though trials are still ongoing to see which drug is preferable. Several multivariate analyses shed light upon the association between choice of thrombolytic agent and various additional physician and hospital characteristics. These data clearly indicate that while new therapies are rapidly implemented by the medical community, considerations of cost have a substantial impact upon the pattern of implementation and reflect a desire to implement cost savings in the use of new drugs.