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Respiratory Care in India -Past, Present and Future
Vijay Deshpande, MS, RRT, FAARC Emeritus Professor, Georgia State University
Atlanta, Georgia USA
Adjunct Visiting Professor
Dept. of Respiratory Therapy Dept. of Medical TechnologyManipal College of Health Sciences Symbiosis Institute of Health SciencesManipal , Karnataka Pune , Maharashtra
Home Respiratory Therapy
♦ Home Oxygen Therapy
♦ Bronchodilator Therapy
♦ CPAP
♦ BiPAP
♦ Trache Care
♦ Mome Mechanicl Ventilation
Mechanical Ventilation
Co-morbid
disorders
Frequent visits to Physician’s office
Frequent Hospitalization
FrequentExacerbation
High Health Care Cost Susceptibility
to infection
COPD
PatientPatient
COPD
PatientHome Care Providers
Primary CarePhysicians
Hospitals
Pulmonologists
Medicare or Reimbursement
system
RespiratoryCare Dept.
Home Care
Providers
Medicare or Reimbursement
system
Primary CarePhysicians
HMO’s
NPPV Manufacturer Hospitals
COPD
Patient
Pulmonologists
HOME CARE RESPIRATORY THERAPIST
Home Care Nutritionist
Home Care Physical Therapist
Thank You !
Home Respiratory Therapy
♦ Asthma
♦ COPD
♦ Chronic CHF
♦ Obstructive Sleep Apnea
♦ Long Term Mechanical Ventilation
COPD- Definition
COPD is a disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases
Global Initiative for Chronic Obstructive Lung Disease, NationalInstitute of Health and National Heart, Lung and Blood Institute,NIH Publication No. 2701B, April 2001.www.copdgold.com
FIGURE 4-1. Normal lung volumes and capacities. IRV = inspiratory reserve volume; VT = tidal volume; RV = residual volume; ERV = expiratory reserve volume;TLC = total lung capacity; VC = vital capacity; IC = inspiratory capacity; FRC = functional residual capcity.
PULMONARY FUNCTION TESTINGPULMONARY FUNCTION TESTING
SPIROMETRY SPIROMETRY – FVCFVC– SVCSVC– ICIC– ERVERV– VTVT– FlowratesFlowrates
Chronic Obstructive Chronic Obstructive Pulmonary DiseasePulmonary Disease
BRONCHITIS EMPHYSEMA
CHRONICBRONCHITIS
EMPHYSEMA
Advancement in Management of COPD Patients
● Oxygen by Nasal Cannula● Oxygen via Venturi Mask
● E Cylinder● Small Portable D cylinder Flasks● Liquid Oxygen cylinder with cannula
● Trans-tracheal oxygen (cosmetic)
● Oxygen Concentrators● Long Term Oxygen Therapy
Indications for LTOT
► PaO2 < 55 Hg or SaO2 < 88% on room air
► PaO2 56-59 mm Hg and one of the following:
Pulmonary hypertension and edema Cor Pulmonale Secondary Polycythemia (56%)
► Pulmonary restrictive disease with PaO2 < 55 mm Hg
► Refractory dyspnea associated with cardiac failure
Benefits of LTOT
► Improves survival in patients with COPD and severe resting hypoxemia
► Decreases frequency of exacerbation of the disease requiring hospitalization
► Improves exercise performance
COPD and SLEEP
Sleep studies performed on COPD patients indicate that compared to normal individuals, the COPD patients:
● have less hours of sleep ● have poorer quality of sleep● have more arousal's at night
Obstructive Sleep Apnea and COPD
● Can coexist May lead to:
Oxygen desaturation during sleep
Decreased ventilation
V/Q mismatch
ATS statement: Standards for Diagnosis and care of Patients with COPDRespiratory and Critical Care Medicine, Nov.1995, 152:S78-S121.
NPPV (Bilevel Positive Airway NPPV (Bilevel Positive Airway Pressure)Pressure)
PressurePressurePSPS PSPS
CPAPCPAP
IPAPIPAP
0
5
10
15
20
TimeTime
Bi-level Positive Airway Pressure
Be nice to your kids. They’ll choose your nursing home.
Management of Advanced COPD
“We cannot add years to their life, but we can add life to their years”.
Home Care Management of COPD Patients
Diagnosis of COPD
Wheezing, Increased Secretions, Abnormal Breath Sounds,Increased Airway Resistance, Use of accessory muscles
Need for Bronchodilator Therapy
Daytime sleepiness, Somnolence,Snoring, Nocturnal Desaturation,
CPAP Therapy
Non-responsive toCPAP Therapy,Polysomnography,Identification of Sleep Apnea
NPPV
Effect of Hypoxemia on Cardiovascular system
Sequence of Blood Flow Through the Heart
Hemodynamics and Pulmonary Vasoconstriction
Cardiovascular Effects of Hypoxemia
Tachycardia
Pulmonary Vasoconstriction
Pulmonary Hypertension
Systemic Hypertension
COPD and Oxygen Economics
Long-term oxygen therapy (LTOT) increases survival and improves the quality of life of hypoxemic patients with chronic obstructive pulmonary disease (COPD)
Each year, approximately one million patients receive LTOT through Medicare, at a cost exceeding two billion dollars per year This cost is increasing at an annual rate of nearly 13 percent
The economic impact of oxygen therapy on the Medicare Budget resulted in stringent Criteria to use LTOT
Long Term Oxygen Therapy (LTOT)
History, Scientific Foundations, and Emerging Technologies
Thomas L. Petty, M.D.Robert W. McCoy, B.S., RRTDennis E. Doherty, M.D.6th Oxygen Consensus Conference Recommendations
National Lung Health Education Program, 2006
► LTOT refers to delivery of oxygen therapy for continuous use at home for patients with chronic
hypoxemia (PaO2 =/< 55mHg)
► Oxygen flow rate must be adequate to increase PaO2 above 60 mm Hg while awake.
► LTOT is likely to be life long
► LTOT is usually given for at least 15 hours daily, to include night time.
Long Term Oxygen Therapy
Indications for LTOT► Chronic Hypoxemia
► Severe chronic Asthma
► Nocturnal Hypoventilation
► Secondary Polycythemia
► Primary Pulmonary Hypertension
► Chronic Heart Failure
► Pulmonary malignancy
LONG TERM MANAGEMENT OF COPD PATIENTS
Absolute Indications for Long-term Oxygen Therapy
● PaO2 < 55 mm Hg or SaO2 < 88 %● PaO2 = 55-59 mm Hg or SaO2 > 89 % with:
Presence of Cor Pulmonale
ECG evidence of “P” pulmonale
Hematocrit > 55 %
Congestive Heart Failure
ATS statement: Standards for Diagnosis and care of Patients with COPDRespiratory and Critical Care Medicine, Nov.1995, 152:S78-S121.
Physiological indications for long-term oxygen therapy (LTOT)
PaO2 mmHg SpO2 % LTOT indication Qualifying condition__________________________________________________________≤55 ≤88 Absolute None
55-59 89 Relative with "P" pulmonale,qualifier polycythemia >55%
History of odema
≥60 ≥90 None except Exercise desaturationwith qualifier Sleep desaturation not
corrected by CPAP Lung disease with severe dyspnea responding to O2
Oxygen Dose•Continuous flow by a double or single nasalcannulae•By demand system with demonstration ofadequate oxygen saturation•Lowest liter flow to raise PO2 to 60-65 mmHg or oxygen saturation to 88-94% •Increase baseline liter flow by 1 L duringexercise and sleep
LTOT may improve outcome measures other than mortality, including:
● quality of life, ● cardiovascular morbidity, ● depression, ● cognitive function, ● exercise capacity, and ● frequency of hospitalization
When appropriately prescribed and correctly used, LTOT has clearly been shown to improve survival in hypoxemic COPD patients. Adherence to LTOT ranges from 45% to 70% and utilization for more than 15 hours per day is widely accepted as efficacious.
More Documented Benefits of LTOT
Two landmark studies, the Nocturnal Oxygen Therapy Trial (NOTT) and the British Medical Research Council (MRC) conducted in the late 1970s have explicitly demonstrated that LTOT (when used for more than 15 hours/day) improves survival rates in patients with severe COPD associated with resting hypoxemia [1, 2]. In terms of maximum benefit, continuous oxygen administration (≥15 h/d) is superior to intermittent or nocturnal use [3]. There is also accumulating evidence that LTOT has favourable effects on other outcome measures, including depression, cognitive function, quality of life, exercise capability, and frequency of hospitalization [4–10]. Moreover, it stabilizes and sometimes reverses the progression of pulmonary arterial hypertension and it diminishes as well cardiac arrhythmias and electrocardiographic findings indicative of myocardial ischemia [11, 12].
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