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].