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Occupational Therapy Clinical Practice Guideline - Home Oxygen Therapy For Adult Patients - 3

This document provides a clinical practice guideline for occupational therapists regarding home oxygen therapy for adult patients. It was developed by the COPD Task Group and Occupational Therapy coordinating committee within the Hospital Authority of Hong Kong. The guideline consolidates best practices for assessing, prescribing, educating and monitoring patients receiving home oxygen therapy based on international guidelines and local evidence. It aims to standardize occupational therapy services for home oxygen patients and promote high quality and effective care.

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0% found this document useful (0 votes)

991 views92 pages

Occupational Therapy Clinical Practice Guideline - Home Oxygen Therapy For Adult Patients - 3

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Document No.

HAHO-COC-GL-OCC-003-v03
Hospital Authority Head Office Issue Date 27/05/2019
Review Date 27/05/2022
Occupational Therapy Clinical Practice Guideline – Home
Oxygen Therapy for Adult Patients Page 1 of 92

Occupational Therapy Clinical Practice Guideline -

Home Oxygen Therapy for Adult Patients

Version Effective Date

1.0 15 Jan 2009
2.0 13 Apr 2013
3.0 27 May 2019

Document Number HAHO-COC-GL-OCC-003-v03

Author COPD Task Group, COC-Grade(OT)
Custodian HO Allied Health Grade Department
Approved/ Endorsed By COC-Grade in Occupational Therapy
Approval Date 27/05/2019
Distribution List All HA Occupational Therapists

This printed copy may not be the most updated version. Please refer to the electronic version for confirmation if in doubt
Document No. HAHO-COC-GL-OCC-003-v03
Hospital Authority Head Office Issue Date 27/05/2019
Review Date 27/05/2022
Occupational Therapy Clinical Practice Guideline – Home
Oxygen Therapy for Adult Patients Page 2 of 92

Acknowledgement

The Hospital Authority Coordinating Committee-Grade in Occupational Therapy would like

to thank the following experts / specialists in Respiratory Care for contributing their
expertise in reviewing the first version of this guideline which has become the fundamental
document for subsequent updates on current evidence.

DR. CHAN Kin Sang, Consultant, Dept. of Medicine, HOHH

MS. CHAN, Rebecca, Senior Occupational Therapist / Training Officer, HAHO

DR. CHAN Wai Man, Johnny, Consultant, Medicine Dept., QEH

DR. FONG Nai Kuen, Kenneth, Assistant Professor, Dept. of Rehabilitation Sciences,
HKPU

DR. HO Kin Sang, Consultant, Family Medicine, Elderly Health Service, Dept. of Health

MR. IP Yee Chiu, Department Manager (Occupational Therapy), KCH / Coordinator,

Clinical Audit & QA Group of OTCOC

MS. KWOK, Shirkey, Nursing Officer (Pneumoconiosis Rehabilitation Center), RHTSK

DR. LAM Chak Wah, Consultant and Head of Department, Respiratory Medicine Dept.,
RHTSK

DR. LAM Siu Pui, Senior Medical Officer, Dept. of Rehab. & Extended Care Unit, WTSH

DR. MOK Yun Wing, Thomas, Consultant, Respiratory Medical Dept., KH

DR. SIN Kit Man, Senior Medical Officer, Dept. of Medicine & Geriatrics, TMH

MS. SO Siu Pin, Grace, Senior Occupational Therapist, Elderly Service, SWD

DR. TAM Cheuk Yin, Consultant, Medicine & Geriatric Dept., TMH

DR. WONG Mo Lin, Maureen, Consultant, Medicine & Geriatric Dept., CMC

DR. WONG Poon Chuen, Consultant, Tuberculosis & Chest Medicine Unit, GH

DR. YU Wai Cho, Consultant, Medicine & Geriatric Dept., PMH

(The job titles and postings were as in 2009.)

For the current revision, we would like to appreciate the kind assistance of the following
experts / specialists in Respiratory Care in offering us valuable comment and support:

DR. CHAN Kin Sang, Consultant, Dept. of Medicine, HOHH

DR. CHOO Kah Lin, Consultant, Dept. of Medicine, NDH

DR. LAU Kam Shing, Consultant, Dept. of Respiratory Medicine & Palliative Care,
RHTSK

DR. MOK Yun Wing, Thomas, Consultant, Respiratory Medical Dept., KH

DR. WONG Kam Cheung, Senior Medical Officer, Dept. of TB & Chest, WTSH
(The job titles and postings were as in 2016.)

Statement of Intent

This document describes a guideline for Occupational Therapy services in the assessment,
equipment prescription, education and monitoring of home oxygen therapy for adult patients.
Since the introduction of low cost home oxygen devices to Hong Kong in mid 1980s,
occupational therapists have been involved in assisting the medical teams in the prescription
of home oxygen therapy for needed patients. Recent local statistics demonstrated that over
a thousand of home oxygen therapy prescriptions were being handled by occupational
therapists in various public clinical settings each year. In keeping with this considerable
service volume, this guideline is therefore developed for the primary users targeted at
Occupational Therapists with the following intents:

 Consolidate a standard of practice based on the best available evidences at the

time it is produced.
 Guide practice and promote a consistent and cohesive approach to care.
 Promote better communication within the profession and with other professionals.
 Assure quality, the effectiveness as well as the cost of the therapy.
 Stimulate and prioritize ideas for future research.

The COPD Working Group of the Hospital Authority Coordinating Committee-Grade in

Occupational Therapy acknowledged that renowned guidelines are available internationally.
These guidelines as well as other major evidence were reviewed carefully and the significant
information was synthesized and adapted to meet local needs. Following the development of
this guideline, certain changes are expected in the structure and process of this specific area
of service with the anticipated outcomes as minimal but essential changes in the practice
among Occupational Therapists in Hospital Authority. These changes include:

 More precise therapy regime identification (LTOT - Continuous Use,

LTOT-Ambulatory/Exertional Use, LTOT-Nocturnal Use, Short Term Oxygen
Therapy and Palliative Oxygen Therapy) through thorough assessments for
different patient groups in order to facilitate focus of therapy monitoring and
subsequent follow-up arrangement.
 Better documentation through standardization of documentation format and the
establishment of minimal data record within individual setting for service
monitoring.
 Establishment of follow-up arrangement for needed patients either by service
within public sector or by community partners.

As the primary users of this guideline are Occupational Therapists, we use a language that
is accessible and meaningful to them. Other members of the health care team can use this
guideline as a reference if indicated.

The essence message of the guideline is: * The right patient receives the right amount
of home oxygen for the right period of time*. In order to achieve this, the occupational
therapists are recommended to follow the nine essential steps as elaborated in Section 6.
Upon its application, the therapists should also exercise their best professional judgment to
make any possible indicated adjustment in order to deal with individual patient needs.

Key to Evidence Statements and Grade of Recommendations

(With reference to the Scottish Intercollegiate Guidelines Network, 2012)
Levels of Evidence
High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of
1 ++
bias
1+ Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias

1- Meta-analyses, systematic reviews, or RCTs with a high risk of bias

High quality systematic reviews of case control or cohort studies

++
2 High quality case control studies with a very low risk of confounding or bias and a high
probability that relationship is causal
Well conducted case control or cohort studies with a low risk of confounding or bias and a
2+
moderate probability that relationship is causal
Case control or cohort studies with a high risk of confounding or bias and a significant risk
2-
that the relationship is not causal.
3 Non-analytic studies, e.g. case reports, case series

4 Expert opinion

Grades of Recommendation
At least one meta-analysis, systematic review, or RCT rated as 1 ++ and directly applicable
to the target population; or
A A body of evidence consisting principally of studies rated as 1 +, directly applicable to the
target population, and demonstrating overall consistency of results
++
A body of evidence including studies rated as 2 , directly applicable to the target

B population, and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 1 ++ or 1 +
A body of evidence including studies rated as 2 +, directly applicable to the target

C population, and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 2 ++
Evidence level 3 or 4; or
D Extrapolated evidence from studies rated as 2 +
Good Practice Points
Important Practical Points for which there is no research evidence, nor is there likely to be

 research evidence. Our guideline development group wishes to emphasize these are
Good Practice Points.

Table of Contents

1. Executive Summary .................................................................................................... 10

2. Introduction ................................................................................................................. 15
2.1 Definition ............................................................................................................ 15
2.2 The Need for a Guideline .................................................................................. 15
2.3 The Need for Team Work................................................................................... 16
3. The Right PATIENT .................................................................................................. 17
3.1 COPD Patients with Stable Chronic Hypoxaemia ........................................... 17
3.2 COPD Patients with Exertion-induced Desaturation ...................................... 18
3.3 COPD Patients with Nocturnal Desaturation................................................... 20
3.4 Other Chronic Diseases .................................................................................... 22
3.5 Patients with Malignancy or Terminal Diseases ............................................. 23
3.6 Contraindications to Home Oxygen Therapy .................................................. 24
4. The Right AMOUNT (Flow Rate) ............................................................................. 26
4.1 Flow Rate at REST ............................................................................................. 26
4.2 Flow Rate for ADL / Exercise ............................................................................ 27
4.3 Flow Rate for SLEEP ......................................................................................... 28
4.4 With Early Symptoms of Acute Exacerbation ................................................. 29
4.5 During Air-flight ................................................................................................. 29
5. The Right Period of Time (Duration) ...................................................................... 32
5.1 COPD Patients with Stable Chronic Hypoxaemia .......................................... 32
5.2 COPD Patients with Exertion Induced Desaturation ..................................... 33
5.3 COPD Patients with Nocturnal Desaturation .................................................. 33
5.4 Other Chronic Diseases ................................................................................... 33
6. Monitoring of Patient and Therapy ........................................................................ 34
6.1 Re-Assessment................................................................................................. 34
6.2 Compliance to Home Oxygen Therapy ........................................................... 36
6.3 High Risk Groups for Further Service ............................................................ 37

7. Recommended Procedures for Professionals ...................................................... 38

7.1 Validating the Appropriate Patients ................................................................. 38
7.2 Recommended Appropriate Flow-Rate Related to Rest, Sleep & Activities . 40
7.3 Gaining Patients’ Consensus & Participation ................................................. 41
7.4 Selecting the Appropriate Oxygen Equipment ............................................... 41
7.5 Screening Need for Financial Assistance ....................................................... 42
7.6 Educating and Training on Operation, Precautions & Maintenance ............ 43
7.7 Liaison for Equipment Delivery on Discharge ............................................... 44
7.8 Monitoring and Follow Up................................................................................ 45
7.9 Documentation ................................................................................................. 46
8. Information for Patients & Professionals .............................................................. 47
8.1 Oxygen Supply System ..................................................................................... 47
8.2 Oxygen Conserving Device ………………………………………………………...48
8.3 Accessories …………………………………………………………………………....49
8.3.1 Oxygen Administration Device ..……………………………………..……....49
8.3.2 Extension Tubing ...................................................................................... 50
8.3.3 Humidifier .................................................................................................. 51
8.3.4 Carrying Devices for Oxygen Cylinder .................................................... 51
8.4 Potential Hazard & Precautions ....................................................................... 52
8.5 Cleansing and Maintenance: ............................................................................ 53
8.6 Using Oxygen in Air Flight................................................................................ 54
9. Implementation & Audit .......................................................................................... 56
10. Development of the Guideline ................................................................................ 57
10.1 Systematic Review .......................................................................................... 57
10.2 Drafting and Sorting Comments from Stake Holders ................................... 58
10.3 External Validation .......................................................................................... 59
10.4 Pilot Study of the Guideline ............................................................................ 62
10.5 Updating the Guideline ................................................................................... 62
10.6 Conclusion ....................................................................................................... 64

REFERENCE .................................................................................................................... 65
Terms................................................................................................................................ 69
Annex 1 Working Group Members ................................................................................. 72
Annex 2 ADL METs Levels .............................................................................................. 73
Annex 3 & 3a Desaturation Test , MFTE ................................................................... 74,75
Annex 4 ADL Oxygen Saturation Profile ....................................................................... 76
Annex 5 ADL Oxygen Usage Instruction ....................................................................... 77
Annex 6 Order Consent Form ........................................................................................ 79
Annex 7 MEMO to MSW for Application of CSSA Supplement .................................... 81
Annex 8 Application for Pneumoconiosis Funding ...................................................... 82
Annex 9 Checklist for Patient Education in Home Oxygen Therapy ........................... 83
Annex 10 Checklist for Follow-Up of Patients on Home Oxygen Therapy ................. 84
Annex 11 Home Oxygen Therapy Follow-up Record Sheet ......................................... 86
Annex 12 Report to Medical Officers ............................................................................. 88
Annex 13 Home Oxygen Therapy Report ...................................................................... 89
Annex 14 Home Oxygen Therapy Data Entry Sample Record Form ........................... 90
Annex 15 Allied Health Discharge Summary …………………...………………….………91
Annex 16 FAA Approved Portable Oxygen Concentrator ............................................ 92

1. Executive Summary
“Clinical Practice Guideline: Home Oxygen Therapy for Adult Patients”
3rd edition – 2018
By the Task Group on Chronic Obstructive Pulmonary Diseases, OTCOC, HA

The essence message of the guideline is: * The right patient receives the right amount of
home oxygen for the right period of time.*

Home Oxygen Therapy refers to the setting up of an oxygen system to be used by a patient at
home or in a residential institution, upon the recommendation by the respective case medical
officer for treating or preventing the symptoms and manifestations of hypoxia. It is primarily a
medical prescription, and this implies that the occupational therapists should work in close
liaison with all the other medical team members when handling such prescription. The ‘Right
Patient’ and therapeutic goals are elaborated in Table 1. The process of Home Oxygen Therapy
is summarized in Diagram 1.

Eligible Patient Oxygen Therapy Principal Therapy

Regime Goal
1. COPD patients, who LTOT - Continuous Use  Improve survival
 exhibit chronic hypoxaemia; and/or (>15 hrs, including
 established hypoxia-related sequelae such as activity and sleep)
right heart failure syndrome (cor-pulmonale)

2. COPD patients, who meet criteria for LTOT & LTOT - Ambulatory /  Correct exertion-
 exhibit exertion-induced desaturation to  88%; Exertional Use induced
and (mainly for use during hypoxaemia
 demonstrate full compliance and report objective activity and exercise)  Improve activity
and/or subjective improvement in activity level level and exercise
and quality of life from a trial use of the therapy capacity

3. COPD patients, who meet criteria for LTOT & LTOT - Nocturnal Use  Correct
 have oxygen desaturation to  88% at night as (mainly during sleep) desaturation during
illustrated in overnight oximetry or sleep study, sleep resulted from
and compounding
 demonstrate full compliance and improve in effects of ventilatory
symptoms and quality of life deficits due to
(Patients complicated with sleep related breathing COPD
disorders require further assessment for the need of  Minimize symptoms
ventilatory support other than oxygen therapy.) of hypoxia-related
consequences
4. Patients with various chronic diseases or COPD Short Term Oxygen  Correct hypoxaemia
patients not optimally treated, who Therapy (STOT), when clinical
 do not meet stringent criteria for LTOT or (depends on individual conditions unstable
assessment for ‘Right Patient’ not feasible nor needs, can be and treatment may
completed continuous, exertional not be fully
 demonstrate persistent desaturation at rest and or nocturnal use) optimized at the
fail to wean off oxygen therapy at the time of time of discharge.
discharge  Its long term
 demonstrate persistent exertional desaturation on benefits require
pulse oximetry but do not demonstrate full re-evaluation
compliance to long term use

5. Patients with malignancy or terminal diseases in Palliative Oxygen  Relieve symptoms

the presence of desaturation, or Therapy especially for
Patients with COPD, various chronic or terminal (may be continuous, for intractable dyspnea
diseases without documented desaturation, who exertion, sleep or as  Minimize possible
 demonstrate intractable dyspnea needed basis complications
 report improvement in symptoms and comfort; according to patient’s during the end of
and unresponsive to all other treatment modalities response in life
(Prescription to the latter group is not generally symptomatic relief)
recommended due to lacking strong evidence
support)

Table 1 Eligible Patient, Respective Regime and Treatment Goals

“Desaturation Test” with continuous oximetry monitoring is the procedure to verify the
presence of exertional desaturation and evaluating the benefit of supplementary oxygen in
correcting the desaturation to substantiate the need of Home Oxygen Therapy. ‘Right Patient’
assessment for the Ambulatory / Exertional Use is illustrated in Box 1.

While performing the same series of functional tasks (from different METs levels) with and then without
supplemental oxygen; the degree of exertional desaturation, activity tolerance and dyspnea level (with Borg
scale) are compared.

Box 1 Desaturation Test

To titrate the appropriate flow-rate for different scenario, “Dose Titration” with continuous
oximetry monitoring is the recommended procedure. Overnight oximetry or sleep study may be
considered whenever necessary. The ‘Right Amount’ flow-rate recommendation principles are
summarized in Table 2. Upon the completion of the ADL Oxygen Saturation Profile in Dose
Titration, the therapist should instruct the patient on the proper oxygen usage and inform the
respective medical team.

Scenario Flow Setting principles

․ SpO2 is recommended to be >90% during rest with minimal oxygen flow-rate.

Rest: ․ A more optimal SpO2 range may be considered for patients with borderline
saturation and frequent desaturation.

․ SpO2 is recommended to be targeted at >90% for dose titration on all ADL tasks.
․ ADL Oxygen Saturation Profile assessment is highly recommended. In the
titration procedure, at least two ADL exertion levels are involved to match the
exertion demand in patients’ life roles. Actual ADL tasks or simulated functional
tasks with standardized procedures can be assessed. In general, the flow-rate
ADL:
may need to be increased by 1 L/min (or more) above the resting flow setting for
exertional ADL tasks.

․ SpO2 is recommended to be targeted at >90% during sleep.

․ Routine increase of flow-rate by 1L/min above the daytime resting flow-rate is
NOT recommended.
․ For patients with signs of cor-pulmonale, morning headaches, persistent edema
Sleep:
or secondary polycynthaemia despite daytime normoxaemia, an overnight
oximetry is recommended to determine the best sleep oxygen flow setting.
․ The flow-setting for sleep also applies to the condition during nap at daytime.

With early symptoms ․ Maintain their original oxygen therapy regime and flow-rate, and change should
of Acute Exacerbation only be made according to medical advice.
of COPD ․ Increasing oxygen flow-rate automatically is NOT recommended.

․ In general, patients with resting SpO2 ≤ 95% or exertional desaturation should

need further assessments on possible in-flight hypoxaemia.
․ A supplemental oxygen at 3L at rest should be considered for those with
Air Flight moderate to severe hypoxaemia. More accurate flow titrations can be obtained in
a simulated chamber or device. Medical consultation is highly recommended
prior to air flight to evaluate risks and enhance safety.

Table 2 Summary of Flow Setting for Different Scenario

The occupational therapist is recommended to adhere to the nine procedures as below and
use the standard documentation in handling the prescription of Home Oxygen Therapy.

1. Validating the appropriate patients and respective therapy regimes

2. Recommending appropriate flow-rates with respective to rest, sleep and various daily
activities
3. Gaining consensus and participation from the patients and/or care-givers
4. Selecting the appropriate equipment to fit the home environment and lifestyle
5. Exploring the need for financial assistance
6. Educating and training on goals, operation, maintenance and precautions
7. Liaison for equipment delivery on discharge
8. Monitoring and arranging follow-up service
9. Maintaining important documentation

* Adherence to the above procedures will be regulated by audit exercise in periodically.

In monitoring the patient as well as the therapy, the following is recommended:

a) A reassessment or community follow-up service is recommended for every case

prescribed for Home Oxygen Therapy between 1 and 3 months upon its initiation,
although the principal purpose of the reassessment may be different for different
indicated groups. For those on LTOT, the purpose will be adjusting flow-rates (ADL
Oxygen Saturation Profile Assessment) and monitoring course of the disease and any
rehabilitation needs. For those on STOT, the goal will be re-certification for the therapy
(Desaturation Test or other simulated functional assessment to substantiate exertional
desaturation). However, for those prescribed for palliative oxygen therapy, such
reassessment is not necessary and the monitoring process may be done by
colleagues of the home care team to facilitate adaptations at home.

b) Thorough education, reinforcement and psychological support are essential in the

process of Home Oxygen Therapy prescription to enhance the compliance, knowledge
and skills with home oxygen therapy. Continuous support to patients at home will
further enhance their compliance at longer term.

c) Community based support and/or rehabilitation service, preferably with a

communication link with the patients’ case medical doctors, is indicated. Upon the
constraint in resources, factors to consider for prioritizing services should include
depressive mood, malnutrition, being home-bound and at risk of anemia.

* This is a guideline for Occupational Therapy services in the assessment, equipment

prescription, education and monitoring of home oxygen therapy for adult patients. The primary
users will be targeted at Occupational Therapists. Other members of the health care team can
use this guideline as a reference if indicated.

Clinical Assessments for hypoxaemia:

 Blood gas  related lab. result, or
 Desaturation Test, or
 Overnight oximetry  sleep study

For patients with various chronic Not supported by evidence for

Documented diseases, COPD patients or terminal home oxygen therapy & is not
NO recommended .
oxygen diseases with intractable dyspnea, who
desaturation?  report improvement in symptoms,
function and quality of life
On occasion considered by
specialist teams if intractable
YES dyspnea is unresponsive to all
other treatment modalities
For patients suffering malignancy or
Malignancy terminal diseases with intractable
YES
or terminal dyspnea, who
disease?  report improvement in symptoms, Palliative
function and quality of life Oxygen Therapy
NO

For patients with various chronic

diseases, or COPD patients, who Regime: Varies, according
Clinically NO  demonstrate oxygen desaturation or a to individual needs
stable reliance on oxygen therapy at the time
during Ax? of hospital discharge, and not being
optimally treated.

YES

Stable chronic hypoxaemia

Long Term Short Term

Oxygen Therapy Oxygen Therapy
Review for
Review for
Re-certification
Dose Titration
between 1 & 3
in 6-12 months
months

For COPD patients,: For COPD patients, who: For COPD patients, who:
 whose hypoxaemia, i.e. ≤ 7.3kPa (or  have oxygen desaturation in  have oxygen desaturation to SpO2
55mmHg), or in the range 7.4-7.9kPa (or exertion to SpO2 88% in 88% as illustrated in overnight
56-59mmHg) together with hypoxia-related oximetry or sleep study, and
desaturation test, and
consequences such as cor pulmonale,  demonstrate full compliance to the
pulmonary hypertension, secondary  demonstrate full compliance to trial use of the therapy, and
polycythaemia with haematocrit >56%) are the trial use of the therapy, and improvement in symptoms and
ascertained based on repeated ABG, and report improvement in  quality of life.
 who should have received optimal medical symptoms, function and quality  Further assessment required for
treatment, especially after episodes of of life. patients complicated with
acute exacerbation sleep-related breathing disorders

Continuous Ambulatory/Exertional Nocturnal


Use Use Use

Regime: Use >15 hours per day, Regime: Use only for specific daily Regime: Use only for sleep
including sleep activities that caused desaturation

Diagram 1 Flowchart for Home Oxygen Therapy

2. Introduction

2.1 Definition
Home Oxygen Therapy refers to the setting up of an oxygen system for a patient to be used at
home or in a residential institution, upon the recommendation by the respective case medical
officer for treating or preventing the symptoms and manifestations of hypoxia.

2.2 The Need for a Guideline

For patients with severe chronic obstructive pulmonary diseases (COPD), Home Oxygen
Therapy is the standard of care providing a non-pharmacological intervention (ATS & ERS,
2004; GOLD 2015). The demand for home oxygen therapy is huge and expected to be
increasing. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) in 2015
reported that COPD was the fourth leading cause of death the world. The problem associated
with morbidity and mortality of the disease may be underestimated in Hong Kong as a
significant proportion of COPD patients go undiagnosed (Department of Health, 2004).

On the other hand, as Home Oxygen Therapy has become more convenient and affordable, it
is also widely applied to other disease groups, such as patients with heart failure, cystic
fibrosis, interstitial lung disease and patients suffering from end stage of terminal diseases
(BTS, 2015; Elphick & Mallory, 2013.), and sometimes Home Oxygen Therapy is even applied
outside the common international guidelines (Ringbaek, 2006; Ringbeak & Lange, 2006).
Respective therapy regimes also vary. The situation is similar in Hong Kong, where practices
vary among different public hospitals.

As home oxygen is an effective treatment, but potentially carries considerable risk and cost, a
more stringent approach in the assessment, prescription and monitoring of the therapy for
needed patients is recommended. With the goals to i) facilitate communication within the
occupational therapy profession, with other professionals and with patients and caregivers, ii)
clarify the goal and regime of the oxygen therapy, and iii) determine the focus of monitoring
and follow-up, our working group (Annex 1) has reviewed various local and international
guidelines, position statements and systematic reviews on Home Oxygen Therapy by various
renowned professional bodies, including American Association for Respiratory Care (AARC),
American Thoracic Society / European Respiratory Society Standards for the Diagnosis and
Management of Patients with COPD (ATS-ERS), British Thoracic Society (BTS), The Global
This printed copy may not be the most updated version. Please refer to the electronic version for confirmation if in doubt
Document No. HAHO-COC-GL-OCC-003-v03
Hospital Authority Head Office Issue Date 27/05/2019
Review Date 27/05/2022
Occupational Therapy Clinical Practice Guideline – Home
Oxygen Therapy for Adult Patients Page 16 of 92

Initiative for Chronic Obstructive Lung Disease (GOLD), Handbook of Internal Medicine,
Central Coordinating Committee (Medicine) Hospital Authority, Hong Kong (HIM), Thoracic
Society of Australia and New Zealand (TSANZ), the Long-term Oxygen Therapy Consensus
Conference Writing Committee, the Cochrane Airways group, etc., published in the recent 10
years (also refer to the Chapter on Terms). Practice key-points are summarized, and
standardized terms as well as subsequent procedures are recommended. The essence
message of the guideline is: * The right patient receives the right amount of home oxygen
for the right period of time *.

2.3 The Need for Team Work

Home Oxygen Therapy is primarily a medical prescription. Thus, it implies that the
occupational therapists should work in close liaison with medical officers and other relevant
medical team members for provision of home oxygen therapy service. Close collaboration
between the patients, their caregivers, the medical team, the oxygen equipment providers and
other relevant community partners will also be essential for effective long-term management
for patients in need.

3. The Right PATIENT

The evidences related to the indications and therapeutic values of Home Oxygen Therapy are
summarized from references extracted from ACP, ACCP, ATS & ERS (2011), BTS (2015) (=
Hardinge et al., 2015), GOLD (2015), TSANZ (2014), and the Handbook of Internal Medicine
from the Hong Kong Hospital Authority (2015).

3.1 COPD Patients with Stable Chronic Hypoxaemia

The criteria to define COPD patients with chronic hypoxaemia for Long-term Oxygen
Therapy (LTOT) – Continuous Use are i) patient should have received optimal medical
treatment, clinically stable and free from exacerbation, and ii) PaO2 <7.3kPa (55mmHg), or in
the range of 7.4-7.9kPa (56-59mmHg) together with hypoxia-related consequences such as (a)
cor pulmonale (illustrated by clinical signs, e.g. pedal oedema, jugular venous distension or
ECG evidence), (b) pulmonary hypertension (echocardiogram evidence), and/or (c) secondary
polycythaemia (haematocrit >56%) (ACP, ACCP, ATS & ERS, 2011; BTS, 2015). Patients with
a resting stable oxygen saturation (SpO2) of ≤ 92% should be referred for a blood gas
assessment in order to assess eligibility for LTOT (BTS, 2015). The standard procedure to
ascertain hypoxaemia before initiating continuous LTOT is measurement of arterial blood gas
(ABG) after breathing room air for 20 to 30 minutes (BTS, 2015). These guidelines
emphasized that the patients should be clinically stable and on optimal medical treatment,
rather than during or immediately after an exacerbation. Optimally, stable hypoxaemia should
be assessed at least twice and 3 weeks apart. Reassessment should be done at a time of at
least 8 weeks of stabilization from last exacerbation. Patients with frequent exacerbations may
need to be assessed at earlier time frame (BTS, 2015).

Besides the results from the two hallmark cohort studies (Medical Research Council, 1981;
Nocturnal Oxygen Therapy Trial, 1980), the Cochrane Airways group conducted a systematic
review on randomized controlled trials of continuous LTOT; >15 hours of daily use
(Cranston et al., 2005) and concluded that continuous LTOT improved survival in a selected
group of COPD patients with severe hypoxaemia (arterial PaO 2 less than 8.0 kPa).
Stabilization in pulmonary haemodynamics and reduction in secondary polycythaemia appear
to play a role in the mechanism for improved survival (BTS, 2015; Criner, 2013).

The indicated patients for LTOT - Continuous Use (>15 hours of daily use) are
those COPD patients with chronic stable hypoxaemia,
a) Whose PaO2 is 7.3kPa (or 55mmHg), or

b) in the range 7.4-7.9kPa (or 56-59mmHg) together with hypoxia-related

consequences such as cor pulmonale, pulmonary hypertension,
secondary polycythaemia with haematocrit >56% which are
ascertained based on repeated ABG, and
c) who should have received optimal medical treatment, clinically stable
and free from exacerbation, before considering initiating Continuous
Use LTOT.

Every patient intended for continuous LTOT should have a baseline arterial
blood gases (ABG) when breathing room air to document oxygenation, arterial
carbon dioxide tension and acid base status. The expected benefit is to
improve the survival and quality of life.

3.2 COPD Patients with Exertion-induced Desaturation

Some COPD patients become hypoxaemic only during an exertion. These patients should be
distinguished from those with stable chronic hypoxaemia requiring continuous LTOT.
Evaluation for desaturation during daily activities should be done, especially for those patients
with BODE score 7, which may be an important goal for COPD management (Cutaia et al.,
2011). The ATS and ERS (2004) pointed out that for patients with adequate PaO2 who have
severe dyspnea relieved by low-flow oxygen; or for patients who are limited in their exertional
capacity but have their exercise performance improved with supplemental oxygen, ambulatory
oxygen may be considered. Recent research (Copur et al., 2015) also found that anemia was
a strong predictor for exercise-induced desaturation. Oxygen therapy for Ambulatory (or
Exertional) Use is the use of supplemental oxygen during physical and other daily living
activities only. Systematic reviews provided little support on the benefit of ambulatory oxygen

in improving exercise performance and participation in daily activities (Bradley & O’Neill, 2005;
Nonoyama et al., 2007). The mechanism for improvement may be related to i) reduction in
dyspnea (Cote & Celli, 2005); ii) reduction of oxygen cost of ventilation and iii) reduction in
right ventricular workload and improved cardiac output (Criner, 2013). More recent
guidelines suggest that ambulatory oxygen should not be generally prescribed to COPD
patients who are normoxaemic or only mildly hypoxaemic at rest (BTS, 2015, GOLD, 2015,
TSANZ, 2014). When resting hypoxaemia is not present, oxygen therapy is only justified upon
assessment for specific activities of daily living while there is documented proof of functional
improvement and full compliance (TSANZ, 2014). Exertional desaturation is defined as being
a drop of SpO2 of >=4% and below 90% by BTS (2015), and as SpO2 88% by ATS & ERS
(2004). BTS (2015) suggests the indication of exertional oxygen only if 2 out of 3 of the
following criteria are fulfilled when supplemental oxygen is provided: (a) SpO2 ≥90%
throughout the activities ; (b) ≥ 10% increase in walking distance from baseline ; (c)
improvement in BORG of at least 1 point from baseline.

The indicated patients for LTOT - Ambulatory / Exertional Use are those who,
a) meet the criteria for stable chronic hypoxaemia, and
b) demonstrate oxygen desaturation in exertion to SpO2 88%, and
c) full compliance to the trial use of the therapy, and report improvement in
symptoms, function and quality of life.

The use of oxygen will be confined to participation in specified physical and

daily living activities, and the expected benefit is to improve related
performance but not in other aspects, such as decreasing mortality, sleep, etc.

Desaturation Test (Box 1) with continuous oximetry monitoring is the

recommended procedure to substantiate exertional desaturation. Functional
Improvement and decrease in exertional dyspnea are other parameters for
consideration of exertional use of oxygen.

Because pulse oximetry has essentially supplanted arterial blood gases as a measure of
oxygenation in non-hospitalized patients, it is reasonable to use oxygen saturation measured
by pulse oximetry (SpO2) as a surrogate for PaO2 during oximetry monitoring. On the basis of
the typical relationship between PaO2 and SpO2 as defined by the oxyhaemoglobin dissociation
curve, SpO2 of 55 mm Hg or less correlates approximately with SpO2 of 88% or less (Qaseem,
et al., 2011).

3.3 COPD Patients with Nocturnal Desaturation

Thirty to fifty percentages of COPD patients without daytime hypoxaemia have been found to
experience nocturnal desaturation (Fletcher et al., 1987; Plywaczewski et al., 2000).
Desaturation during sleep may suggest consideration of oxygen therapy specifically only
under these conditions. However, the beneficial and long-term effects of Nocturnal Oxygen
Therapy, especially for patients who do not fulfill criteria for LTOT, are inconsistent in more
recent studies (BTS, 2015). The criteria to define nocturnal desaturation are also controversial
in different countries. The TSANZ (2014) criteria require a repeatedly drop of oxygen
desaturation to less than 88% for more than a one-third of the night and who have evidence of
hypoxia-related sequelae, provided that any contributing factors such as obstructive sleep
apnoea, congestive heart failure and airways disease have been addressed optimally. The
Medicare coverage (CMS, 2007) supports nocturnal oxygen usage for patients, either with
desaturation at or below 88% during sleep, or with a greater than normal fall in oxygen level
during sleep (a decrease in oxygen saturation >5%) associated with symptoms or signs
reasonably attributable to hypoxaemia (e.g. impairment of cognitive processes and nocturnal
restlessness or insomnia). Evidence suggests that nocturnal oxygen therapy can be
provided for severe heart failure patients who are symptomatic with sleep-related breathing
after other causes of nocturnal desaturation has been excluded (TSANZ, 2014). Besides, it
should also be noted that when administered to patients who are either normoxaemic or have
This printed copy may not be the most updated version. Please refer to the electronic version for confirmation if in doubt
Document No. HAHO-COC-GL-OCC-003-v03
Hospital Authority Head Office Issue Date 27/05/2019
Review Date 27/05/2022
Occupational Therapy Clinical Practice Guideline – Home
Oxygen Therapy for Adult Patients Page 21 of 92

baseline ABG levels above the threshold for LTOT, nocturnal oxygen therapy alone does not
show consistent improvements in pulmonary haemodynamics leading to a survival benefits
(BTS, 2015; Chaouat et al., 1999). Hence, recent BTS (2015) guideline does not recommend
Nocturnal Oxygen Therapy for COPD patients who have solely nocturnal hypoxaemia. For
patients with restrictive lung diseases (Buyse et al., 2003; Gustafson et al., 2006) or
complicated with sleep-related breathing disorders (Elliott, 2002; Stradling & Davies, 2004),
who demonstrated nocturnal desaturation, other means of ventilatory support such as BIPAP
or CPAP may need to be considered. The assessment procedure for non-invasive ventilation
in chronic respiratory failure is beyond the scope of this guideline.

The indicated COPD patients for LTOT - Nocturnal Use are those who
a) meet criteria for stable chronic hypoxaemia, and
b) have oxygen desaturation to <88% during the night as illustrated in
overnight oximetry or sleep study, and
c) demonstrate full compliance to the trial use of the therapy, and
improvement in symptoms and quality of life.

Patients with the presence of hypoxia-related consequences such as i)

daytime somnolence, ii) daytime hypercapnia, iii) polycythaemia, iv)
pulmonary hypertension, or v) right heart failure can be considered for sleep
study with overnight oximetry. For patients with restrictive lung diseases or
complicated with sleep-related breathing disorders, non-invasive ventilatory
support may need to be considered.

3.4 Other Chronic Diseases (including cystic fibrosis, interstitial lung diseases, congestive
heart disease, COPD not optimally treated, etc.)
There are other patient groups, including patients with i) cystic fibrosis, ii) interstitial lung
diseases, iii) congestive heart failure, iv) Eisenmenger Syndrome, v) COPD not optimally
treated, etc., who demonstrate oxygen desaturation or a reliance on oxygen therapy at the
time of hospital discharge, but do not fulfill the stringent criteria as mentioned in Sections 2.1
to 2.3, being prescribed a course of Short-term Oxygen Therapy by the medical officer.
Although there is evidence supporting the use of Home Oxygen Therapy in improving sleep
and exercise in people with cystic fibrosis (Elphick & Mallory, 2013), in improving hypoxemia
and dyspnea in eisenmenger syndrome (Mebus et al., 2010), in relieving hypoxaemia and
pulmonary hypertension with interstitial lung disease (Criner, 2013); and in improving oxygen
saturation and apnea hypopnea index in patients with congestive heart failure, especially
those with Cheyne-Stokes respiration (Criner, 2013). The possible benefits of Home Oxygen
Therapy in patients with various medical conditions are principally extrapolated from studies in
COPD with stable chronic hypoxaemia. In patients presenting with hypoxaemia during
exacerbation, their conditions should be re-evaluated within 3 months (BTS, 2015; TSANZ,
2014). Previous study found that up to 38% of such patients did not fulfill criteria for long-term
oxygen therapy at their subsequent review (Eaton et al., 2001).
On the other hand, if hypoxaemia persists in the re-evaluation, long-term supplemental
oxygen may be required (BTS, 2015; GOLD, 2015, TSANZ, 2014). Normally, patients should
not have home oxygen therapy ordered at the time of an acute exacerbation of their
underlying condition. However, if home oxygen is ordered (eg, at hospital discharge), it should
be limited to patients with an SpO2 of ≤92%, who are breathless and unable to manage off
oxygen (BTS, 2015).

When patients do not fulfill the stringent criteria as mentioned in Sections 2.1 to
2.3 for Home Oxygen Therapy, but demonstrate oxygen desaturation or a
reliance on oxygen therapy at the time of hospital discharge, being put on a
course of Short-term Oxygen Therapy, they should be re-evaluated between
1 to 3 months to determine the continued need of the therapy.

3.5 Patients with Malignancy or Terminal Diseases

Palliative oxygen therapy is defined as the use of oxygen to relieve the sensation of
refractory persistent breathlessness in advanced disease or life-limiting illness irrespective of
underlying pathology where all reversible causes have been treated optimally (BTS, 2015). A
systematic review by Uronis et al. (2008) evaluated 5 randomized clinical trials on oxygen
therapy in advanced cancer patients. The effects were similar to air in 4 trials with
non-hypoxaemic or mildly hypoxaemic cancer patient in relieving dyspnea. Although another
systematic review (Uronis et al., 2011) on COPD patients indicated that oxygen can relieve
dyspnea in mildly and non-hypoxaemic patients, yet the small sample sizes and heterogeneity
amongst studies made it difficult to provide a firm conclusion. Later in another well-designed
randomized controlled trial by Abernethy et al.( 2010), the effects of palliative oxygen were
compared against room air in 239 patients with life limiting illnesses. The majority were
non-hypoxaemic with a mixed diagnosis of COPD, other lung diseases, primary and
secondary lung cancer. There was no significant difference between the two groups in
breathlessness and quality of life. BTS (2015) stated that patients with cancer or end-stage
cardiorespiratory disease who are experiencing intractable breathlessness should not receive
palliative oxygen therapy if they are non-hypoxaemic or have mild levels of hypoxaemia above
current continuous oxygen therapy thresholds (i.e. SpO2 ≥92%). Thus, oxygen prescription to
non-hypoxaemic COPD patients solely for symptomatic relief is generally not recommended in
this guideline. In case when oxygen therapy has to be prescribed, this should be based on
individual patient’s responses and would be on occasion be considered by specialist teams.
The goal of the treatment is to improve symptom and comfort (Stringer, McParland, &
Hernandez, 2004), and there is limited other supported therapeutic values. BTS (2015) stated
that in those instances, individual formal assessment of the effect of palliative oxygen on
reducing breathlessness and improving quality of life should be made. Before oxygen
prescription in such situation, the use of other treatments for relieving intractable dyspnea in
patients with end-stage diseases, which include maximizing treatment for underlying diseases,
any reversible causes for breathlessness, and the assessment for a trial of opioid. As
distress from breathlessness can be multi-dimensional, psycho-social factors should be
addressed. Other non-pharmacological measures may include teaching of breathing
relaxation and life modifying strategies as well as use of hand-held fan. As distress from
breathlessness may not be correlated to degree of hypoxemia, it is suggested by BTS (2015)
that oxygen flow rates be determined by symptom score on an individual basis rather than

SpO2 reading. Additional consideration needs to be given to potential risks of hypercapnia if

oxygen is given at higher flow rates. This palliative usage may be as-needed or continuous,
according to patient’s need.

Palliative Oxygen Therapy is considered for patients suffering from malignancy

or terminal diseases in the presence of hypoxemia

Palliative Oxygen Therapy may be on occasion be considered by specialist

teams for non-hypoxaemic patients with end-stage disease with intractable
dyspnea and reported benefit, after various possible treatment measures have
been addressed.

3.6 Contraindications to Home Oxygen Therapy

There are several contraindications discussed in renowned international guidelines where

patients who continue to smoke remain the major concern (BTS, 2015, TSANZ, 2014). As
explained in TSANZ (2014), oxygen therapy is not indicated for patients i) who continue to
smoke, for fear of fire hazard and more importantly, the possibility that the poorer prognosis
conferred by smoking will offset treatment benefit, and/or ii) who do not undertake the
appropriate discipline required for oxygen therapy. In BTS (2015), despite the potential
harmful effects of cigarette smoking on secondary polycythaemia, accelerated decline in lung
function and increased mortality in COPD patients, there is insufficient evidence to determine
the outcomes of LTOT patients who continue to smoke as compared to non-smokers.
Therefore, if LTOT is prescribed for a smoker, the potential for more limited clinical benefit and
increased fire hazards should be discussed thoroughly. On the other hand, assessment for
smoking status upon prescription of home oxygen and referral to smoking cessation
interventions for active smokers should always be considered. Besides, home oxygen therapy
is also not recommended for patients who has not receive optimal treatment for their
underlying medical conditions or those who are not sufficiently motivated to undertake the
required discipline in using home oxygen therapy (TSANZ, 2014). Short burst of oxygen to
relieve dyspnea, and/or to accompany exercise training on as-needed basis is generally not

Desaturation Test is an assessment for identifying the presence of exertional

desaturation and evaluating the benefit of supplementary oxygen in correcting the
desaturation to substantiate the need of Home Oxygen Therapy. While performing
the same series of functional tasks (from different METs levels in Annex 2) with and
then without supplemental oxygen, the degree of exertional desaturation, activity
tolerance and dyspnea level (with Borg scale) are compared. Patient’s oxygen
desaturation is monitored by continuous oximetry throughout the test (Fussell et al.,
2003). Any ADL tasks relevant to patient’s life role can also be used for evaluation.
Therapists can also apply the Monitored Functional Task Evaluation (MFTE) (Fong et
al., 2001), which is a standardized functional assessment developed for COPD
patients. This assessment also stipulates certain safety measures to follow which
serve as a reference for performing similar desaturation test. Either the patient or the
therapist can terminate the assessment at any time when undue discomfort is
observed or reported. Usually, the test is recommended to be conducted after the use
of bronchodilators. Sample form is attached in Annex 3.

Box 1 Desaturation Test

4. The Right AMOUNT (Flow Rate)

International guidelines emphasized that the oxygen prescription should always include the
source of supplemental oxygen, method of delivery, duration of use, and flow-rate at rest,
during exercise, and during sleep (ATS & ERS, 2004; BTS, 2015; Doherty & Petty, 2006;
TSANZ, 2014). In this guideline, we also consider flow-rates for special occasions, such as
when COPD patients presenting with early symptoms of acute exacerbation, and when during
air travel. The universal principle of flow-rate setting for Home Oxygen Therapy is to increase
the baseline PaO2 (at rest) to at least 8.0kPa (or 60mmHg) at sea level, and/or produce SpO 2
at least 90% with as little supplemental oxygen as possible (ATS & ERS, 2004; BTS, 2015;
TSANZ, 2014). Reversal of hypoxaemia should supersede concerns about carbon dioxide
retention (ATS & ERS, 2004).

4.1 Flow Rate at REST

Oxygen flow-rate is primarily decided by arterial blood gases (ABG) results to achieve PaO2 >
60mmHg (8.0 kPa) (BTS, 2015, TSANZ, 2014). Besides evaluations on blood gas results,
Guyatt et al. (2001) recommended a titration protocol, in which the flow-rate is to be increased
by 1 L/min if the SpO2 (at rest, room-air) is in the range of 85% to 89%, and by 2 L/min if the
SpO2 (at rest, room-air) is in the range of 80% to 84%. BTS (O'driscoll et al., 2008)
recommended that during acute exacerbation on admission, a target saturation range of 88–
92% is suggested for most patients with known COPD or other known risk factors for
hypercapnic respiratory failure (e.g. obesity, chest wall deformities or neuromuscular disorders)
and 94% to 98% for other patient types. For satisfactory correction of hypoxaemia, the
therapeutic goal of oxygen therapy is to maintain saturation greater than 90% during rest,
sleep and exertion at the lowest setting (ATS & ERS, 2004; BTS, 2015, TSANZ, 2014).
However, there is no consensus on the targeted upper range after stabilization. Nevertheless,
finer titration of oxygen flow-rates is recommended to suit patients’ requirements (BTS, 2015).
Rechecking ABG results to confirm a target PaO2 > 60 mmHg after completion of oxygen
titration, is also recommended (BTS, 2015; TSANZ, 2014).

Resting oxygen flow-rate is initially confirmed by ABG with PaO2 > 60 mmHg
(8.0 kPa). Finer titration is recommended to suit patients’ requirements.

Flow-rate at REST: the minimal flow-rate with SpO2 maintained > 90% during
rest More optimal SpO2 may be considered for patients with special needs.
Finer titration is recommended to suit patient’s requirements.

4.2 Flow Rate for ADL / Exercise

Many COPD patients showed additional desaturation during exercise and/or activities of daily
living than at rest. Significant exercise-induced desaturation is defined as a fall in SpO2 of >4%
to a value of SpO2 <90% (BTS, 2015). Thus, higher oxygen flows may be necessary when
performing ADL tasks. International guidelines (ATS & ERS, 2004; BTS, 2015) recommended
titration of oxygen flow-rate against different activities to achieve SpO2 greater than 90%
during exertion. Hodgkin, Celli, & Connors, (2000) also suggested to maintain SpO2 above
90% during all phases of daily life (Annex 4 - ADL Oxygen Saturation Profile Form). Using
ambulatory monitoring, individualized specific activity / oxygenation profile could be used to
optimize oxygen prescription in achieving adequate oxygenation in daily activities (Cutaia et
al., 2011). As different ADL tasks demand different oxygen consumption, it is recommended
that, during the titration procedure, at least 2 ADL exertion levels are involved to match the
exertion demand in patients’ life roles and actual ADL tasks. In general, the flow-rate may
need to be increased by 1 L/min (or more) above the resting flow setting for exertional ADL
tasks. The 6th Oxygen Therapy Consensus Conference also highly recommended using the
same set of home oxygen devices during assessment, especially for adjusting an appropriate
flow setting delivered by the oxygen conserving device (Doherty & Petty, 2006).

Flow-rate for ADL / Exercise: the minimal flow-rate with SpO2 maintained
above 90% during all activities through “Dose Titration”. Different activities will
require different flow-rates.

4.3 Flow Rate for SLEEP

ATS & ERS (2004) and other international guidelines recommended that SpO2 be targeted
above 90% during sleep. Although the NOTT standard recommended that the flow-rate for
sleep could be increased by 1L/min above the daytime resting prescription, study results were
controversial. Several studies (Nisbet et al., 2006; Plywaczewski et al., 2000) suggested that a
flow rate established from resting ABGs while awake may not allow adequate oxygenation
overnight with patients spending around 25% of the time with SpO2 <90% overnight. Recent
study indicated that most COPD patients on continuous long-term oxygen therapy did not
exhibit overnight desaturation despite not increasing their overnight oxygen dosage (Nisbet et
al., 2006). Selmolski et al. (2010) studied the increase of 1-liter oxygen flow in COPD patients
with chronic hypercapnic respiratory failure and found out that the regime improved nocturnal
oxygenation, but it also led to greater hypercapnia and respiratory acidosis in a considerable
proportion of patients.
BTS (2015) suggested that increasing flow-rate by 1L/min at night time may be considered to
correct desaturation for patients with chronic hypoxaemia, only if in the absence of
hypercapnia and any contraindications. Overnight oximetry should be considered to support a
more accurate prescription. In general, increasing flow-rate by 1L/min above the daytime
resting prescription is not recommended without proper assessment.

Flow-rate for Sleep: the minimal flow-rate with SpO2 maintained at above 90%,
as shown in sleep study with overnight oximetry. An increase of 1L/min at night
time to correct desaturation may be considered upon assessment and in the
absence of any contraindications. A routine increase by 1L/min above the
daytime resting prescription is not recommended. The flow-rate setting for
sleep is also applied to daytime nap.

4.4 With Early Symptoms of Acute Exacerbation

People with COPD are prone to acute episodes, when their symptoms get worse and their
oxygen level may fall. Initial treatment during these episodes usually includes oxygen, but
this may cause a concurrent rise in the carbon dioxide levels that become subsequently
harmful. A systematic review identified that there is no evidence to indicate that whether
different oxygen therapies in the pre-hospital setting have an effect on outcome for people with
acute exacerbations of COPD (Austin & Wood-Baker, 2006).

Patients on Home Oxygen Therapy should maintain their original oxygen

therapy regime and flow-rate even at times with early symptoms of acute
exacerbations. Change should only be made according to medical advice.
Increasing oxygen flow-rate automatically is not recommended.

4.5 During Air-flight

During air-flight, commercial passenger aircrafts operate at cabin pressures equivalent to

2500 meters above sea level, which is equivalent to breathing 15% of oxygen at sea level.
Patients who are qualified for continuous oxygen at home will require additional oxygen
supplementation in order to keep the PaO2 above 50 mmHg. Studies indicated that this can be
achieved in those with moderate to severe hypoxemia at sea level by supplemental oxygen at
3L/min via nasal cannulae (GOLD, 2015). Further evaluation may be needed to evaluate
oxygen requirements during in-flight conditions if the patients have i) previous significant

respiratory symptoms associated with air travel; ii) severe chronic obstructive pulmonary
disease (FEV1 <30% predicted), bullous lung disease, difficult-to-control asthma, cystic
fibrosis or pulmonary tuberculosis; iii) severe restrictive lung disease, chest wall and
respiratory muscle disease, especially if associated with hypoxaemia and/or hypercapnia; iv)
co-morbidity with conditions made worse by hypoxaemia (e.g. cerebrovascular disease,
cardiac disease, pulmonary hypertension); v) recent pneumothorax or within six weeks of an
acute respiratory illness; vi) risk of, or previous history of, venous thromboembolism or vii)
pre-existing requirement for oxygen, continuous positive airways pressure or ventilator
support. BTS suggested that usual oxygen requirement at sea level at a flow rate exceeding 4
L/min is contraindicated for commercial air flight (Ahmedzai et al., 2011).

The standard evaluation on the extent of desaturation during in-flight condition can be
performed by a Hypoxic Challenge Test (HCT) using a gas mixture containing 15% oxygen in
nitrogen which the patient is required to breathe for 20 mins in a special chamber. HCT
assessment is considered for patients at risk with a SpO2 < 95% at sea level. If the resulting
SpO2 is < 85% in HCT, in-flight oxygen is required at a rate of 2L/min via nasal cannulae.
(Ahmedzai et al., 2011). The conditions of having exercise tolerance being > 50 meters and
without dyspnea as well as full recovery from recent exacerbation are favored by some local
airlines. The 6 or 12 min walk test or the shuttle walk test may also be utilized as stated in the
BTS (Ahmedzai et al., 2011). Failure to complete the task (whether distance or time), or with
moderate to severe respiratory distress, will alert the physician to a possible need for in-flight
oxygen. Edvardsen et al. (2012) had constructed a clinical algorithm by analyzing a
prospective cohort study of 100 patients with moderate to very severe COPD with respect to
the resting room air oxygen saturation (SpO2) and lowest 6-Minute Walk Test saturation
(6MWT SpO2). Those patients with resting SpO2 > 95% AND 6MWT SpO2 >= 84% would not
need in-flight oxygen, whereas those either with resting SpO2 < 92% or with 6MWT SpO2 <
84% would definitely need oxygen without need of further HCT. There are also several
predictive equations (Ahmedzai et al., 2011; Billings et al., 2013) which may be a further option
for identifying those patients who require sophisticated HCT assessment. Hence, careful
consideration should be given to any co-morbidity that may impair oxygen delivery to tissues
and prior medical consultation is highly recommended.

In general, patients with resting SpO2 ≤ 95% or marked exertional desaturation

should need further assessments on possible in-flight hypoxaemia. A
supplemental oxygen at 3L at rest should be considered for those with
moderate to severe hypoxaemia. More accurate flow titrations can be obtained
in a simulated chamber or device. Medical consultation is highly recommended
prior to air flight to evaluate risks and enhance safety.

“Dose Titration” is a dynamic and comprehensive approach in which the patients will
perform various ADL tasks with continuous monitoring by pulse oximetry. In the
titration procedure, the therapist should,
 check patient’s ADL oxygen saturation profile by pulse oximetry,
 involve at least two ADL exertion levels which match the exertion demand in
his/her life roles; a) moderate exertion: such as dressing, indoor level ground
walking, and b) high exertion: such as carrying heavy groceries, walking
upstairs,
 use the same (or at least similar) source and method of delivery of
supplemental oxygen to be used at home,
 adjust the oxygen flow-rate at 0.5-1 LPM for each increment interval,
 allow 5 - 10 minutes after each increment for the equilibration between blood
and tissue oxygen (TSANZ, 2014)

Box 2 Dose Titration Procedures for ADL Oxygen Saturation Profile

5. The Right Period of Time (Duration)

The period of time or duration of Home Oxygen Therapy refers to two aspects. Firstly, if the
oxygen therapy is to be continued for the rest of the life once initiated, it should be regarded as
long-term administration. Short term oxygen therapy refers to the administration of oxygen
therapy that can be withdrawn once the medical condition is reversed. Secondly, it relates to
the number of hours and situations the oxygen being used in a day. Both aspects will depend
on the patient groups indicated for the therapy.

5.1 COPD Patients with Stable Chronic Hypoxaemia i.e. PaO2 7.3kPa (or 55mmHg), or
in the range of 7.4-7.9kPa (or 56-59mmHg) together with hypoxia-related consequences
such as pulmonary hypertension, cor pulmonale, secondary polycythaemia
(haematocrit >56%)

For stable COPD patients with severe hypoxaemia, the Medical Research Council (MRC,
1981) study showed that those patients receiving a daily average of at least 15-hour
continuous oxygen therapy survived longer than those not receiving oxygen therapy; whilst the
Nocturnal Oxygen Therapy Trial (NOTT, 1980) demonstrated a further reduction in mortality in
patients receiving longer hours of continuous oxygen therapy (an average of 18 hours per day).
Thus, the recommendation is generally that the oxygen be used for as many hours out of 24
as possible. As stipulated by international guidelines (ATS & ERS, 2004; BTS, 2015, TSANZ,
2014), the standard for administration of LTOT should be continuous with ambulatory
capability.

At least 15, and preferably longer hours of daily oxygen usage at the
prescribed flow-rate is recommended for COPD patients with stable chronic
hypoxaemia.

5.2 COPD Patients with Exertion-induced Desaturation

Some COPD patients become hypoxaemic only during exertions. Desaturation during exertion
suggests consideration of oxygen therapy specifically only under these conditions (ATS &
ERS, 2004).

Oxygen usage should be confined to physical and daily living activities that
result in oxygen desaturation or demonstrate functional improvement.

5.3 COPD Patients with Nocturnal Desaturation

Some COPD patients become hypoxaemic only during sleep. Desaturation during sleep
suggests consideration of oxygen therapy specifically only under this condition (ATS & ERS,
2004). This rationale does not apply to COPD patients with co-existing sleep apnea syndrome.
In such cases, non-invasive ventilatory support is indicated (Croxton & Bailey, 2006).

Oxygen usage should be confined to sleep and/or daytime nap that induce
oxygen desaturation.

5.4 Other Chronic Diseases (including cystic fibrosis, interstitial lung diseases,
congestive heart diseases etc.)

The duration for daily oxygen usage will depend on individual case management. There are no
consensus guidelines yet. On the other hand, several re-evaluation studies (Eaton et al., 2001;
NOTT, 1980; Oba et al., 2000) demonstrated that 25% to 60% of these patients would
subsequently recover to the point of no longer requiring oxygen. For them, the medical regime
may not be optimal at the time of their discharge from hospital when Home Oxygen Therapy is
given. Thus, these patients should be re-evaluated within 3 months to determine continued
need (ATS & ERS, 2004; BTS, 2015; GOLD, 2015; TSANZ, 2014).

Close liaison with the case medical officer related to the daily usage of oxygen
for each individual case is essential. Furthermore, these patients should be
re-evaluated within 3 months to determine continued need of the therapy.

6. Monitoring of Patient and Therapy

Home Oxygen Therapy should not be viewed just as a one-off medical prescription.
Whereas many other aspects should be put as much consideration as the initial prescription in
order to achieve the optimal benefit of the therapy. Firstly, for some patients their medical
condition may not be optimized at the time when home oxygen is prescribed, they will need
re-certification. Secondly, chronic illness always entails greater importance in
self-management and, on the other hand, may turn into a risk for non-compliance. In COPD,
compliance does not simply refer to whether patients take their medications properly; it also
comprises a range of non-pharmacologic management including using home oxygen
effectively, undertaking and sustaining smoking cessation, as well as maintaining home
exercise program that require continued monitoring (BTS, 2015; GOLD, 2015; TSANZ, 2014).
Thirdly, a high proportion of these patients are at the late stage of their disease conditions
during which time many other problems may emerge. A local survival analysis found out that
the median survival time of patients on LTOT was 41 months after initiation of oxygen therapy,
and the survival rates at 1st, 3rd and 5th year were 88%, 56% and 29% respectively (So et al.,
2004).

6.1 Re-Assessment
Several re-evaluation studies (Eaton et al., 2001; NOTT, 1980; Oba et al., 2000) demonstrated
that 25% to 60% of these patients initially prescribed for Home Oxygen Therapy without
fulfilling the criteria for LTOT, would subsequently heal to the point of no longer requiring
oxygen, and strongly recommended a re-evaluation be done within 90 days of discharge (ATS
& ERS, 2004; Doherty et al., 2006). Repeat ABG analysis is essential in re-certifying for long
term continuous oxygen use. The implementation of an oxygen therapy clinic for
re-assessment produces a significant decrease of inappropriate oxygen use resulting in
significant cost savings (Chaney et al., 2002).

However, for those patients who have fulfilled all the stringent criteria for LTOT should
continue the therapy, despite the condition that some patients may show a sustained rise
in PaO2 to a value greater than 8 kPa (60 mmHg) when breathing air. This should not be a
rationale for stopping therapy as the improvement in oxygen saturation may represent its
reparative effects after use. The 5th Oxygen Therapy Consensus Conference recommended
periodical re-assessment after initial oxygen therapy setup (Petty & Casaburi, 2000). The goal
of the re-assessment is to assess the need for readjustment of flow-rate and monitoring other
health problems for these patients. Recent guideline recommends initial reassessment for
LTOT patients at 3-month follow up, follow-up visits can be conducted at 6 to 12 months
afterwards. Follow-up assessment can be done either home based or combination of hospital
or clinic visits (BTS, 2015).

A clinic or home-based reassessment is recommended for patient prescribed for

home oxygen therapy between 1 and 3 months upon initiation of the therapy,
although the principal purpose of the reassessment may be different for different
indicated patient groups. Follow up assessments can be arranged at 6 to 12
months period when resources allow.

For those on STOT, the goal will be re-certification for the therapy. For those on
LTOT, the purpose will be adjusting flow-rate, and monitoring course of the
disease and any rehabilitation needs. However, for those prescribed for
Palliative Oxygen Therapy, the focus of follow up would be on supportive care
and symptom relief at home situation.

6.2 Compliance to Home Oxygen Therapy

Previous studies have evaluated the compliance of LTOT with rates ranging from 45 to 70%
(Katsenos & Constantopoulos, 2011). Low rate of compliance, 21%, was also reported (Neri et
al., 2006). There are many psychological barriers like “query about the need for therapy when
symptoms improved”, “fear of oxygen addiction”, “stigma” and “autonomy restriction” etc.
among the COPD patients contributing to non-compliance (Cullen, 2006). Earnest (2002)
described the stages of change from “part-time oxygen use”, to “as-needed oxygen use”, then
to “full-time oxygen use” among patients on Home Oxygen Therapy and discussed a model in
striving a balance in the management of four aspects: function, health, social and symptom to
facilitate moving toward full-time use. Patients may experience some side-effects of oxygen
use, such as nasal dryness, nasal bleeding, dizziness, some loss of taste and smell, cosmetic
effects or the potential restriction to daily activities, causing adherence issues to therapy
(Katsenos & Constantopoulos, 2011). Formal assessment and training at the time of
prescription is shown to improve compliance (BTS, 2015). A well- organized home care
program, regular follow up and sincere clinician-patient communication has potential to
enhance patients’ positive attitude regarding LTOT thus improving its long-term efficacy
(Katsenos et al., 2004; Rizzi et al., 2009). Moreover, incorporating oxygen use into different
activities of daily living at home also poses challenges to the patients. Developing confidence
in using portable oxygen for outdoor activities improves the compliance and treatment efficacy
with Home Oxygen Therapy in COPD patients (Ram & Wedzicha, 2002). There are many
other different aspects in the use of Home Oxygen Therapy that are initiated in hospitals, can
be further reinforced in homes. Support at home can be a cost-effective mode of follow up
service for patients on Home Oxygen Therapy (ATS, 2005).

Thorough education & in-depth counseling are essential in the prescription of

Home Oxygen Therapy in order to enhance compliance to the therapy.
Continue support to patients at home will further enhance compliance.

6.3 High Risk Groups for Further Service

The patients on LTOT are usually reported to have various health problems indicated for
further service. Significant depressive symptoms and depression are highly prevalent in
patients with severe COPD on LTOT. There is strong evidence that depression is
under-recognized and under-treated in this group of patients (Lacasse et al., 2001). In addition,
malnutrition is highly prevalent in home-assisted respiratory patients as well. Their quality of
life is compromised. Limitation for outdoor activity and a low haematocrit value (<39% in man
& <36% in woman) are also independent predictors for high mortality (Chambellan et al., 2005;
Ringbaek & Lange, 2005). Community based support and/or rehabilitation services, preferably
with a link with the patients’ case medical officers is beneficial. A 10-year case control study
has suggested home care follow up decrease exacerbation rates for LTOT patients (Farrero et
al., 2001). A more recent study on home-based program (monthly phone call, home visits
every 3 months, and home or hospital visits on a demand basis) for follow up of LTOT patients
versus conventional medical care, demonstrates significantly decreased costs in the
homecare follow-up group by reducing the use of hospital resources (Rizzi et al., 2009).
Current clinical guidelines for COPD management emphasize the importance of care that
encompasses both pharmacological and non-pharmacological interventions designed to
improve quality of life and survival (BTS, 2015; GOLD, 2015 & TSANZ, 2014) where
pulmonary rehabilitation and home oxygen therapy are the two major interventions to achieve
such benefits. Therefore, improvement in accessibility and utilization of these interventions
among people with COPD would have good potential to improve long-term health outcomes
(Marks et al., 2013).

Community based support and/or rehabilitation service, preferably with a

communication link with the patients’ case management team, is beneficial.
Various problems such as depressive mood, malnutrition, being home-bound
and at risk of anemia should be considered for prioritizing further services.

7. Recommended Procedures for Professionals

Incorporating the evidence as discussed through sections 2 to 4, our Working Group

recommends occupational therapists to refer to the following nine steps in handling the
prescription of Home Oxygen Therapy. Details for each step are described in the following
sections.

1. Validating the appropriate patients and respective therapy regime

2. Recommending appropriate flow-rates with respective to rest, sleep and
various daily activities
3. Gaining consensus and participation from the patients and/or care-givers
4. Selecting the appropriate equipment to fit the home environment and
lifestyle
5. Exploring the need for financial assistance
6. Educating and training on operation, maintenance and precautions
7. Liaison for equipment delivery on discharge
8. Monitoring and arranging follow-up service
9. Documentation

7.1 Validating the Appropriate Patients

On receiving a referral from a medical officer, the therapist should validate the indications for
Home Oxygen Therapy (Refer to Section 2) and the respective therapy regime (Refer to
Section 4) for the patient by making reference to relevant medical information,
i. The principal disease leading to respiratory failure,
ii. Stability of the disease, e.g. presence of acute infection or influenza symptom,
iii. Medical investigation results e.g. Lung Function Test, Astrup (ABG), etc.,
iv. Any proposed purpose and regime of Home Oxygen Therapy by the referring medical
officer.
together with findings in the Desaturation Test or other simulated functional assessment for
specific condition, performed with full participation from the patients. In case when the
prescription criteria are not met, the therapist should initiate discussion with the referring
medical officer for any further management advices.

Home O2 Therapy Regime Principal Therapy Goal Eligible Criterion

1. LTOT - Continuous Use  Improve survival COPD patients, who

(>15 hrs, including activity ․ exhibit chronic hypoxaemia; and/or
and sleep) ․ establish hypoxia-related consequences e.g.
right heart failure syndrome (cor-pulmonale)

2. LTOT - Ambulatory /  Correct exertion induced COPD patients, who

Exertional Use hypoxaemia ․ meet criteria for LTOT,
(mainly for use during activity  Improve activity level ․ exhibit exertion-induced desaturation to
and exercise) and exercise capacity 88%; and
․ demonstrate full compliance and report
objective and/or subjective improvement in
activity level and quality of life from a trial
use of the therapy

3. LTOT - Nocturnal Use (mainly  Correct sleep related COPD patients, who
during sleep) hypoxaemia ․ meet criteria for LTOT
 Minimize symptoms of ․ demonstrate sleep-related oxygen
hypoxia-related desaturation in overnight oximetry, during
consequences the nocturnal recording time with arterial
oxygen saturation 88%.
Further assessment required for patients with
restrictive lung diseases or complicated with
sleep related breathing disorders

4. Short Term Oxygen Therapy  Correct hypoxaemia Patients with various chronic diseases or COPD
(STOT), when proper diagnosis patients not optimally treated, who
(depends on individual needs, and treatment may not ․ do not meet stringent criteria for LTOT or
can be continuous, exertional be fully optimized at the assessment for ‘Right Patient’ not feasible
or nocturnal use) time of discharge and its nor completed.
long term benefits ․ demonstrate persistent desaturation even at
require re-evaluation rest and unable to wean off oxygen therapy
at the time of discharge.
․ demonstrate persistent exertional
desaturation on pulse oximetry but does not
demonstrate full compliance to long term use

5. Palliative Oxygen Therapy  Relieve symptoms Patients with malignancy, terminal diseases with
(may be continuous, especially for intractable the presence of desaturation or Patients with
exertional or PRN use) dyspnea COPD, various chronic or terminal conditions
 Minimize possible without documented desaturation, who
complications during the  present with intractable dyspnea
end of life.  report improvement in symptoms, function
and quality of life; and unresponsive to all
other treatment modalities

Table 1 Therapy Regimes, Goals and Eligible Criteria of Home Oxygen Therapy

7.2 Recommended Appropriate Flow-Rate Related to Rest, Sleep & Activities

The therapist should refer to section 3 for related evidence in flow-rate setting, and
recommend the oxygen flow-rates against rest, sleep and different ADL and/or exertion levels
with reference to i) findings from the “Dose Titration” procedures, ii) patients’ life roles, instead
of maximum capacity, and iii) patients’ home environment. Such recommendation can be
documented in a) “ADL Oxygen Saturation Profile” (Annex 4) for record in the medical file of
the patient, and b) “Oxygen Usage Instruction” ( 日常生活氧氣治療指引 ) (Annex 5)
for issuing to the patients and/or caregivers, and with the aim to facilitate compliance. Some
local oxygen vending agencies can provide service in conducting overnight oximetry at home
setting for their potential clients. Below is a summary of the information (Table 2).

Scenario Flow Setting Principle

․ SpO2 is recommended to be > 90% during rest with minimal flow-rate.

․ A more optimal SpO2 range may be considered for patients with borderline
Rest:
saturation and frequent desaturation.

․ SpO2 is recommended to be targeted at >90% for dose titration on all ADL

tasks.
․ ADL Oxygen Saturation Profile assessment is highly recommended. In the
titration procedure, at least two ADL exertion levels are involved to match the
ADL: exertion demand in patients’ life roles. Actual ADL tasks or simulated functional
tasks with standardized procedures can be assessed. In general, the flow-rate
may need to be increased by 1 L/min (or more) above the resting flow setting
for exertional ADL tasks.

․ SpO2 is recommended to be targeted at >90% during sleep.

․ Routine increase of flow-rate by 1 L/min above the daytime resting flow-rate
without proper assessment is NOT recommended.
․ An overnight oximetry is highly recommended for determining the best sleep
Sleep:
flow-setting, especially when there are signs of cor pulmonale, morning
(Nocturnal)
headache, persistent edema or secondary polycynthaemia, despite daytime
normoxaemia.
․ The flow-setting for sleep applies to the condition during nap at daytime.

With early symptoms ․ Maintain their original oxygen therapy regime and flow-rate, and change should
of only be made according to medical advice.
Acute Exacerbation of ․ Increasing oxygen flow-rate automatically is NOT recommended.
COPD
․ In general, patients with resting SpO2 ≤ 95% or exertional desaturation should
need further assessments on possible in-flight hypoxaemia.
․ A supplemental oxygen at 3L at rest should be considered for those with
Air Flight
moderate to severe hypoxaemia. More accurate flow titrations can be obtained
in a simulated chamber or device. Medical consultation is highly recommended
prior to air flight to evaluate risks and enhance safety.
Table 2 Summary of Flow Setting Principles for Different Scenarios

7.3 Gaining Patients’ Consensus & Participation

The therapist should involve the participation from patients across all the Home Oxygen
Therapy arrangement procedures, and provide counseling, if necessary. Comprehensive
education of knowledge of Home Oxygen Therapy to patients and caregivers is essential to
gain their consensus. Prepare the ‘Order Consent Form’ ( 租用或購買家居氧氣設
備同意書 ) (Annex 6), if applicable, for them to sign after the patients have confirmed the
chosen vending agency and equipment (refer to the following section).

7.4 Selecting the Appropriate Oxygen Equipment

The therapist should assist the patients in selecting various components of the Home Oxygen
Therapy equipment, among various available models in the local market, with reference to the
cost-effectiveness, patient’s need and preference, home and social environment as well as
patient’s lifestyle. The step-by-step procedures are:

i. Providing information on the Home Oxygen Therapy equipment and the rental or
purchase services of the vending agency and the most updated respective price
information.
ii. Assisting in model selection with demonstration on specific features of different
models, and with reference to their compatibility with other respiratory equipment, e.g.
BiPAP, ventilator, etc; if any.
iii. Confirming the specific plan of oxygen equipment, including model of oxygen
concentrator, accessories and ambulatory oxygen system, with patient and caregiver.
iv. Estimating the need of extension tubing for ADL at home and giving advice on other
needed accessories.
v. Signing the ‘Order Consent Form’ ( 租用或購買家居氧氣設備同意書 ),
if applicable, to confirm the chosen vending agency and equipment.
vi. Giving information of selected vending agency to patient and/or caregiver and a copy
of the ‘Order Consent Form’, if applicable.

7.5 Screening Need for Financial Assistance

In Hong Kong, the patients who are receiving Home Oxygen Therapy are either self-financed
or being subsidized by some funding sources (Table 3). Total reimbursement of expenses
utilized in Home Oxygen Therapy is possible for patients receiving Comprehensive Social
Security Assistance (CSSA), Pneumoconiosis Compensation Fund Board (PCFB) or Special
Care Subsidy for the Severely Disabled under the Community Care Fund. The occupational
therapist should screen for the need of referring patients to appropriate sources of funding
assistance. As practices may vary in different hospitals, the therapist will also need to follow
the concerned procedures in respective hospitals for funding assistance for individual patients
regarding rental service of Home Oxygen Therapy equipment. When assessing patients’ for
funding support for respiratory equipment, it is generally recommended to start with a system
of lower price first and work upward to find one most optimal to patient's condition, taking into
the consideration of patient's physical capacity, life role demands, ability to operate the
concerned equipment and the effectiveness of the portable oxygen system in relieving
patient's dyspnea, maintaining saturation at an acceptable level as well as improving physical
activity. Therefore, the practice of patient purchasing equipment on himself without prior
assessment then asking for reimbursement is not recommended. Liaison with social service
department and endorsement from physicians after assessment are also common and formal
practice in most clinical settings.

Type of Recipient Funding Source & Application Procedure

For CSSA Recipients Follow the practices in respective hospitals in liaising with medical social
workers (MSW) or social security officers in Social Security Field Unit for
public funding procedure concerning rentals of Home Oxygen Therapy
equipment; or,
Fill in the form ‘Funding for Home Oxygen Therapy’ (Annex 7), if applicable,
with the relevant quotation attached and endorsed by case MO if needed.
Send the originals to MSW for further processing.

For Pneumoconiosis Contact the staff of the Board and confirm whether patient is entitled for
Fund Recipients subsidy with patient’s board number.
Fill in the form ‘Home Oxygen Therapy Recommendation Form’ (Annex 8), if
applicable, with endorsement by case medical officer.
Assist/instruct the patient to send the form to the Board.
Confirm types of devices offered and date of delivery.
Assist in negotiating home oxygen follow-up program by the OT in the
association.

Community Care Fund For patients who are not on CSSA but eligible for HDA and express financial
Recipients difficulty, Special Care Subsidy for Severely Disabled under Community Care
Fund may be considered. Application form, procedure and explanatory notes
can be downloaded from the homepage of Social Welfare Department for
self-application. Therapists may assist potential clients to liaise with MSW for
their assistance.

For patients who does Discuss with MSW and case MO on the eligibility of financial assistance for
not receive any public supplement of Home O2 rental charges
funding assistance, but
reported of financial
difficulties

Table 3 Funding Sources for Different Recipients and Respective Application Procedures

7.6 Educating and Training on Operation, Precautions & Maintenance

Education should be given to both the patients and their caregivers. Education should include
live demonstration being supplemented with audio-visual and written materials when available
as well as a “Return Demonstration” during which the patients and/or caregivers are asked to
demonstrate back the instruction or skills (Therapists can refer to section 7 for some related
information). A checklist is attached in Annex 9 for reference. The content of education should
include:

i. the rationale and importance of home oxygen therapy,

ii. the therapy regime, including a) the specific plan of oxygen usage schedule –
Continuous, Ambulatory/Exertional or Nocturnal Use, b) daily usage hour (e.g. 15 to
24 hrs), and c) the flow settings at rest, on exertion, in the activities of daily living and
during sleep
iii. key points on equipment selection,
iv. equipment installation, operation and maintenance,
v. use of accessories, cleansing, disinfection and application
vi. safety precautions and application of Home Oxygen Therapy, and,
vii. what to do in emergency situations, e.g. loss of electrical power.

7.7 Liaison for Equipment Delivery on Discharge

For continuity of the Home Oxygen Therapy, the oxygen equipment should be delivered to the
patients’ residences prior to their discharge from the hospital unless they are living alone and
no alternative is available for such arrangement. When necessary, a set of portable oxygen
can be delivered to the hospital before discharge for use during the journey back home. Table
4 lists some special considerations for patients with different needs.

Different Patient Need Special Consideration

Living with Family  Confirm the address and telephone number of patient’s home/OAH.
Member/in old age home  Inform family member and/or OAH in-charge that the patient will be
(OAH) discharged soon and the patient will be prescribed with Home Oxygen
Therapy equipment upon discharge.
 Request family member or the OAH staff to arrange power outlet and
good ventilation for the oxygen concentrator.
 Order the oxygen equipment from the vending agency and confirm the
date and time of delivery.
 Inform ward nursing staff when the equipment is ready.

Living Alone  Explore if there is any support that can be employed for the arrangement
of delivery, e.g. patient’s relative, neighbors, home helpers etc.
 Inform the vending agency the approximate time of discharge, if
available; or, give the phone number of the agency to the patient for self-
arranging the equipment delivery once discharged home.
 May need to arrange portable oxygen to hospital for accompanying
patient home while waiting for delivery of Home Oxygen Therapy
equipment from the vending agency.

Living in remote areas  Confirm the exact address and the availability of the services coverage
(i.e. Cheung Chau, from vending agency, particularly in mainland China.
Lamma Island or  Liaison with ward and vending agency to ensure sufficient O2
Mainland China) supplement be available on the way to home
 Inform the vending agency the approximate time of discharge, if
available; or, give the phone number of the agency to the patient for
self-arranging the equipment delivery once discharged home
.
Table 4 Special Considerations for Arranging Delivery of Home Oxygen Equipment

7.8 Monitoring and Follow Up

To ensure the continuity of care, a re-assessment is suggested. It is recommended that at
least one follow up (FU) service should be done within 3 months after commencing Home
Oxygen Therapy or after discharge from the hospital. In general, an outpatient FU session is
recommended except for those patients on Palliative Oxygen Therapy. Depending on
availability of resources, for patients with specific individual needs, an on-site visit can be
provided by i) the prescribing therapist, ii) the therapist within the respective hospital cluster, iii)
a community partner, or iv) the therapist of the residential care home. Telephone phone follow
up can be considered if clinic or home-based reassessment cannot be arranged due to
resources issues. Purpose of the FU and any additional aims for selected patient groups are
listed in Table 5. If resources allowed, a pre-discharge or early post-discharge (within 4 weeks)
FU for more complex cases is also encouraged. A checklist for follow-up visit, a record form
and sample of letter for reporting to case medical officer are listed in Annex 10, Annex 11 and
Annex 12 respectively for reference.

General Aim  To assure appropriate use and promote good compliance at home.
 Identify the non-compliance issues and potential risks of therapy
 To educate and train the patients and/or their caregivers to monitor
effective oxygen therapy at home.
 To initiate recommendations to case medical officers on regulating oxygen
dosage with respect to change in medical conditions

Special Aim For patients on STOT:

 To reassess patient’s progress and re-certify further need of oxygen
therapy.

For patient on Palliative Oxygen Therapy:

 To enhance comfort and facilitate care and adaptation at home
 To educate and train the patient and/or their caregivers to monitor
effective oxygen therapy at home, or work in cooperation with community
care support agency in monitoring through better documentation.

Additional aim subject  To reinforce the application of the learnt pulmonary rehabilitation skills in
to available resources daily activities in order to maximize patient’s functional level within the
of individual settings limit of pulmonary impairment.
 To improve quality of life.
 To screen cases for participation in pulmonary rehabilitation program and or
earlier medical FU.
 Factors to consider for prioritizing community services should include
depressive mood, malnutrition, being home-bound and at risk of anemia.

Table 5 Aims of Home Visit for Specific Patient Groups

7.9 Documentation
There should be a central register, either in the form of hard copies or soft copies, listing the
details of Home Oxygen Therapy equipment prescription done within each department for
record and audit purpose. The use of the Allied Health Discharge Summary to document the
Home Oxygen Therapy electronically is highly recommended for clinical handover and audit
purpose. Some of the documentation can be stored within each case’s respective file but
should be available when needed. The minimum, but essential, data to be captured include:
* Personal particulars: patient identity and contact means, caregivers (if any).
* Clinical information: diagnosis, blood gases, Desaturation Test (if any), smoking status
* Home Oxygen Therapy goal and regime.
* Dose Titration: oxygen flow-rate settings related to Rest, Sleep and Exertion (ADL
Oxygen Saturation Profile for different levels, if any).
* Details of the Home Oxygen Therapy equipment (such as model of oxygen
concentrator & oxygen conserving device, size and number of cylinder, etc.) and the
respective vending agency.
* Funding source (if any), Disability Assistance, CSSA supplement, Pneumoconiosis
funding, etc.
* Schedule of FU service by whom and when (optional).
* Copies of consent form and other documentation between MO and MSW, if any.

A sample of data entry record for Home Oxygen Therapy Registry and for e-documentation by
Allied Health Discharge Summary are attached in Annex 14 & 15.

8. Information for Patients & Professionals

The following notes are provided for use by clinicians in discussing home oxygen therapy with
patients. This information is not intended for direct distribution to patients but can be
incorporated into locally-produced patient information materials for use.

8.1 Oxygen Supply System

Oxygen Supply Features

System

Oxygen Oxygen concentrators (OC) are electrically powered units. Room air is supplied to the
Concentrator OC by an internal compressor. The molecular sieves remove nitrogen from filtered room
air and deliver high concentration of oxygen. Due to their cost-efficiency and reliability,
A low flow oxygen OC are the most commonly used stationary home oxygen delivery devices.
system, which
refers to device
supply oxygen at Points to note:
flows that are less
than the patient’s
 Most commonly used OC can deliver supplementary oxygen from 0.5L/min to 5L/min.
total inspiratory For patients who require higher flow-rate than usual, there are some models with 6, 8
demand, i.e. the or 10 liters flow available in the market.
delivered oxygen is  OC are able to deliver high concentration of oxygen, at or above 92% at flows 1 to 2
diluted with room L/min and 85% to 93% at 3 to 5 L/min (Wilkins, Stoller & Scanlan, 2003). When used
air. with patients receiving low-flow O2, OC are just as effective in raising blood O2 levels
as 100% cylinder gas (Wilkins et al., 2003).
 The room should be well ventilated with continuous supply of fresh air.
 The air entrance should not be obstructed.
 For proper maintenance of OC, frequent replacement of internal filters and regular
check-up of the devices are required to be performed by vending agency.

Portable Oxygen Utilized AC power, charged battery or automobile battery. Its portability may facilitate
Concentrator outdoor mobility and community integration, compliance to total usage hours and
(POC) enhance ability of some patients visiting their homeland in China or arranging air travel to
overseas (AARC, 2013).

Points to note:
 Due to advance in technology in recent decades, more compact and light-weight POC
models are now available in market. However, the market prices of POC are usually
more expensive than stationary OC and the rental services are also less readily
available locally.
 Some models may be capable of delivering both continuous flows and intermittent
flows while others may be capable of intermittent flows only. Some may have fixed
flow volume but others may be capable of delivering a series of flow volume allowing
adjustment by users upon different activity levels.
 Devices equipped with rechargeable external batteries will enhance the duration of
oxygen use outside home.
 Patients may have difficulty to trigger delivery of oxygen from pulse-dose devices.
The oxygenation levels of patients during activities while using intermittent flows of
oxygen may be less optimal than using continuous flows.
 Initial evaluation on a specific device using an accurate pulse oximeter to monitor
continuously on the oxygenation levels of a patient upon activities is recommended
before selection or purchase of equipment.
This printed copy may not be the most updated version. Please refer to the electronic version for confirmation if in doubt
Document No. HAHO-COC-GL-OCC-003-v03
Hospital Authority Head Office Issue Date 27/05/2019
Review Date 27/05/2022
Occupational Therapy Clinical Practice Guideline – Home
Oxygen Therapy for Adult Patients Page 48 of 92

 Assessment to establish that the device can meet the supplemental oxygenation
needs for a patient upon various activities of daily living is important.
 The oxygen requirements of a patient may change over time. If a patient is already on
a maximum setting of a POC, it may soon be inadequate for his daily use.
 POC is a more convenient respiratory device for air travel arrangement. In order to
comply with international air travel safety regulations, users are recommended to
check with local air carriers if a particular model of POC is allowed to board onto
aircraft. A list of FAA approved POC is outlined In following appendix, most current
updates can be assessed in the net:
https://www.faa.gov/about/initiatives/cabin_safety/portable_oxygen/

Portable Oxygen Inside the portable oxygen cylinders are the compressed gas. Some are having around
Cylinder 93% oxygen purity, but others reach at or above 99.6% as generated by different
methods. A regulator is needed for regulating pressure when gas is released from the
cylinder. The flow-rate can be adjusted by an adjustable regulator.

Points to note:
 They may be provided in steel or lightweight aluminum cylinders.
 The lightweight aluminum cylinders with different sizes, size B, C and D are more
commonly used for home oxygen therapy and are available from various vending
agencies in Hong Kong.
 The weight of filled-up cylinders ranges from 5 lbs to 8 lbs.
 The duration of oxygen supply of a particular cylinder depends on the size of the
cylinder and the flow-rate needed by the user. At 2L/min flow-rate, a full-filled C-size
cylinder will supply approximately 2-hour supplementary oxygen.

8.2 Oxygen Conserving Device

Oxygen Conserving Mechanism & Feature

Device (OCD)

Reservoir Cannulae Mechanism

 By adding to the anatomical reservoir; a 20ml of O2 is stored in the device
during exhalation and will be delivered at the early portion of the next
inspiration.
 The reservoir cannulae allow O2 savings up to 75%, which is dependent on
the individual’s breathing pattern and nasal anatomy (Wilkins et al., 2003).

Types
 Nasal oxymizer: the reservoir is on the face.
 Oxymizer pendant: the collection device is hanging in front of the chest wall,
where it can be hidden-up by clothing.
 The delivery efficacies of the two are roughly equivalent (ATS & ERS, 2004).

Disadvantage
 Need regular replacement, approximately every 3 weeks (Wilkins et al., 2003)
thus incur higher cost.
 Exhalation through pursed lips may impair performance as patients must
exhale through the nose to reopen or reset the reservoir membrane.
 The reservoir should be kept dry in order to maintain performance.

Demand Oxygen Delivery Mechanism

System  By delivering oxygen at the leading edge of inhalation and to avoid delivery
(DODS) during exhalation and dead-space inhalation.
 A sensor senses the beginning of inhalation by temperature or pressure
changes through the nasal cannulae and quickly delivers a bolus of oxygen.
 The degree of oxygen conservation is usually greater than 50% at rest.

Features
Pulse-type vs. Demand-type delivery system
 Pulse-type system: O2 is delivered in a short burst at the early inhalation and
it is shut off prior to the end of the inspiratory cycle. Therefore, more oxygen
is in the effective portion of the breath.
 Demand-type system: O2 is delivered throughout the entire inspiratory phase
of the breathing. Demand system flow-rates are not as high as with pulse
systems, so the volume of oxygen delivered per breath to alveoli is less.
Besides, the demand-type DODS may not be triggered if the patient
mouth-breathes (BTS, 2015).

Electronic vs. Pneumatic Sensors

 Electronic sensor: powered either by battery or by built-in rechargeable
batteries, providing visible and audible indicators for feedback of proper
operation.
 Pneumatic sensor: no batteries to replace; thus, the pneumatic unit can be
operated at various temperatures and conditions without the fear of failure.
Relatively lighter and quieter in operation.

Double lumen vs. Single Lumen.

 Different pneumatic conserving devices are designed to fit only double or
single lumen cannula.
 Double lumen: delivers oxygen on demand through one tube while inspiratory
effort is sensed through the other tube. The advantage of double lumen is the
entire breathing cycle can be continuously monitored.
 Single lumen: the advantage is the convenience of using the same single
oxygen cannulae with oxygen concentrators, thereby reducing costs.

8.3 Accessories

8.3.1 Oxygen Administration Device

The standard nasal cannula is the commonest oxygen administration device in use with Home
Oxygen Therapy. It allows patients to eat, talk and expectorate without discontinuing therapy.

O2 Administration Feature
Device

Nasal Cannula  delivers a maximal of 6L/min flow-rate, and an inspiratory oxygen fraction (FiO2)* of
24 – 40%, depending on the flow-rate through it (ATS & ETS, 2004)

Flow rate through FiO2 *

Nasal cannula
1 L/min 24%
2 L/min 28%
3 L/min 32%
4 L/min 36%
5 L/min 40%

 Various lengths of nasal cannula are available commercially, such as 7 feet, 16 feet,
25 feet, etc.
 Should be changed every 2 to 3 months due to the oxidation process.
 In case of skin irritation caused by prolonged wearing for some patients, the cheek
and ear can be protected by moleskin

Simple Oxygen  In case when patients find nasal cannula irritating to nostrils, a simple oxygen mask
Mask can be considered. In such cases, the flow settings may need to be reassessed.

Venturi Mask  NOT designed for use in conjunction with oxygen concentrator as it cannot generate
adequate flow-rate and gas pressure to drive the venturi system.
 It is used for high-flow demand patient as it delivers an exact FiO2 and is particularly
useful for tighter control of arterial blood gases especially when CO2 retention is
concerned.

Tracheostomy  For the tracheostomy cases, special home-use tracheostomy oxygen mask is
Oxygen Mask available commercially for connection to the oxygen concentrator. The flow settings
will need assessment.

* The FiO2 also affected by the respiratory pattern of the patient, such as rate of breathing, inspiratory time,
presence of mouth-open breathing, etc (Wilkins et al., 2003).

8.3.2 Extension Tubing

Extension tubing with various lengths can be attached to the nasal cannula with a connector to
achieve the desired length to be used at home. Maximum length of extension tubing,
depending on the maximum output pressure of the concentrator, is recommended not to be
longer than 40 feet. If flow-rate is less than 1 L/min, a shorter tubing in order to maintain a
more accurate flow-rate is recommended.

8.3.3 Humidifier
Humidifier is generally NOT recommended for use and should be replaced by the adapter
whenever possible. It is because the entrainment of ambient air supplies sufficient
humidification (TSANZ, 2014). There is actually no evidence showing that humidification is
necessary when oxygen is given by nasal cannulae at flows ≤ 4 L/min (AARC, 2002). Oxygen
is sometimes humidified to prevent drying effect of oxygen if delivered at high flow rates or in
patients with excessive chest secretions such as those with cystic fibrosis or bronchiectasis.
However, there is no evidence to support the use of continuous humidification and the effects
on patient comfort are negligible (BTS, 2015). Humidifier is also not indicated in use with
reservoir cannulae, as excess moisture can hinder proper action of the reservoir membrane
(Hoffman, 1994). One should also note that a major proportion of emergency calls made to our
local oxygen vending agencies are due to the insecure anchoring of the humidifiers to the
oxygen concentrators after water refill.

However, humidification is still essential for patients i) receiving high flow oxygen or oxygen
through tracheostomy even at low flow-rate, and/or ii) complaining mucosal dryness with
excessive or thick secretions when using supplemental oxygen (BTS, 2015). The aim is to
prevent over-dryness and building up of secretions. In case when humidifier is used, stringent
practice of infection control is recommended and refilling it with sterile water is preferred. The
water inside the humidifier should be replaced daily (Centre for Health Protection under
Department of Health, 2007b).

8.3.4 Carrying Devices for Oxygen Cylinder

For improving portability of oxygen cylinder and enhancing the compliance of Home Oxygen
Therapy during outdoor activities, carrying devices such as carrying bag, oxygen trolley,
shopping cart, rollator etc. can be introduced to the patients. Choices of device should be
made according to the need, functional level and the community environment of the patients.
The use of an oxygen trolley will save energy among patients with low residual exercise
capacity (Crisafulli et al., 2007).

8.4 Potential Hazard & Precautions

Potential Hazard Fact & Precaution

Oxygen Toxicity Oxygen toxicity is not commonly seen at the low flow-rate used for Home Oxygen
Therapy. Only a FiO2 of  50% for longer than 24 to 48 hours is associated with the
development of oxygen toxicity which leads to lung tissue damage (Wilkins et al.,
2003).

Carbon Dioxide Administration of low-flow oxygen resulting in hypercapnia and respiratory acidosis is
Retention rare. However, serious hypercapnia may occasionally develop especially during acute
exacerbation and in those who are generally more hypoxaemic. The development of
hypercapnia is suggested by an obvious decrease in respiratory rate and depth, as
well as the development of somnolence and disorientation (TSANZ, 2014)
Precautions
 The best practice is to titrate oxygen flow to maintain PaO2 at 8.0-8.6 kPa (60-65
mmHg), which can minimize the likelihood of hypercapnia and respiratory
acidosis (ATS & ETS, 2004).
 When hypercapnia is present, initial oxygen delivery settings should be titrated
using serial ABG assessments rather than relying solely on oximetry.

Fire Oxygen supports combustion and fires will burn faster and hotter than usual in an
oxygen-enriched environment. However, major accidents associated with oxygen
therapy are rare and can often be avoided.
Precautions
 Patients, family, and other caregivers must be strictly warned not to smoke (ATS
& ETS, 2004).
 Use of electrical or electromagnetic stove is much safer than gas stove.
 Oxygen should not be used in areas with combustible materials such as
petroleum products, oil, gasoline, grease, lotion and aerosol sprays. When
using lubricant at concerned facial areas, use only water-soluble lubricant.
 Regular checking is needed for proper functioning of washers/seals in various
regulators as leakage and build-up of oxygen may induce fire hazard (NIOSH &
FDA, 2006).
 Electrical appliances should be kept away from oxygen equipment to prevent
sparkling.

Explosion Explosion will only occur due to improper handling. Dropping and knocking of
cylinders should be avoided. Valves of regulators must be closed when not in use
Precautions
 All types of oxygen system should be stored in a well-ventilated environment to
prevent gas build-up
 Compressed gas cylinders should be secured in a stand or cart in vertical
position.
 Compressed gas cylinders must be stored at least 6 feet away from direct heat
origins such as direct sunlight, open flames, ovens, heater and radiators and
other sources of heat or flame (ATS & ETS, 2004).
Maximum storage of compressed gas in a household environment should be limited
to 2 cylinders (Fire Services Department, 2015).

Electrical
The electrical system should be able to support the oxygen concentrator. If possible,
a separate circuit for the oxygen concentrator and/or a back-up electricity supply
system is suggested.

Precautions
 Electrical cords should be inspected regularly to avoid fraying and should be
positioned properly to prevent tripping over of any person in the home
environment.
 Extension cords should also be avoided.

8.5 Cleansing and Maintenance:

According to the infection control guideline from the Association for Professionals in Infection
Control and Epidemiology (APIC, 2005), respiratory therapy equipment are regarded as
semi-critical devices which will need high-level disinfection. Apart from ensuring safety for the
patients, proper administration of maintenance procedures is also important for maintaining
optimal functioning of equipment. Besides, regular replacement of nasal cannulae and
humidifiers is also recommended to maintain optimal functioning of the accessories in time.
Furthermore, defective accessories should be replaced immediately.

Equipment Part Cleansing & Maintenance Procedure *

Nasal cannula / Daily:

Extension Tubing  clean the nasal area of the cannula with soapy water

Weekly:
 soak with 1:49 bleach* for at least 10 (preferably up to 30) minutes
 rinse thoroughly with sterile or cooled freshly boiled water#
 air-dry for use later

Every 2-3 month:

 replace the nasal cannulae & the extension tubing

O.C. air inlet filter Weekly:

(if any) rinse with water and dry thoroughly weekly (Wilkins, 2003)

Humidifier Daily:
(if any)  discard all liquid in humidifier
 wash the bottle in warm, soapy water
 rinse thoroughly with sterile or cooled freshly boiled water#
 fill in sterile water (minimal level to 1/2 full depending on the relative humidity at
indoor environment)

Weekly:
 wash the bottle in warm, soapy water
 soak with 1:49 bleach* for at least 10 (preferably up to 30) minutes
 rinse thoroughly with sterile or cooled freshly boiled water#
 fill in sterile water (minimal level to 1/2 full)

Half-yearly:
 replace with a new one

Exterior of the oxygen  Wipe with 1:49 bleach*

concentrator  Allow the solution to remain on the surface for 10 min, and then rinse off and dry.

With reference to various disinfection guidelines, including ATS (2005), APIC (2005), the Centre of Health
Protection (2015), WHO ( 2007) & recommendations from HA Chief Infection Control Officer (CICO) Office(2018).
* 1 part of household bleach containing 5.25% sodium hypochlorite with 49 parts of water
# If sterile water is not available, boiled water (after cooling down) can be used as an alternative

8.6 Using Oxygen in Air Flight

Air travel is generally safe for most patients with chronic respiratory diseases who are on
long-term oxygen therapy (GOLD, 2015). BTS (Ahmedzai et al., 2011) recommended that
those with the following conditions should be assessed with history and examination as a
minimum:
1. Previous air travel intolerance with significant respiratory symptoms (dyspnoea, chest
pain, confusion or syncope).
2. Severe COPD (FEV1 <30% predicted) or asthma.
3. Bullous lung disease.
4. Severe (vital capacity <1 litre) restrictive disease (including chest wall and respiratory
muscle disease), especially with hypoxaemia and/or hypercapnia.
5. Cystic fibrosis.
6. Comorbidity with conditions worsened by hypoxaemia (cerebrovascular disease,
cardiac disease or pulmonary hypertension).
7. Pulmonary tuberculosis.
8. Within 6 weeks of hospital discharge for acute respiratory illness.
9. Recent pneumothorax.
10. Risk of or previous venous thromboembolism.
11. Pre-existing requirement for oxygen, CPAP or ventilator support.
Contraindications to commercial air travel
1. Infectious tuberculosis.
2. Ongoing pneumothorax with persistent air leak.
3. Major haemoptysis.
4. Usual oxygen requirement at sea level at a flow rate exceeding 4 l/min.

Adjustment made according to the continuous monitoring by a reliable oximeter may be a

practical and more valid measure under the real situation. Regulations do not allow
passengers to provide their own compressed oxygen for use onboard aircraft. A few airlines
may allow patients to transport and use their portable oxygen concentrator. In arranging
oxygen supply for the flight, the airline company will request the patients to submit a
“Passenger Medical Clearance Form” completed by the case medical officer at least 72 hours
before departure. Example of the related forms can be downloaded at the airline company
websites. Passengers should be cautioned that those airlines that do provide oxygen usually
only do so in-flight. Therefore, a traveler cannot always count on having oxygen continuously
available from point of origin to destination. Most of the commercial airlines are only able to
provide oxygen at 4L/min at maximum, patients are recommended to check with respective
airlines before flying.

If users plan to use their own portable oxygen concentrator in flight, they need to write down
the specifications of the concentrator on the “Passenger Medical Clearance Form” for further
technical evaluation by the airline company. For the Federal Aviation Administration (FAA)
approved portable oxygen concentrator (POC) lists, please refer to “Annex 16: FAA approved
Portable Oxygen Concentrator – Positive Testing Results”. Usually, additional charges will not
be required. However, if portable oxygen from the airline company is arranged, additional
charges will be incurred. The POC is required to be self-powered using approved battery
packs. Passengers should bring batteries sufficient to power the device for at least 150% of
the expected maximum flight duration. Terminals of all spare lithium batteries placed in
carry-on baggage must be protected from short circuit by enclosing them in their original retail
packaging, or taping over the terminals, or placing each battery in a separate plastic bag.

9. Implementation & Audit

This document intends to describe a guideline for Occupational Therapy Services in the
assessment, equipment prescription, education and monitoring of Home Oxygen Therapy for
adult patients. The working group will recommend OTCOC members to conduct internal audit
in the future on:

i) the necessary hardware to facilitate patient education, and

ii) the compliance to the minimum data set in documentation.

The following aspects would be checked:

Department Set Up
 Updated information on the Home Oxygen Therapy systems, including different
oxygen supply systems, models and the cost of rental packages,
 Oxygen concentrators (at least 3 models), portable oxygen system with
conserving devices (at least 3 models) and accessories,
 Education package including, leaflet or booklet and audiovisual materials,
 At least one pulse oximeter, preferably with computer analysis software, for
continuous oximetry monitoring.

Operation Procedures
 As a mean to validate if the nine steps (refer to section 6) have been done, the
department should keep a minimum set of data (refer to section 6.9) in
hardcopies or electronic copies.

10. Development of the Guideline

The development of the guideline involved three phases i) a systematic literature review, ii)
preliminary drafts followed by internal review, and iii) external review with the use of the
AGREE instrument. The working group members declare no conflict of interest with any
oxygen vending agencies.

10.1 Systematic Review

Three sources of data were identified for locating relevant and updated information for drafting
the guideline.

1) Publications by Relevant Professional Bodies and two guideline databases, the National
Guideline Clearinghouse & Scottish Intercollegiate Guideline Network.
2) EBM reviews, (which include Cochrane Database of Systematic Reviews / ACP Journal
Club / Database of Abstract of Reviews of Effects / Cochrane Central Register of
Controlled Trials),
3) Entrez PubMed on the web: http://www.ncbi.nlm.nih.gov/sites/entrez.

For the 2nd & 3rd data source, the following keywords combinations are used [Oxygen
therapy AND (Home OR Domiciliary OR Long term OR Short term OR ambulatory OR
supplemental OR intermittent)], and limiting to 4 conditions i) human objects, ii) >19 year of
age, iii) published in past 10 years, and iv) English. Abstracts were first reviewed for their
relevance to the topic. Irrelevant papers, such as those on oxygen therapy for acute use,
hyperbaric oxygen therapy, etc. were excluded. Full content of those relevant papers was
retrieved for in-depth study to consolidate the major scientific content in the guideline.
Further information in the guideline is also supplemented with manual or electronic searches
for potential relevant materials.

There were 8 guidelines from professional bodies and 7 systematic reviews identified in the
first edition of this guideline. 463 abstracts were also initially reviewed and 135 relevant papers
were selected for detailed revision.

10.2 Drafting and Sorting Comments from Stake Holders

The draft was first prepared by three therapists with rich experience in conducting
Occupational Therapy Services in Home Oxygen Therapy, and then discussed in three
meetings together with representatives from each cluster of the Hong Kong Hospital Authority
which formed a working group. The meetings achieved to compromise principles, terminology,
minimum procedures to be undertaken by each potential setting, and to recommend
standardized documentations. The cluster representatives would brief the potential users
within their own cluster and collect relevant feedback for subsequent discussions.

A workshop focused on home oxygen therapy for adult patients was conducted to
occupational therapists practicing in the Hospital Authority (HA) and community settings with
frontline and administrative clinicians. A total of 68 occupational therapists had participated in
the workshop. Feedback were collected and the participants were invited to complete the
AGREE instrument (AGREE, 2001), developed by the AGREE Collaboration, as evaluation
and additional comment on the guideline. The AGREE Collaboration started in 1998 as a
research project ‘Appraising clinical guidelines' under the Biomedicine and Health Research
(BIOMED 2) Programme, funded by the European Union. The AGREE instrument is a generic
tool, and it intends to provide a framework for assessing the quality of clinical practice
guideline in any disease area including those for diagnosis, health promotion, treatment or
interventions. It covers 23 items from 6 domains, and each item is rated on a 4-point scale.
Domain Scores can be calculated by summing up all the scores of the individual items in a
domain and by standardizing the total as a percentage of the maximum possible score for that
domain. A higher score indicates a higher degree of agreement. A total of 41 AGREE
instruments were collected from the workshop participants, results are listed as follows:

Domain Score

1. Scope & Purpose 92.4%

2. Stakeholder Involvement 85.2%

3. Rigor of Development 87.9%

4. Clarity of Presentation 87.8%

5. Applicability 81.8%

6. Editorial Independence 87.8%

Table 6 Domain Scores from the Stake Holders in the AGREE Instrument

In the overall comments, 32 occupational therapists strongly recommended this guideline, 8

occupational therapists recommended the guideline with some provisions. Many of them
stated that this guideline was clear, specific and comprehensive.

10.3 External Validation

A group of specialists, composing of renowned clinicians from different disciplines as listed
below (according to alphabetical order of the surname; and the job titles were as in 2009),
were invited to evaluate the guideline and give comment.

 DR. CHAN Kin Sang, Consultant, Dept. of Medicine, HOHH

 MS. CHAN, Rebecca, Senior Occupational Therapist / Training Officer, HAHO
 DR. CHAN Wai Man, Johnny, Consultant, Medicine Dept., QEH
 DR. FONG Nai Kuen, Kenneth, Assistant Professor, Dept. of Rehabilitation Sciences,
HKPU
 DR. HO Kin Sang, Consultant, Family Medicine, Elderly Health Service, DH
 MR. IP Yee Chiu, DMOT (KCH) / Coordinator, Clinical Audit & Quality Assurance Group of
OTCOC
 MS. KWOK, Shirkey, Nursing Officer (Pneumoconiosis Rehabilitation Center), RHTSK
 DR. LAM Chak Wah, Consultant and Head of Department, Respiratory Medicine Dept.,
RHTSK
 DR. LAM Siu Pui, Senior Medical Officer, Dept. of Rehabilitation & Extended Care Unit,
WTSH
This printed copy may not be the most updated version. Please refer to the electronic version for confirmation if in doubt
Document No. HAHO-COC-GL-OCC-003-v03
Hospital Authority Head Office Issue Date 27/05/2019
Review Date 27/05/2022
Occupational Therapy Clinical Practice Guideline – Home
Oxygen Therapy for Adult Patients Page 60 of 92

 DR. MOK Yun Wing, Thomas, Consultant , Respiratory Medical Dept., KH

 DR. SIN Kit Man, Senior Medical Officer, Dept. of Medicine & Geriatrics, TMH
 MS. SO Siu Pin, Grace, Senior Occupational Therapist, Elderly Service, SWD
 DR. TAM Cheuk Yin, Consultant, Medicine & Geriatric Dept., TMH
 DR. WONG Mo Lin, Maureen, Consultant, Medicine & Geriatric Dept., CMC
 DR. WONG Poon Chuen, Consultant, Tuberculosis & Chest Medicine Unit, GH
 DR. YU Wai Cho, Consultant, Medicine & Geriatric Dept., PMH

The reviewers were also requested to investigate the quality of the guideline by means of the
AGREE instrument. 8 replies were obtained for the AGREE instrument, results are listed as
follows:

Domain Score

1. Scope & Purpose 93%

2. Stakeholder Involvement 77%

3. Rigor of Development 90%

4. Clarity of Presentation 94%

5. Applicability 79%

6. Editorial Independence 88%

Table 7 Domain Scores from the External Reviewers in the AGREE Instrument

Valuable comments were obtained from the reviewers and incorporated in the follow-up
revision of the guideline where appropriate. Regarding the overall comments, 7 out of 8
reviewers strongly recommended this guideline, whereas one of them recommended it with
some alterations required.

Moreover, the Service Development Committee and the Quality Assurance Committee of the
Coordinating Committee in Occupational Therapy, as well as the Allied Health Evidence
Based Center of HA were involved in monitoring the standard of the guideline.

The draft of this guideline was also forwarded to the Centre of Allied Health Evidence of the
University of South Australia for review twice during the development phase. Precious
recommendations were received in both occasions which had guided this Working Group a
step closer to quality health care in guideline development and implementation.

The involved parties in the development of this guideline were summarized in the following
diagram (Diagram 2).

External Independent Evaluation Consultant

Center of Allied Health Evidence

Guideline Development Team Stakeholder Reference Group

• Representatives from each of the 5 clusters • 16 Experts in Medicine, Nursing & Academic
• Representatives from settings of major • 43 Target users
caseload
• Mix of staff ranks (SOT, OTI, OTII)
Approval
• Expertise with EBP (trained in Biostatistics
& Epidemiology) Quality Assurance
Team of OTCOC

Drafting
(2 drafts prepared) Modification

Stakeholder Feedback

Diagram 2 Essential Parties in the Guideline Development.

10.4 Pilot Study of the Guideline

Pilot Study of the guideline was performed in five Occupational Therapy departments from
four hospital clusters of Hospital Authority during the year 2008 to assess its implement ability.
Home oxygen therapy prescriptions arranged from January to October were identified and
labeled according to the definitions of various Home Oxygen Therapy regimes. Consecutive
outcome measurements were recorded during the 3-month Home Oxygen Therapy follow-up
assessments. There was a total of 250 patients recruited for this pilot study. 50% of them were
excluded for the follow-up assessment as they were on Palliative Oxygen Therapy regime,
discharged to old aged homes, or with financial difficulty. Follow-up appointments were
scheduled for the remaining 50% (n=126). Eventually, 32% (n=40) of them defaulted follow-up
due to deaths, hospital admissions or refusals. A total of 86 patients (68%) completed the
follow-up assessments. After evaluation, 64% of them (n=55) stayed with the same oxygen
regimes. The other 36% of the total follow-up cases (n=31) had their regimes amended, in
which 7% (n= 6) could have their home oxygen therapy weaned off and 29% of them (n=25)
had their regimes changed differently. There were many recommendations for dosage
alterations observed during follow-up assessments, thorough analysis will be implemented in
the next coming audit. The results of this pilot study confirmed the applicability of the guideline
as well as a need for re-evaluation of the prescribed home oxygen regime, especially after
patients were discharged from hospital admission.

10.5 Updating the guideline

An EKG alert for automatic search every 3 months for any update literatures on related topic
was submitted to the EKG system of Hong Kong Hospital Authority. Related search results will
be issued to the COPD task group members regularly.

For the present revision, the search from PubMed database was adjusted to the following 4
conditions: i) humans, ii) "middle aged (45 plus years)", iii) published since 2000, and iv)
English language. The most updated search result was summarized in Table 8.

Data Source Result (as updated on 1 Sep 2015)

Publications by Relevant 14 Guidelines:

Professional Bodies and i. AARC Clinical Practice Guideline : Oxygen Therapy in the Home or
two Guideline Databases Alternate Site Health Care Facility – 2007 Revision & Updated
ii. AARC Clinical Practice Guideline : Oxygen Therapy for Adults in the
Acute Care Facility - 2002
iii. ACP, ACCP, ATS & ERS : Diagnosis and management of stable
chronic obstructive pulmonary disease: a clinical practice guideline
update (2011)
iv. ACP Clinical Practice Guideline: Diagnosis and Management of
Stable Chronic Obstructive Pulmonary Disease (2007)
v. American Thoracic Society & European Respiratory Society
Standards for the Diagnosis and management of Patients with
COPD (2004)
vi. BTS Guidelines for Home Oxygen Use in Adults (2015)
vii. BTS Guideline for emergency oxygen use in adult patients (2008)
viii. BTS: Clinical Component for the Home Oxygen Service in England
and Wales (2006)
ix. Global Initiative for Chronic Obstructive Lung Disease (2015)
x. Handbook of Internal Medicine, Hospital authority, Hong Kong
(2015)
xi. NHS Primary Care Commissioning : Home Oxygen Services -
Assessment & Review - Good Practice Guide (2011)
th
xii. Recommendations of the 6 Long-Term Oxygen Therapy
Consensus Conference (2006)
xiii. Recommendations of the 5th Oxygen Consensus Conference
(2000)
xiv. TSANZ: Adult Domiciliary Oxygen Therapy – Position Statement of
the Thoracic Society of Australia and New Zealand (2014)

EBM Reviews 7 systematic reviews:

i. Short-term Ambulatory Oxygen for COPD (Review) – CD004356
ii. Oxygen therapy in the pre-hospital setting for acute exacerbations
of COPD – CD005534
iii. Oxygen therapy for Cystic Fibrosis (Review) – CD003884
iv. Oxygen therapy during exercise training in COPD (Review) –
CD005372
v. Domiciliary oxygen for interstitial lung disease (Review) –
CD002883
vi. Domiciliary oxygen for COPD (Review) – CD001744
vii. Ambulatory oxygen for people with COPD who are not hypoxaemic
at rest (Review) – CD000238

PubMed From the 327 abstracts initially reviewed, 192 relevant papers were
selected, which includes regional reviews of practice and studies on the
compliance with the existing international guidelines:

Table 8 Summary of Search Result for Scientific Literature on Home Oxygen Therapy

10.6 Conclusion
This finalized guideline will be revised regularly or in view of any major amendment needed in
the content for keeping abreast with the evolving evidence. The COPD Working Group has put
much effort in developing this guideline with the aim to provide a framework for delivering
quality service for patients requiring home oxygen therapy. This framework is not created to
replace the current practice. However, the incorporation of this guideline of various extents in
different settings within the system of the Hospital Authority may induce minimal but significant
changes towards quality care in the service provided by Occupational Therapists.

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Terms
American Thoracic Society (2005) guideline stipulated
 “LTOT” for chronic hypoxaemia as well as for certain qualifiers such as exercise
desaturation, sleep desaturation not corrected by CPAP and lung disease with severe
dyspnea responding to oxygen.

British Thoracic Society (BTS, 2015) offered some definitions as follows:

 “Long term oxygen therapy (LTOT)” refers to the provision of oxygen therapy for
continuous use at home for patients with chronic hypoxaemia. Once started, this therapy is
likely to be life-long. LTOT is usually given for at least 15 hours daily; to include night time,
in view of the presence of worsening arterial hypoxaemia during sleep.
 “Ambulatory oxygen therapy” refers to the provision of oxygen therapy during exercise and
activities of daily living. Ambulatory oxygen therapy can be prescribed for patients on LTOT,
who are mobile and need to or can leave the home on a regular basis.
 “Short burst oxygen therapy” refers to the intermittent use of supplemental oxygen at home
usually for a period of about 10 to 20 minutes to relieve dyspnea. Yet, there is no adequate
evidence available for firm recommendations. It should also be differentiated from the
provision of continuous oxygen for exercise, which is termed ambulatory oxygen therapy.

Thoracic Society of Australia and New Zealand (TSANZ, 2014) uses other terms to define
the timing for oxygen therapy.
 “Continuous oxygen therapy” is long term continuous administration of oxygen for at least
15 hours a day. The recommendation is to use oxygen as many hours out of 24 as
possible.
 “Intermittent oxygen therapy” resembles ambulatory oxygen therapy as stated in other
international guidelines. It may be useful for improving exercise capacity, dyspnea and
quality of life, irrespective of absence of resting or exercise-induced hypoxaemia. It
may also be used to optimize the level of fitness of patients in rehabilitation programs or
before lung surgery. Symptomatic relief for terminal illnesses and emergency use for
severe asthma are other indications.

 “Nocturnal oxygen therapy” is indicated for patients whose oxygen saturation during sleep
falls below 88% for more than a third of the night or in the presence of hypoxia-related
consequences such as daytime somnolence, daytime hypercapnia, polycythaemia,
pulmonary hypertension or right heart failure. Hypoxaemia associated with sleep apnoea
should be distinguished.

In this guideline, the following terms are advocated and defined as follows:

1. Long Term Oxygen Therapy (LTOT) stands for long-term prescription of oxygen
therapy for use at home, and is determined upon stringent assessment procedures, e.g.
repeated blood gases review after the medical condition of the COPD patients have
been optimally treated, over-night oximetry, etc (refer to the following chapters). Once
started, LTOT should be considered as a lifetime commitment. As stipulated by
international guidelines (ATS & ERS, 2004), the standard for administration of LTOT
should be continuous with ambulatory capability. For the ambulatory clients, both
stationary and mobile units of oxygen delivery systems are required. The duration of
use in a day can be short or long, and the following terms are also recommended, in
addition to LTOT, for describing the duration of use: continuous use (e.g. >15 to 24 hrs),
ambulatory/exertional use or nocturnal use.

1. Palliative Oxygen Therapy (BTS, 2015) refers to the use of oxygen to relieve the
sensation of refractory persistent breathlessness in advanced disease or life-limiting
illness irrespective of underlying pathology where all reversible causes have been or
are being treated optimally. In the present guideline, this therapy may on occasion be
considered by specialist teams for non-hypoxaemic patients who use oxygen therapy
solely for symptomatic relief of intractable breathlessness unresponsive to all other
modalities of treatment, despite it is not generally recommended. This palliative
usage may be as-needed or continuous, according to patient’s need.

2. Short Term Oxygen Therapy (STOT) refers to prescription of Home Oxygen Therapy
to patients who, at the time of discharge from hospital, demonstrate i) consistent
desaturation, ii) reliance on oxygen therapy, but do not fulfill the stringent assessment
criteria for LTOT in Danish guideline (Ringbaek, 2006). After receiving Home Oxygen
Therapy for 1-3 months, these STOT cases worth comprehensive reviews for
evaluation of a need for upgrading to LTOT or terminating therapy.

Annex 1 Working Group Members

Chan Lap Chi, Lewina Ruttonjee and Tang Shiu Kin Hospitals
Cheung Hoo Ming, Sammy Tuen Mun Hospital
Chu Wai Yu, Aileen Princess Margaret Hospital
Leung Kwan Lok Grantham Hospital
Leung Sze Nok, Frank Pamela Youde Nethersole Eastern Hospital
So Chi Tao** Kowloon Hospital
Wu Sze Wai, Nonnie United Christian Hospital

** Coordinator for reviewing the guideline and preparing the latest version

Annex 2 ADL METs Levels

Metabolic Simulated ADL *Actual ADL Task

Equivalent Functional Task
(MET) Level

1-2 METs Sit  Stand Bed mobility, bed  chair transfer

Transfers Sitting: talking, eating & grooming.
Standing quietly for < 5-minute

2-4 METs Indoor Mobility, OR Dressing & undressing, indoor level

Lifting Objects ground walking (slow to moderate

pace), toileting (for urination),
sponge bath or doing light
housework; e.g. making a bed,
sweeping floor, vacuuming,
preparing simple meal.

4 - 6 METs Carrying Objects Standing hot shower, walking

(moderate pace) with grocery-
carrying (~15lbs), walking upstairs
or doing heavy housework.

 6 MET Transferring Objects Carrying groceries upstair(> 16lbs),

walking uphill, moving heavy
furniture, jogging or running.

Reference: Kaminsky et al., 2006; Reed, 2001 & Neistadt & Crepeau, 1998.

Annex 3 Desaturation Test

______________ Hospital
Occupational Therapy Department
Desaturation Test
A). On Room Air Resting Pulse (P):____ (* Max.: _____)
Simulated ADL Task
METs SpO2 Pulse Dyspnea Recovery Participation
(Actual ADL Task, if a/v)
----- Resting ------- -------
1-2 Sit <=> Stand Transfer /
( )
2-4 Indoor Mobility / Lifting /
( )
4-6 Carrying Objects /
( )
6-8 Transferring Objects /
( )
* Maximum tolerable pulse rate = (220 – age - P) x 70% + P
B). On Supplementary O2: ____ LPM
Simulated ADL Task
METs SpO2 Pulse Dyspnea Recovery Participation
(Actual ADL Task, if a/v)
----- Resting ------- -------

1-2 Sit <=> Stand Transfer /

( )
2-4 Indoor Mobility / Lifting /
( )
4-6 Carrying Objects /
( )
6-8 Transferring Objects /
( )
C). On Supplementary O2: ____ LPM
Simulated ADL Task
METs SpO2 Pulse Dyspnea Recovery Participation
(Actual ADL Task, if a/v)
----- Resting ------- -------

1-2 Sit <=> Stand Transfer /

( )
2-4 Indoor Mobility / Lifting /
( )
4-6 Carrying Objects /
( )
6-8 Transferring Objects /
( )
Remarks: _________________________________________________________________

Therapist: ___ Date of Assessment: _

Annex 3a Monitored Functional Task Evaluation

1 2 3 4 5
Indoor
Task Lifting 3kg Stepping Carrying 6kg Sit<=>Stand
Mobility
2 mins completed yes / no yes / no yes / no Yes / no yes / no
Duration ：：：：：
Number / 2 mins
Pace even / rush even / rush even / rush even / rush even / rush
RPD / RPE / RPT / / / / / / / / / /
Recovery 2 mins / 2 mins / 2 mins / 2 mins / 2 mins /
SpO2 % % % % %
Pulse Rate
Marks
Overall Result:
Max Dyspnea: / 10 ; Max Exertion: /10 ; Max Tiredness: /10 ; Total MFTE marks: /20
At RA/ L min-1, SpO2 desat. range: % %; Oxygen Desaturation: heavy / moderate / mild / nil

ADL Checklist Premorbid ADL level : (Marks ); Present ADL level : (Marks )
ADL level Activity Premorbid Present Marks
resting on chair / watching TV
1
Level 1 feeding
grooming (e.g. wringing towel / shaving)
2
managing bowel
transfers to / from bed
3
Level 2 dressing garments
dressing shoes / socks
4
indoor mobility
bathing (shower / basin / bathtub)
5
Level 3 washing hair
simple households (e.g. washing utensils)
6
simple cooking (e.g. rice-cooker)
walking up one flight of stairs
7
Level 4 strolling for 20 mins
complex households (e.g. bedmaking)
8
complex cooking (e.g. frying)
laundry / ironing
9
Level 5 shopping (carrying 61bs for 15 mins)
public transport (taxi / bus) by self
10
heavy households (e.g. mopping floor)

Annex 4 ADL Oxygen Saturation Profile

______________ Hospital
Occupational Therapy Department
ADL Oxygen Saturation Profile

THERAPY REGIME:
 LTOT - Continuous Use  LTOT - Exertional Use

 STOT - Continuous Use  STOT - Exertional Use

A). Resting Oxygen Dosage recommended by medical officer: __________ LPM
B). ADL Assessment Resting Pulse (P):____ (* Max.: _____)
(i). Moderate Exertion Level ADL Task ( 2 to 4 METs):
Supplementar Resting Post Pulse Dyspnea Recovery Independency Remarks
y Oxygen SpO2 SpO2

LPM % % I/S/A
LPM % % I/S/A
LPM % % I/S/A
(ii). Heavy Exertion Level ADL Task ( 4 to ___ METs ):
LPM % % I/S/A
LPM % % I/S/A
LPM % % I/S/A
* Maximum tolerable pulse rate = (220 – age - P) x 70% + P

ADL Oxygen Dosage & Recommendation

(i). Recommended amount of supplementary oxygen in ADLs:

ADL Activity Level Supplementary Oxygen Need

Moderate LPM

Heavy LPM
(ii). Patient is able to tolerate ADL task independently up to ____________ METs level.
C). Sleeping Oxygen Dosage: _________ LPM (overnight oximetry:  yes /  no)
Remarks: _________________________________________________________________
Therapist: _________________ Date of Assessment: ______________

Annex 5 Oxygen Usage Instruction

___________醫院
職業治療部

日常生活氧氣治療指引

姓名: _ 日期: _

活動度數
睡覺時
(包括小睡，例如:午睡)

休息及輕巧的活動:
例如:談話、進食、梳洗(坐著進
行)、看電視或文書工作。

中量的活動:
例如:穿衫褲、如廁、在屋內行
走或做輕巧家務---收摺床被、掃
地、吸塵、煮飯(簡單無火煮食)。
繁重的活動:
例如:沖涼、購物、手提物件、
行上樓梯/斜坡或做繁重家務---
抹地、洗晾衣服(大件衣物)。

註: 如感到不適，請勿自行調高氧氣度數，應儘快向醫生求診。

_____________ Hospital
Occupational Therapy Department

Oxygen Usage Instruction

Name: _____________________ Date: __________________
Activity Flow
Rate

Sleeping (includes nap)

Resting and Light Activity:

such as - talking, eating, grooming
(perform whilst sitting), watching TV or
desk work.

Moderate Activity:
such as - Dressing, toileting, walking
around your own home or doing light
housework, e.g. making a bed, sweeping
floor, vacuuming, preparing simple meal
(no-flame).

Heavy Activity:
such as - Standing shower, shopping
with grocery-carrying, walking
upstairs/uphill or doing heavy
housework, e.g. scrubbing floors,
washing & hanging heavy clothes.

Remark: Please seek advice from physician if increase distress.

Annex 6 Order Consent Form

醫院職業治療部
租用或購買家居氧氣治療設備同意書

病人姓名: ____________________ 香港身份証號碼： ( )

*本人 / 下方簽署人自決選用以下供應公司之家居氧氣治療設備。職業治療師已向

*本人 / 下方簽署人講解有關氧氣設備的用處，及已提供有同類設備之供應公司的資料。
在簽署此同意書之前，*本人 / 下方簽署人已經詳閱此同意書，並明白是項交易並沒有
為職業治療部及其職員帶來任何直接或間接的利益。在有需要時，*本人 / 下方簽署人同
意職業治療部可把以上病人的個人資料及下述資料發放予供應公司，以作訂送氧氣治療
設備的安排。

現選用以下氧氣治療設備:
供應公司:
聯絡電話:
配套:
 製氧機型號
 氧氣樽類型 (x 數量)
 省氧頭型號
 氧氣樽直流錶頭

姓名簽署

病人或家人:
與病人關係: (聯絡電話: )

職業治療師:
日期: / /

備註：
1. 家居氧氣治療設備之價格乃由供應公司所定，任何價格的轉變，概與本職業治療部無
關，本部門亦不會個別通知。
2. 本職業治療部並不處理任何金錢來往。
3. 本職業治療部只提供對氧氣設備的資料及聯絡供應公司有關之安排；而所選設備的質
素、保養、維修及其他服務均由供應公司負責。
*請刪去不適用部份

Hospital
Occupational Therapy Department
Order Consent Form for Home Oxygen Therapy Equipment
Patient’s name: HKID: ( )

I, *the above-named patient / undersigned person, hereby agree to select the vending agency below
for the ordering of home oxygen therapy equipment. The Occupational Therapist has explained the
arrangement for the home oxygen therapy equipment and has provided the information about other
vending agencies with the same type home oxygen therapy equipment. Before I sign this order consent
form, I have read this consent form thoroughly and I understand that this arrangement does not have
any direct or indirect benefit to the Occupational Therapy Department and its staff in this hospital. I
agree to the release of the personal data of the above-named patient and the below information to the
vending agency in respect of the home oxygen therapy equipment ordering and delivery arrangement.

Selected Home Oxygen Therapy Equipment:

Vending Agency:
Tel:
Equipment:
 Oxygen Concentrator Model:
 Oxygen Cylinder Size (& Quantity):
 Oxygen Conserving Device Model:
 Oxygen Regulator

Full Name Signature

Patient or Representative:
Relationship: (Tel: )

Occupational Therapist:
Date: / /

Remarks:
1. The price of the home oxygen therapy equipment is set by the vending agency. Any price change is
not related to our Occupational Therapy Department and we will not give any notice.
2. Our Occupational Therapy Department will not involve with any money dealings.
3. Our Occupational Therapy Department will only provide information on the home oxygen therapy
equipment and contact the vending agency for the equipment arrangement. The vending agency
shall undertake to ensure the quality and to provide all the necessary maintenance, repair & other
service of the selected equipment.

*Please delete where inappropriate

Annex 7 MEMO to MSW for Application of CSSA Supplement

MEMO

To : Medical Social Worker,

From : Occupational Therapist, __________________ Hospital
Tel :
Fax :
Date :

Re : Application for Financial Assistance for Home Oxygen Therapy

Name:

I.D.No.: Patient’s Gum Label

Ward/Bed:

This is to certify that the above-named patient with the diagnosis of , needs
Home Oxygen Therapy. To facilitate patient’s rehabilitation, oxygen therapy device(s) is/are
recommended for long-term use. As the above-named is a CSSA recipient, please kindly render any
necessary financial assistance to him / her on the following items: -
 (1) monthly rent for Home Oxygen Concentrator with accessories
 (2) monthly rent for Portable Oxygen Device, oxygen cylinder refill-fee and
accessories
 (3) one-off expense for oxygen cylinder trolley

The above oxygen devices were installed / revised on . Quotation is attached for
your reference. Kindly note that the accessories including nasal cannula / oxygen mask, connection
tubing, tubing connector, humidifier, sterile water or dust filter as well as the oxygen cylinder refill needs
periodic replacement and reimbursement. Consumption of oxygen cylinders will be varied due to
changing weather or fluctuating shortness of breath symptom. Occupational Therapy follow-up
service may need to be arranged to ensure correct operation and use of devices. Kindly also endorse
the necessary expenses on this service, if being provided by non-government or non-HA agencies.

Should you have query, please feel free to contact me for further information.
With
Dept. Chop

OT Signature: Endorsed by : Dr.

Name in Full: ( ) Name in Full: ( )
Occupational Therapist Case Medical Officer
Unit: Ward ____ / SOPD: - _________

Annex 8 Application for Pneumoconiosis Funding

To : Pneumoconiosis Compensation Fund Board (Tel: 25410032, Fax: 25410211)

Date :

Reimbursement of Medical Appliance Expenses

Pneumoconiosis Compensation Scheme

The above named patient was admitted to our hospital from ________
to ____ because of the suffering from which is
related to Pneumoconiosis and/or Mesothelioma.
We recommend this patient to use LTOT - Oxygen Concentrator / Portable Oxygen Cylinder /
Conserving Device / Trolley) at a flow rate of _________ litre per minute and/or Rechargable
Portable Oxygen Concentrator (POC) – Model: AirSep Freestyle, AirSep Focus, Philips Simply
Go, Others: _______________ / Manual Wheelchair (Please provide 3 quotations by OT/PT) /
*Electrical Wheelchair – Model: Invacare Nutron R51LXP-16, Others: __________________.
Please arrange the selected items to the above named patient.

Signature : ____________________________
Name : Doctor. ______________________
Post : Medical Office
Department/Ward : ____________________________
Hospital : ____________________________
Contact No. : ____________________________
OT/PT tel. no. : ____________________________

Remarks
* Please circle above items whichever is/are appropriate
* Original letter should be sent to our Pneumoconiosis Compensation Fund Board for approval. Correspondence
address: 15/F, 148 Nam Wo Hong Building, Sheung Wan, HK – Compensation Department. To speed up the
application process, please also fax this letter to 2541 0211 before mailing.

Annex 9 Checklist for Patient Education in Home Oxygen Therapy

Essential Points

 1. Reason for prescription & condition requiring home oxygen therapy as

Continuous and/or Ambulatory / Exertional Use.

 2. Explanation of requirements for taking continuous use for the right period of
time (at least 15 hours daily).

 3. Education on the principles of Ambulatory / Exertional Use, in relation to

individual needs.

 4. Explanation of the principles of the oxygen concentrator and/or portable

oxygen equipment.

 5. Assessment on the need of back up cylinder for the concentrator.

 6. Assessment on the home environment with respect to installation and

storage of home oxygen equipment; stress on the need of an electricity
socket solely for use by the concentrator.

 7. Explanation on the financial involvement (i.e. rental fee, oxygen cylinder refill
fee and electricity cost) & reimbursement procedure if indicated.

 8. Demonstration of refilling and maintenance of portable equipment.

 9. Explanation of cleansing & disinfection methods and maintenance schedule

for the home oxygen equipment accessories.

 10. Warning about the dangers of cigarette smoking and open-flame in the
presence of home oxygen equipment.

 11. Provision of contact telephone numbers of the oxygen vending agency as

well as the therapist that of in case of emergency breakdowns and other
problems.

 12. Advice on travel with oxygen therapy.

Annex 10 Checklist for Follow-Up of Patients on Home Oxygen Therapy

Area Description of Assessment Possible Management if Problems

Identified

Health No. of hospital admission(s) since discharge If exacerbation with increased SOB &
Condition or last follow-up, especially for respiratory greenish or yellowish sputum, early follow up
problems. or admission may be considered. May assist
Alertness, nutritional status, dyspnea, cough, patient to call for an earliest F/U appointment
sputum and other significant respiratory or arrange A&E admission if appropriate.
symptoms. General counseling and education for
Smoking status smoking cessation or referral to professional
intervention
ADL Function ADL status in order to record the ADL Level, Adjust flow-rate if desaturation noted at rest
if applicable. or exertion.
Reassess ADL O2 Saturation Profile with Instruct the patient & the caregivers (issue a
life-role activities, including resting, indoor revised “Oxygen Usage Instruction”, if
mobility, dressing or grooming tasks and/or applicable).
outdoor strolling to park with portable Suggest home program if indicated. After
oxygen. analyzing demand on daily activities and role
expectation, relevant pulmonary
rehabilitation skills will be educated, such as
Coordinated Breathing Pattern in ADL,
Energy Conservation Techniques, Panic
Control Skills, Relaxation Techniques,
Conditioning Activities, etc.

Compliance to Compliance on prescribed time and the Reinforce patient to have a good compliance
Home Oxygen flow-rate on resting, nocturnal, exertional & with home oxygen (referred to the prescribed
Therapy outdoor activities (referred to the ADL O2 minimum recommended daily usage hours
Saturation Profile, if applicable). for continuous use cases)
Total oxygen usage hours, built-in hour If indicated, prescribe and teach the use of
counter of O2 concentrator or some assistive device for reducing energy
sophisticated service tracking system, expenditure.
whichever that is available. Reinforce the safety precautions.
Number of cylinders used per month by
patient in order to better estimate portable
oxygen compliance and outdoor activities
frequency.

Management Patient’s ability to operate Home Oxygen Demonstration & return demonstration to
of Home Therapy equipment and their accessories. reinforce proper techniques.
Oxygen Check the cleanliness of filter, adapter / Stress on the importance of routine
Therapy humidifier, nasal cannula & extension tubing. cleansing & disinfection procedure.
Equipment Patients’ ability to call the vending agency for Stress on the importance of NOT smoking.
help in necessary conditions.
Patients’ the ability of urgent arrangement for
sudden lack of electricity.
Safety precautions regarding use of oxygen
equipment.

Service Record any change of concentrator and Liaise with vending agency if quality of
Quality of conserving device model and the size of service is deficient or change agency if
Home Oxygen oxygen cylinder. necessary.
Therapy Quality of maintenance service by vending
Vending agency e.g. frequency of regular check, time
Agency of refill oxygen cylinder, and reaction of
emergency call, etc.
Check for purity and accuracy of flow from
concentrator, if indicated.

Environmental Specially examine architectural construction Advise proper set-up of Home Oxygen
Assessment and identify barriers that hinder the usage of Therapy equipment. Patient should
home oxygen and the ADL independence at demonstrate understanding and keep the
home. concentrator in a well-ventilated area.
Check adequate illumination & ventilation of Provide advice on home adaptation or
home environment for the oxygen modification and examine the need and
concentrator. possibility of rearrangement furniture,
installing or use adaptive devices to improve
patient’s ADL performance.
Suggest and assess possibility of arranging
special electrical supply for home oxygen
therapy from the power company.
For patients in OAH, liaise with OAH staff to
facilitate convenience in usage, as needed.

Infection Control Measures for On-site Follow-Up

i. Stringent perform hand hygiene (washing hand or using hand rub) is the first line of
infection control measure.
ii. Beware of patient’s fever, impending respiratory signs and symptoms. Wear
disposable gloves and surgical mask if necessary. Dispose the gloves and perform
hand hygiene immediately after contact patient or his/her surroundings.
iii. Bring along with you a disposable gown and plastic bag. Put on the gown if your
patient presents with respiratory symptoms. Dispose the gown properly afterwards.
iv. If you wear only your own clothes during the follow-up, you should change
and wash your own clothes immediately after returning home.
v. Bring along with you some disposable masks. Ask your patient to wear a mask if
he/she presents with respiratory symptoms.
vi. If possible, bring along with you alcohol swab to wipe the instruments before and after
using them for each patient.

Annex 11 Home Oxygen Therapy Follow-up Record Sheet

______________ Hospital
Occupational Therapy Department
Home Oxygen Therapy Follow-up

Date of FU: _________ FU Status:1st / _ (COT / SOPD / _____)

Family Member / Caregiver Present: ________________________________________

(A) Home Environment (for initial visit or change of environment only)

Living with: □ relative ______ / maid □ lives alone □ NOT daytime alone □daytime alone
Type of home: □ public housing □ private / rent (flat/room) □ other: _________________
Accessibility: □ lift-landing □ non lift-landing □ FOS ______ □ slope □ other: _______
Bathroom: □ bath-tub □ shower cubicle □ shower area □ basin/bucket □ water heater
Bathing Posture: □ standing, □ sitting □ squatting
Location of OC: □ living room □ bedroom □ other:__________ □ not fixed: __________
Ventilation: □ satisfactory □ fair □ poor
Lighting: □ satisfactory □ fair □ poor
Financial Support: □ nil □ DA □ CSSA □ Silicosis Compensation □ other:__________
Smoking Status: current smoking □ No □ Yes _____, passive smoking: □ No □ Yes ____

(B) Present Functioning

BADL: □ independent: feed, groom, dress, toilet, bath
□assisted: feed, groom, dress, toilet, bath □ dependent
IADL: □ independent:_____________ □assisted:______________ □ dependent
Leisure: □ strolling/ex. □ morning tea □ community ctr. □ other: ________________
Mobility:□ bed bound □chair bound □ home bound □ domestic walker □ community walker
□ unaided □ stick □ quad □ frame □ supervision □assisted
Sleeping Pattern: □ satisfactory □ average □ disturbed

(C) Home Oxygen Compliance

* Average daily oxygen usage: _____ hours/day
ADL compliance: □ sleeping ____ LPM □ grooming ___ LPM □ dressing ___ LPM
□ toileting _____ LPM □ bathing _____ LPM □ IADL ____ LPM ______________
□ outdoor: frequency ____ hrs/ ___ day/week, ___ LPM, ______________________

Remarks: ______________________________________________________________
_______________________________________________________________________

(D) Home Oxygen Therapy Equipment and Supplier Service

 Same as last prescribed, supplier: Period :________

 Changed, reason: ___________________________________________________
Supplier: _________, OC model: ___________, OCD (if any) : _______________
Regular check from supplier: □ No □ Yes (Last maintenance record date: _________ )
Comment about services provided by the supplier:
□ satisfactory □ average □ unsatisfactory (reason: ______________________ )

(E) ADL Techniques in Home Oxygen Therapy

Techniques Items Comment Intervention
Oxygen Operation of O2 concentrator
Equipment Operation of Portable O2
Management Accessibility of nasal cannula
Safety Measure
Maintenance NC & extension tube
Air Filter (if any)
Bubble Humidifier (if any)
Home Program Coordinated Breathing in ADL
(if applicable) Energy Conservation
Techniques
Panic Control Skills
Other:

(F) ADL O2 Saturation Profile Re-assessment

Dose Resting and

Recommendation: Light Exertion Moderate Exertion Heavy Exertion

Last Prescribed LPM LPM LPM

After Re-assessed LPM LPM LPM

Remarks: _____________________________________________________________

(G) Further Management

□ Further FU is necessary □ Case closed

Next medical FU date: ________ SOPD (_)/Chest Clinic/GOPD/__________

Memo to MO given: □ Yes □ No (Reason: _________________________________)

Change of dose recommended: □dose increased □dose decreased □no change

Change of HOT regime suggested: □yes (__________________________) □ no

Other Recommendation: _________________________________________________

Annex 12 Report to Medical Officers

Report to case M.O. for patient’s progress and need of flow-rate titration and request
for reconfirmation of flow-rate adjustment if able. The content of report includes the
followings, and a sample is enclosed in Annex 13.

 patient’s general condition and presence / absence of respiratory signs and

symptoms
 the optimal flow settings at rest, during sleep and on exertional activities
 oxygen compliance and oxygen therapy hours/day
 specific assessment result
 chart patients’ progress with “Home Oxygen Therapy Follow-up” form
 patient’s functional level or activity level
 any further follow-up session required
 specific recommendation may be given for further investigation or decision by
medical officer. E.g. “Repeating ABG” for patient with significant deteriorated or
improved condition, or “Termination of Home Oxygen Therapy” for medical officer
considering termination for those STOT cases without hypoxaemia condition in
re-assessment, etc.

Further liaison for continuous care may be indicated. This may include:

 Inform MSW or field worker of SWD, whoever applicable, with updated quotation, if
necessary, when patients are on social funding in support of home oxygen therapy.
If rental package need to be changed, arrange for the patient. Sample of MEMO is
enclosed in Annex 7.
 Identify support network available in patient’s community and liaise with appropriate
community services for needed patients.
 May recruit or refer suitable case for PRP according to practices of individual
hospitals.

Annex 13 Home Oxygen Therapy Report

Home Visit Report for Patient M.O.’s COPY / O.T.’s COPY

The above-named patient is a known case of COPD / Bronchiectasis / ____ who
From : Occupational Therapist To : Case Medical Officer
Hospital
Tel : :
Fax : :
Date :
has been receiving home oxygen therapy since _____________.
A follow-up domiciliary visit has been conducted with the following results obtained:

O2 Devices used: □ Oxygen Concentrator □ Portable O2 – regulator / conserving device

Flow-rate (LPM) Usage (  )
At At On moderate / Continuou Nocturnal Ambulatory /
rest sleep heavy exertion s Exertion
Prescribed
Regime
O2
Compliance
Daily oxygen usage: ___________ hours per day
ADL Assessment:
□ Basic ADL and outdoor activities independent
□ Basic ADL and outdoor activities with supervision / assistance
□ Basic ADL independent but homebound
□ Basic ADL partially dependent, assistance needed in bathing /__________________.
□ Basic ADL dependent (chair-bound / bed-bound)
Modified MRC Dyspnea Scale: Grade _______________
Assessment RA: SpO2/pulse SOB __ L O2: SOB level __ L O2: SpO2/pulse SOB level
Tasks level SpO2/pulse
At rest / / /
/ / /
/ / /
REMARKS:

Recommendation:
___________________
(Occupational Therapist)

MEDICAL OFFICER’ S REMARKS: Date: __________________

____________________
(Medical Officer)

Annex 14 Home Oxygen Therapy Data Entry Sample Record Form

Annex 15 Allied Health Discharge Summary

Annex 16 FAA approved Portable Oxygen Concentrator

– Positive Testing Results

Positive Testing Results (as in Oct 2015):

•AirSep FreeStyle
•AirSep LifeStyle
•AirSep Focus
•AirSep Freestyle 5
•(Caire) SeQual eQuinox / Oxywell (model 4000)
•Delphi RS-00400 / Oxus RS-00400
•DeVilbiss Healthcare iGo
•Inogen One
•Inogen One G2
•lnogen One G3
•lnova Labs LifeChoice Activox
•International Biophysics LifeChoice / lnova Labs LifeChoice
•Invacare XPO2 / XPO100
•Invacare Solo 2
•Oxylife Independence Oxygen Concentrator
•Precision Medical EasyPulse
•Respironics EverGo
•Respironics SimplyGo
•Sequal Eclipse
•SeQual SAROS
•VBox Trooper

This printed copy may not be the most updated version. Please refer to the electronic version for confirmation if in doubt

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Occupational Therapy Clinical Practice Guideline - Home Oxygen Therapy For Adult Patients - 3

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Occupational Therapy Clinical Practice Guideline - Home Oxygen Therapy For Adult Patients - 3

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Document No.

Occupational Therapy Clinical Practice Guideline -

Home Oxygen Therapy for Adult Patients

Version Effective Date

Document Number HAHO-COC-GL-OCC-003-v03

The Hospital Authority Coordinating Committee-Grade in Occupational Therapy would like

DR. CHAN Kin Sang, Consultant, Dept. of Medicine, HOHH

MS. CHAN, Rebecca, Senior Occupational Therapist / Training Officer, HAHO

DR. CHAN Wai Man, Johnny, Consultant, Medicine Dept., QEH

MR. IP Yee Chiu, Department Manager (Occupational Therapy), KCH / Coordinator,

MS. KWOK, Shirkey, Nursing Officer (Pneumoconiosis Rehabilitation Center), RHTSK

DR. MOK Yun Wing, Thomas, Consultant, Respiratory Medical Dept., KH

DR. YU Wai Cho, Consultant, Medicine & Geriatric Dept., PMH

(The job titles and postings were as in 2009.)

DR. CHAN Kin Sang, Consultant, Dept. of Medicine, HOHH

DR. CHOO Kah Lin, Consultant, Dept. of Medicine, NDH

DR. MOK Yun Wing, Thomas, Consultant, Respiratory Medical Dept., KH

 Consolidate a standard of practice based on the best available evidences at the

The COPD Working Group of the Hospital Authority Coordinating Committee-Grade in

 More precise therapy regime identification (LTOT - Continuous Use,

Key to Evidence Statements and Grade of Recommendations

1- Meta-analyses, systematic reviews, or RCTs with a high risk of bias

High quality systematic reviews of case control or cohort studies

B population, and demonstrating overall consistency of results; or

C population, and demonstrating overall consistency of results; or

1. Executive Summary .................................................................................................... 10

7. Recommended Procedures for Professionals ...................................................... 38

Eligible Patient Oxygen Therapy Principal Therapy

5. Patients with malignancy or terminal diseases in Palliative Oxygen  Relieve symptoms

Table 1 Eligible Patient, Respective Regime and Treatment Goals

Box 1 Desaturation Test

Scenario Flow Setting principles

․ SpO2 is recommended to be >90% during rest with minimal oxygen flow-rate.

․ SpO2 is recommended to be targeted at >90% during sleep.

․ In general, patients with resting SpO2 ≤ 95% or exertional desaturation should

Table 2 Summary of Flow Setting for Different Scenario

1. Validating the appropriate patients and respective therapy regimes

* Adherence to the above procedures will be regulated by audit exercise in periodically.

In monitoring the patient as well as the therapy, the following is recommended:

a) A reassessment or community follow-up service is recommended for every case

b) Thorough education, reinforcement and psychological support are essential in the

c) Community based support and/or rehabilitation service, preferably with a

* This is a guideline for Occupational Therapy services in the assessment, equipment

Clinical Assessments for hypoxaemia:

For patients with various chronic Not supported by evidence for

For patients with various chronic

Stable chronic hypoxaemia

Long Term Short Term

Continuous Ambulatory/Exertional Nocturnal

Diagram 1 Flowchart for Home Oxygen Therapy

2.2 The Need for a Guideline

2.3 The Need for Team Work

3. The Right PATIENT

3.1 COPD Patients with Stable Chronic Hypoxaemia

b) in the range 7.4-7.9kPa (or 56-59mmHg) together with hypoxia-related

3.2 COPD Patients with Exertion-induced Desaturation

The use of oxygen will be confined to participation in specified physical and

Desaturation Test (Box 1) with continuous oximetry monitoring is the

3.3 COPD Patients with Nocturnal Desaturation

Patients with the presence of hypoxia-related consequences such as i)

3.5 Patients with Malignancy or Terminal Diseases

SpO2 reading. Additional consideration needs to be given to potential risks of hypercapnia if

Palliative Oxygen Therapy is considered for patients suffering from malignancy

Palliative Oxygen Therapy may be on occasion be considered by specialist

3.6 Contraindications to Home Oxygen Therapy

There are several contraindications discussed in renowned international guidelines where

recommended due to limited documented benefits.

Desaturation Test is an assessment for identifying the presence of exertional

Box 1 Desaturation Test

4. The Right AMOUNT (Flow Rate)

4.1 Flow Rate at REST

4.2 Flow Rate for ADL / Exercise

4.3 Flow Rate for SLEEP

4.4 With Early Symptoms of Acute Exacerbation

Patients on Home Oxygen Therapy should maintain their original oxygen

4.5 During Air-flight