1. Respiratory Care in India - Past, Present and Future
Vijay Deshpande, MS, RRT, FAARC
Emeritus Professor, Georgia State University
Atlanta, Georgia USA
Adjunct Visiting Professor
Dept. of Respiratory Therapy Dept. of Medical Technology
Manipal College of Health Sciences Symbiosis Institute of Health Sciences
Manipal , Karnataka Pune , Maharashtra

2. Home Respiratory Therapy
Home Oxygen Therapy
Bronchodilator Therapy
CPAP
BiPAP
Trache Care
Mome Mechanicl Ventilation

5. Frequent visits to Physician’s office High Health Care Cost
Susceptibility to infection
COPD
Patient
Co-morbid disorders
Frequent
Exacerbation
Mechanical Ventilation
Frequent Hospitalization

6. Medicare or Reimbursement
Primary Care
Physicians
Medicare or Reimbursement
system
Pulmonologists
COPD
Patient
Hospitals
Home Care
Providers
Respiratory
Care Dept.

7. Medicare or Reimbursement system
Primary Care
Physicians
Medicare or Reimbursement system
Pulmonologists
COPD
Patient
NPPV
Manufacturer
Hospitals
Home Care
Providers
HMO’s

9. HOME CARE RESPIRATORY THERAPIST

10. Home Care Nutritionist

11. Home Care Physical Therapist

12. Thank You !

14. Home Respiratory Therapy
Asthma
COPD
Chronic CHF
Obstructive Sleep Apnea
Long Term Mechanical Ventilation

15. COPD- Definition COPD is a disease state characterized by
airflow limitation that is not fully reversible.
The airflow limitation is usually both
progressive and associated with an abnormal
inflammatory response of the lungs to noxious
particles or gases
Global Initiative for Chronic Obstructive Lung Disease, National
Institute of Health and National Heart, Lung and Blood Institute,
NIH Publication No. 2701B, April 2001.

16. FIGURE 4-1. Normal lung volumes and capacities
FIGURE Normal lung volumes and capacities. IRV = inspiratory reserve volume; VT = tidal volume; RV = residual volume; ERV = expiratory reserve volume;TLC = total lung capacity; VC = vital capacity; IC = inspiratory capacity; FRC = functional residual capcity.

18. PULMONARY FUNCTION TESTING
SPIROMETRY
FVC
SVC IC
ERV VT
Flowrates

19. Chronic Obstructive Pulmonary Disease
BRONCHITIS
EMPHYSEMA
BRONCHITIS
EMPHYSEMA

20. Advancement in Management of COPD Patients
Oxygen by Nasal Cannula
Oxygen via Venturi Mask
E Cylinder
Small Portable D cylinder Flasks
Liquid Oxygen cylinder with cannula
Trans-tracheal oxygen (cosmetic)
Oxygen Concentrators
Long Term Oxygen Therapy

21. Indications for LTOT PaO2 < 55 Hg or SaO2 < 88% on room air
PaO mm Hg and one of the following:
Pulmonary hypertension and edema
Cor Pulmonale
Secondary Polycythemia (56%)
Pulmonary restrictive disease with PaO2 < 55 mm Hg
Refractory dyspnea associated with cardiac failure

22. Benefits of LTOT Improves survival in patients with
COPD and severe resting hypoxemia
Decreases frequency of exacerbation
of the disease requiring hospitalization
Improves exercise performance

23. COPD and SLEEP
Sleep studies performed on COPD patients indicate that compared to normal individuals, the COPD patients:
have less hours of sleep
have poorer quality of sleep
have more arousal's at night

24. Obstructive Sleep Apnea and COPD
Can coexist
May lead to:
Oxygen desaturation during sleep
Decreased ventilation
V/Q mismatch
ATS statement: Standards for Diagnosis and care of Patients with COPD
Respiratory and Critical Care Medicine, Nov.1995, 152:S78-S121.

26. NPPV (Bilevel Positive Airway Pressure)20 15 PS
CPAP
IPAP
Pressure 10 5
Time
Bi-level Positive Airway Pressure

27. Be nice to your kids.
They’ll choose your nursing home.

31. Management of Advanced COPD
“We cannot add years to their life, but we can add life to their years”. 3

32. NPPV Diagnosis of COPD Need for Bronchodilator Therapy CPAP Therapy
Home Care Management of COPD Patients
Diagnosis of COPD
NPPV
Wheezing, Increased Secretions,
Abnormal Breath Sounds,
Increased Airway Resistance,
Use of accessory muscles
Non-responsive to
CPAP Therapy,
Polysomnography,
Identification of
Sleep Apnea
Need for Bronchodilator
Therapy
CPAP Therapy
Daytime sleepiness, Somnolence,
Snoring, Nocturnal Desaturation,

35. Effect of Hypoxemia on
Cardiovascular system

36. Sequence of Blood Flow Through the Heart

37. Hemodynamics and Pulmonary Vasoconstriction

38. Cardiovascular Effects of Hypoxemia
Tachycardia
Pulmonary Vasoconstriction
Pulmonary Hypertension
Systemic Hypertension

39. COPD and Oxygen Economics
Long-term oxygen therapy (LTOT) increases survival and improves the quality of life of hypoxemic patients with chronic obstructive pulmonary disease (COPD)
Each year, approximately one million patients receive LTOT through Medicare,
at a cost exceeding two billion dollars per year
This cost is increasing at an annual rate of nearly 13 percent
The economic impact of oxygen therapy on the Medicare Budget resulted in stringent Criteria to use LTOT

40. National Lung Health Education Program, 2006
Long Term Oxygen Therapy (LTOT)
History, Scientific Foundations, and Emerging Technologies
Thomas L. Petty, M.D.
Robert W. McCoy, B.S., RRT
Dennis E. Doherty, M.D.
6th Oxygen Consensus Conference Recommendations
National Lung Health Education Program, 2006

41. Long Term Oxygen Therapy
LTOT refers to delivery of oxygen therapy for continuous use at home for patients with chronic
hypoxemia (PaO2 =/< 55mHg)
Oxygen flow rate must be adequate to increase
PaO2 above 60 mm Hg while awake.
LTOT is likely to be life long
LTOT is usually given for at least 15 hours
daily, to include night time.

42. Indications for LTOT Chronic Hypoxemia Severe chronic Asthma
Nocturnal Hypoventilation
Secondary Polycythemia
Primary Pulmonary Hypertension
Chronic Heart Failure
Pulmonary malignancy

43. LONG TERM MANAGEMENT OF COPD PATIENTS
Absolute Indications for Long-term Oxygen Therapy
PaO2 < 55 mm Hg or SaO2 < 88 %
PaO2 = mm Hg or SaO2 > 89 % with:
Presence of Cor Pulmonale
ECG evidence of “P” pulmonale
Hematocrit > 55 %
Congestive Heart Failure
ATS statement: Standards for Diagnosis and care of Patients with COPD
Respiratory and Critical Care Medicine, Nov.1995, 152:S78-S121.

44. Physiological indications for long-term oxygen therapy (LTOT)
PaO2 mmHg SpO2 % LTOT indication Qualifying condition
__________________________________________________________
≤55 ≤88 Absolute None
Relative with "P" pulmonale,
qualifier polycythemia >55%
History of odema
≥60 ≥90 None except Exercise desaturation
with qualifier Sleep desaturation not corrected by CPAP
Lung disease with severe dyspnea responding to O2

45. Oxygen Dose
•Continuous flow by a double or single nasal
cannulae
•By demand system with demonstration of
adequate oxygen saturation
•Lowest liter flow to raise PO2 to mm
Hg or oxygen saturation to 88-94%
•Increase baseline liter flow by 1 L during
exercise and sleep

46. LTOT may improve outcome measures
other than mortality, including:
quality of life,
cardiovascular morbidity,
depression,
cognitive function,
exercise capacity, and
frequency of hospitalization

47. When appropriately prescribed and correctly used, LTOT has clearly been shown to improve survival in hypoxemic COPD patients. Adherence to LTOT ranges from 45% to 70% and utilization for more than 15 hours per day is widely accepted as efficacious.

48. More Documented Benefits of LTOT
Two landmark studies,
the Nocturnal Oxygen Therapy Trial (NOTT) and the British Medical Research Council (MRC) conducted in the late 1970s have explicitly demonstrated that
LTOT (when used for more than 15 hours/day) improves survival rates in patients with severe COPD associated with resting hypoxemia [1, 2].
In terms of maximum benefit,
continuous oxygen administration (≥15 h/d) is superior to intermittent or nocturnal use [3].
There is also accumulating evidence that LTOT has favourable effects on other outcome measures, including depression, cognitive function, quality of life, exercise capability, and frequency of hospitalization [4–10]. Moreover,
it stabilizes and sometimes reverses the progression of pulmonary arterial hypertension and it diminishes as well cardiac arrhythmias and electrocardiographic findings indicative of myocardial ischemia [11, 12].