Problem With Nocturnal Oxygen Qualifications

Generally speaking, we consider an SpO2 of 90% as acceptable. This is because an SpO2 of 90% typically correlates with a PaO2 of around 60 mmHg, and anything below a PaO2 of 60 mmHg is considered hypoxia that requires treatment with supplemental oxygen.

Medicare, in setting guidelines for oxygen qualification, aims to ensure that people truly need oxygen. So, they set the qualification threshold at 88%. If your oxygen saturation is 88% or less while resting or with exertion, you qualify for home oxygen therapy.

In this case, I have no issue with the guideline—it makes sense. However, qualifying for nighttime or sleep oxygen is a different story. During the day, a saturation of 88% means you qualify for oxygen. But at night, you not only need to drop below 88%, it also has to remain that low for a minimum of five minutes.

For example, in a study we did last night, a patient's SpO2 dipped to 83%, which is considered low. But because of Medicare’s nighttime oxygen requirements, this person doesn’t qualify for oxygen. Even if their SpO2 dropped to 70%, they wouldn’t qualify unless it stayed below 88% for at least five minutes.

I believe this is a flaw in the system. Granted, lower oxygen levels during sleep are often considered normal, but setting a time-based threshold seems unnecessarily rigid. Perhaps Medicare could instead adopt a threshold like 85%—and if anyone’s SpO2 falls below that, even briefly, they should qualify for nighttime oxygen therapy. This would account for those whose saturation dips significantly, even if the drop doesn’t last the full five minutes.

Truly, Medicare does not always have the patient’s best interests in mind when setting qualification policies. What seems to guide their decision-making more is how they can save money. While the guidelines ensure that only those who really need oxygen get it, the rigid thresholds—especially for nighttime oxygen—can leave some patients without necessary support. It seems less about patient care and more about cutting costs.

Does your patient need and qualify for oxygen therapy

The following was originally published on April 15, 2015 at healthcentral.com/copd.

Do you need oxygen therapy? 

Sometimes people with COPD need to inhale more oxygen than what is provided in the air. The way this is accomplished is by using oxygen therapy. So what is oxygen therapy, and do you need it?

Oxygen in room air contains 21 percent oxygen. Usually this is plenty of oxygen. However, certain disease conditions, such as what may occur as COPD progresses, or during COPD flare-ups, may create areas inside your lungs where oxygen is inhaled, but cannot get to your bloodstream. When enough of these areas exist, your blood oxygen levels may decline.

To learn more about oxygen and oxygen levels, please read my post “Understanding Oxygen and Oxygen Levels with COPD.”

What is oxygen therapy? It involves inhaling supplemental oxygen, or oxygen percentages that are greater than 21 percent. It allows you to inhale 22-100 percent oxygen, depending on the device used.

Nasal Cannula. This involves inserting prongs into your nose. A low flow allows you to inhale anywhere from 22-44 percent oxygen. This is all that is needed for most people with COPD. It is very comfortable and tolerable.

Masks. A variety of masks can used to provide up to 100 percent oxygen. These are not used very often, but are available if needed.

To learn more about oxygen devices read my post “Oxygen Therapy Made Easy.”

There are three ways of getting oxygen therapy into your home.

1. Compressed Oxygen Gas Cylinders. These are tanks with regulators and flowmeters. Some are larger and stay at your home, and some are smaller for travel. 
2. Liquid Oxygen. They hold more oxygen and are smaller and more lightweight, making them ideal for people who are constantly on the move.
3. Oxygen Concentrators. They are electronic devices about the size of end tables that make oxygen by concentrating oxygen from room air. These are nice because, so long as you have electricity, you always have a source of supplemental oxygen. 

These are described in more detail in the post “The Three Types of Oxygen Therapy for COPD.”

Most people who require oxygen therapy will use oxygen concentrators at home, and have a variety of tanks as a backup in case of a power outage, and also for travel.

Do you need oxygen therapy? If your oxygen levels are chronically low, this puts strain on your body that can shorten your lifespan. That said, supplemental oxygen is the only drug proven to prolong life.

Common signs and symptoms of low blood oxygen levels (hypoxemia) are.

• Bluish tinge to your fingertips, toes and lips
• Rapid heartbeat
• Sweating
• Confusion
• Feeling winded, especially with exertion

If you, or a loved one, observes these signs, you should seek medical attention immediately. Your doctor may at first treat your COPD flare-up. Once you are deemed to be in a “chronic stable state,” your doctor may qualify you for oxygen therapy.

Do you qualify for home oxygen therapy? The qualifications for home oxygen are set by the Centers for Medicare and Medicaid Services (CMS), and they prefer numbers over subjective signs and symptoms. So qualifying is determined by the following test results:

• Arterial Blood Gas: Your PO2 is at or below 55
• Pulse Oximetry: Your SpO2 is at or below 88 percent

The basic premise goes like this: you qualify for oxygen therapy if your:

• PO2 is 55 or less or your SpO2 is 88 percent or less at rest while breathing room air.
• PO2 is 55 or less or your SpO2 is 88 percent or less while you are sleeping; or, if your PO2 drops 10 percent or more, or your SpO2 drops 5 percent or more, while you are sleeping, and you are also displaying symptoms of hypoxemia. 
• PO2 is 55 or less or your SpO2 is 88 percent or less while you are exercising.

How much oxygen do you need? The goal of oxygen therhapy is to provide you with the least amount of supplemental oxygen to maintain an SpO2 at 90 percent or greater. Usually, a low flow of 2-3 LPM using a nasal cannula works great. And, considering the benefits, most people tolerate it very well.

Further Reading:

• Understanding Oxygen and Oxygen Levels with COPD
• The Natural Progression of COPD
• The Three Types of Oxygen Therapy for COPD
• Oxygen Therapy Made Easy
• How to qualify for home oxygen therapy
• What are blood gases
• Pulse Oximetry Monitoring -- Do You Need It?: