Oxygen

1
Oxygen Air Travel

• Bob Fary, RRT
• Board of Directors
• National Home Oxygen Patients Association
• VP of Sales, Inogen, Inc.

2
Air Travel O2 Why the Fuss?

• In the US there are an estimated 1.5 million home
  O2 users
• Modern home O2 users are often highly active and
  ambulatory
• Modern home O2 users have more disposable income
  than their predecessors
• Modern home O2 users are more informed consumers
  and demand fair and equal access to travel
• New technology enables O2 users to travel

3
Air Travel O2 data

• 20 of adults 55 travel regularly by air
• Only 5 of LTOT patients travel by air
• Problems associated with air travel O2
• Airlines wont provide in-flight O2
• Cost of O2 can exceed ticket price
• Schedule difficulties with layovers, transfers
  and delays
• ATA reports 75,000 O2 passenger enplanements
  before impact of new FAA rules
• Estimates 50,000 new O2 travelers annually in
  response to the new FAA rules

4
Traveling with POCs

• Air Travel
• Train Travel
• Cruise Ships
• Private Automobile
• Travel-Specific Providers

5
History of Airline Oxygen

• Pressurized Cabins
• 8,000-10,000 feet
• Less Oxygen Available
• Sleepy? You PO2 is lower!
• Lung disease? Supplementary oxygen is required
• DOT HazMat Classification
• Requires exemption
• Mainline carriers only

6
History of Airline Oxygen-Providers

• Homecare Providers Travel Programs
• National providers
• Alliances of independents
• Oxygen users travel guide
• Logistical and economic challenge-many
  opportunities for failures
• Service coordination
• Reimbursement/compensation issues
• Costs passed on to oxygen users

7
History of Airline Oxygen-Users

• Find a Willing Provider
• Local provider ability
• Switch providers?
• Make Arrangements with Airline
• 60 day planning
• Medical history
• Flight availability
• Pay Up!

8
History of Airline Oxygen-Airlines

• Hazardous Materials Exemption
• Large paperwork burden
• Logistical Challenges
• Oxygen on the correct flight
• Regulations regarding tanks
• Training issues
• Money-Losing Service
• Carrier bankruptcies
• Fees cover some costs

9
Advocacy Efforts

• NHOPA
• Pioneered efforts to change onboard oxygen rules
• More than 8 years of lobbying activity
• ATS
• AARC
• ACCP
• NAMDRC
• A A Homecare
• HME/RT Committee

10
DOT Rule-SFAR-106

• Allows Use of Portable Oxygen Concentrators
  Onboard Commercial Aircraft
• At discretion of individual carriers
• 4 devices have been approved for this use
• Enables oxygen users to carry-on and use their
  own personal oxygen concentrator

11
SFAR 106 Overview

• FAA issued Special Federal Aviation
  Regulation-106 issued on 7/12/05
• Federal Register (vol. 70, no. 132)
• The rule prescribes special operating rules for
  the use of portable oxygen concentrators (POCs)
  onboard civil aircraft
• POCs perform by separating oxygen from nitrogen
  and other gasses contained in ambient air and
  dispenses it in concentrated form to the user
• Only 2 devices are permitted under this rule
  they have been tested to ensure no interference
  with the electrical, navigation or communication
  equipment of the aircraft will occur
• The FAA estimates approximately 50,000 new
  passengers requiring oxygen per year as a result
  of this SFAR
• POCs have not yet been classified as assistive
  devices by the DOT

12
SFAR 106 Passenger Reponsibilities

• Notify airline of the intent to bring a POC
  onboard
• Possess a physicians statement that includes
• Ability to see/hear alarms and appropriately
  respond
• When oxygen is required (all or a portion of the
  trip)
• Maximum prescribed flow rate during flight
• Bring sufficient number of charged batteries for
  the duration of the flight, plus any
  unanticipated delays
• Ensure POC is clean, in good condition and free
  from damage or other signs of excessive wear or
  abuse
• Properly stow POC during taxi, takeoff and
  landing
• When a power port is utilized, remove battery
  from the POC

13
SFAR 106 Special Conditions

• Pilot must be informed of POCs onboard
• Passengers using POCs may not sit in an emergency
  exit row, or in a seat that restricts other
  passengers access to an emergency exit or aisle
  of the passenger compartment
• Approved POCs may be used during taxi, takeoff
  and landing if required by physicians statement

14
SFAR-106, Continued

• Requires user to carry a letter from their
  physician
• No 60 day notice requirement
• No longer requires airline to have HazMat
  exemption to allow oxygen use
• Allows users to be self-responsible for their
  oxygen needs
• Removes logistical hurdles for providers and
  airlines
• Saves users money-no more fees from provider or
  airline

15
ATA Comments
The DOT should do everything it can to
encourage, not discourage, the use of POCs in
order to improve the accessibility of air
transportation for passengers who require
respiratory therapy.1 - Air
Transport Association
1 Air Transport Association Comments to NPRM
Docket OST-2005-22298 (1/06)
16
When? How? Who?

• AirSep, SeQual, Respironics and Inogen Approved
  by FAA
• Most Airlines Have Approved POC Use
• Independent testing
• Policies and procedures
• Training of employees
• Check Airline and POC Manufacturer Web Sites for
  Current Approvals

17
Approvals as of November, 2006

• Northwest
• America West
• US Airways
• Midwest
• Delta
• Frontier
• Alaska
• ATA
• Midwest

• Lufthansa
• Royal Jordanian
• Air France
• Hawaiian
• Quantas
• Southwest
• Sun Country
• American
• Continental
• jetBlue

18
Approvals Still Pending

• United Airlines
• Concerns on pilot notification requirement
• Concerns about seating requirements

19
Whats Next?

• DOT NPRM Docket OST-2005-22298, Issued September
  7, 2005
• Federal register vol. 70 no. 172
• Requires Airlines to Allow POCs Onboard as
  Personal Assistive Device
• Places use under Air Carrier Access Act
• Comments Accepted and Available for Review
• www.dms.dot.gov

20
DOT NPRM on POCs

• DOT NPRM Docket OST-2005-22298, Issued September
  7, 2005
• Federal register vol. 70 no. 172
• Will require airlines to allow POCs onboard as
  personal assistive device
• Places use under Air Carrier Access Act
• Original comments accepted through Nov 2005
• Commented period was extended at request of the
  airline industry
• No published response to comment posted yet

21
Portable Oxygen Concentrators
22
Oxygen in Flight

• FAA Regulations
• Requires CA be kept below 8000 ft but can alter
  up to 10,000 ft if pilot must fly at higher
  altitudes
• Ground vs. Cabin Ambient O2
• Partial pressure of ambient gas
• Barometric pressure x 0.209 ambient PO2
• Partial pressures of O2
• Sea level 760 x 0.209 159 mmHg
• Flight-8,000 ft 564 x 0.209 118 mmHg
• Gas density in the cabin at altitude is almost
  30 less than sea level
• Net effect is similar to breathing 15.1 O2

23
Predicting Blood Oxygen Levels in Flight

• There is no single, evidenced based and
  standardized method for predicting blood oxygen
  levels at altitude
• As a rule of thumb, it is estimated that tracheal
  PaO2 declines about 5 mmHg per 1,000 feet
  ascended.
• There is no rule of thumb for SpO2
• Healthy, ground-level normoxic passengers will
  experience mild hypoxemia but likely maintain
  SpO2 gt90
• There are a number of predictive, regression
  equations derived from specific altitude studies
  but none considered universal and accurate

24
Predicting Blood Oxygen Levels in Flight

• HAST-high altitude simulation testing is ideal
  and the most accurate tool for assessing an
  individual patient
• Patient challenged with 15.1 and clinical
  response measured
• May be used to titrate supplement O2 for in
  flight
• Accurate and reliable tool for assessing altitude
  tolerance
• Unfortunately, not considered practical for most
  private practices and small facilities

25
PDOD at Altitude

• There are no published controlled studies
  regarding the use of PDOD devices in flight
• No predictable change in performance of PDOD
  devices at altitude
• Ground level titrations and clinical efficacy
  will likely translate to use at altitude
• Normal physiologic increases may be expected in
  RR and minute volume
• Some patients may benefit from increasing PDOD
  setting during flight

26
Clinical Response to Altitude

• Common Pulmonary Effects
• Modest fall in PaO2
• Increased respiratory rate
• Increased minute ventilation
• Potential for mild dyspnea
• Common Hemodynamic Effects
• Elevation in HR
• Elevation in C.O.
• Preferential redistribution of perfusion to
  essential organs and diminished perfusion to
  other organs
• Vasoconstriction of the pulmonary arteries

27
Traveler Issues

• Medical Hazards
• It is estimated that about 5 of commercial
  passengers are under medical care1
• 1 study suggested 35 of patients referred to an
  airlines medical department for travel clearance
  had been hospitalized within 2 weeks of their
  planned trip2
• Despite known effects of altitude, it is
  considered low risk and well tolerated, even for
  patients with chronic lung disease3

1Gong H. Traveling with oxygen. In Tiep BL,
editor. Oxygen at altitude and on aircraft.
Mount Kisco. NY Futura 1991437-469 2Gong H,
Mark JA, Cowan MN. Preflight medical screenings
of patients analysis of health and flight
characteristics. Chest 1993104(3)788-794 3Stolle
r JK. Oxygen and Air Travel. Respir Care
200045(2)214-221
28
O2 Travel Who needs it?

• COPD patients normoxic at ground level1
• PaO2 gt80 mmHg will likely not need O2 in flight
• PaO2 lt60 mmHg will likely need O2 in flight
• PaO2 50 mmHg will need O2 in flight
• One study suggests that 2 L/min covers large
  groups of patients normoxic at ground level but
  needing O2 in flight2

1Stoller JK. Oxygen and Air Travel. Respir Care
200045(2)214-221 2Cramer D, et al. Assessment
of oxygen supplementation during air travel.
Thorax 199651(2) 202-203
29
O2 Travel Who needs it?

• Current LTOT users
• Any patient being treated for chronic hypoxemia
  at ground level
• Changes to ground level O2 Rx?
• No specific guideline exists
• No published evidenced
• Some data suggests increasing O2 flow 1 during
  flight
• POCs produce slightly less total O2 (although at
  a higher purity) at altitude
• Increase POC setting 1 over ground level may be
  prudent approach to compensate for reduced molar
  output

30
Concentrators at Altitude

• No significant evidence surrounding the use of
  PSA systems in flight
• PSA had been successfully used as in flight O2
  source in aeronautics
• Because of the reduced partial pressure of the
  gases, devices may produce a lower molar flow of
  O2
• POC users may benefit from a 1 increase in their
  O2 setting during flight
• This is important because it may effect battery
  life

31
Inspired O2 Calculation

• O2 purity changes via NC have little impact on
  FIO2
• Compare the effect that 85 and 100 source gas
  would have on delivered FIO2 given a tidal volume
  of 500mL, a 1-second inspiratory time and a flow
  of 2 L/min (33.3 ml/sec).

• 100 Oxygen at Ground Level
• 0.21 (500 33.3) (1.0 (33.3)) 26.3
• 500
• 85 Oxygen
• 0.21 (500 33.3) (0.85 (33.3)) 25.3
• 500

32
Clinical Considerations

• All COPD patients planning air travel should be
  seen and evaluated by their physician
• Most COPD patients, including LTOT users will
  tolerate air travel
• First time users of POCs should be clinically
  evaluated and titrated to assure PDOD tolerance
  and consideration should be given to a likely
  increase in RR during flight
• Air travel is unpredictable so patients and
  providers must prepare for delays, cancellations
  and problems

33
Summary

• POCs are Welcomed on Most Airlines
• Freedom for Oxygen Users
• Financial Benefit for Users
• Financial Benefit for Homecare Providers
• More Active Patients
• Subsequent DOT Ruling to Follow

34
Summary

• Like many areas relating to LTOT and homecare,
  there is limited evidence to support protocols
• LTOT user air travel is predicted to grow and so
  will demand for supportive technologies
• POCs and air travel appear to be safe and
  appropriate for most patients with COPD
• Patients should always check with their physician
  before flying

35
Suggested Reading

• Stoller JK. Oxygen and Air Travel. Resp Care
  2000 Feb45(2)214-221
• Seccombe LM, et al. Effect of simulated
  commercial flight on oxygenation in patients with
  interstitial lung disease and chronic obstructive
  lung disease. Thorax 2004 Nov59(11)966-70
• Akero A, et al. Hypoxaemia in chronic
  obstructive pulmonary disease patients during a
  commercial flight. Eur Resp J 2005
  25(4)725-730
• Johnson AOC. Chronic obstructive pulmonary
  disease ? 11 Fitness to fly with COPD. Thorax
  2003 Aug58729-732

36
Thank You!

• Correspondence
• Bob Fary
• E-Mail rsfary_at_inogen.net
• Cell [phone]