Oxygen Therapy: Adapting Old Tools in New Ways

2016 Pneumonia and Diarrhea Progress Report

Oxygen Therapy: Adapting Old Tools in New Ways

Interview with Drs. Trevor Duke and Hamish Graham, Melbourne, AU

Oxygen Therapy is Lifesaving, But Reaching Children in Low-Resource Settings Takes More than New Technology

For decades, tools have existed to diagnose and treat hypoxemia, the dangerously low blood oxygen levels that can occur with severe pneumonia. But what will it take for these technologies to fulfill their potential to save children’s lives everywhere?

The answer: Context is everything, according to Trevor Duke, MD, and Hamish Graham, MBBS, MPH, from the Royal Children’s Hospital in Melbourne, Australia. With funding from the Gates Foundation, they have been testing a strategy to improve the delivery and sustainability of pulse oximetry and oxygen therapy in high-burden, low-resource settings, namely Nigeria and Papua New Guinea (PNG). To them, not only is it about having the right technology, but it is also about strengthening the surrounding health system to optimize its use. Integration is where real innovation begins.

Q: How common is hypoxemia (low blood oxygen) and is oxygen readily available if detected?

A: Duke: On average, 13% of all children who present to a hospital with pneumonia have hypoxemia. But the rates vary from 5% up to 40% in some places.

Health workers find it hard sometimes to detect hypoxemia. Sometimes if a child is hypoxemic, they have blue lips or gums. This can be really hard to see in children with dark skin. A pulse oximeter, a simple monitor that can be placed on the child’s toe or finger to measure oxygen levels in the blood through the skin, is a more accurate way of detecting hypoxemia. It is important to teach health workers how to use a pulse oximeter, and then without much effort, they can identify a potentially deadly situation.

Oxygen is not available everywhere. Where it does reach children, it has mostly been supplied in cylinders that are filled with gaseous oxygen. These cylinders can run out in just over two days for a child with severe pneumonia, and replacements are not always available. The cylinders are heavy and cost a lot of money to transport. If a child has very severe pneumonia, they may be hypoxemic for much longer than two days, making adequate access to oxygen a concern.

Q: How can we increase access to oxygen and improve treatment?

A: Duke: By using oxygen concentrators. Cylinders are an exhaustible source of oxygen, while oxygen concentrators are not. An oxygen concentrator makes oxygen by extracting it from atmospheric air, which is 21% oxygen and 79% nitrogen. A concentrator removes the nitrogen and concentrates up the oxygen to around 90%. If there is adequate power and a concentrator is well maintained, it can just keep making oxygen out of the air.

Concentrators have been around for a long time. They have mostly been made for people who have chronic lung disease in western countries. We thought they would be useful for small hospitals in low-income countries where it is really hard to afford and deliver oxygen cylinders.

A: Graham: We are hoping to demonstrate what needs to be put in place for concentrators to work and be sustainable—and for health care workers to use it effectively. Some of this includes:

• An oxygen source: concentrator or cylinder. If it’s a concentrator, a reliable power source.
• Tools to help health care workers recognize when a child needs oxygen, and administer it appropriately (e.g., pulse oximeters, clinical guidelines).
• Skilled health care workers who are motivated to use oxygen therapy effectively, and a work environment that makes it easy.
• Skilled technicians, with maintenance facilities, tools and structures to keep the equipment functioning well.
• Financing mechanisms, so that oxygen is affordable to patients and sustainable for the health system.

Many of these things are also important not only for delivering oxygen, but also for many other aspects of care. We hope that by addressing the ‘oxygen problem,’ hospitals and health departments can begin to build stronger health care systems that impact health much more broadly.

Q: What does it take for oxygen concentrators to work well in low resource settings?

A: Graham: Since the 1990s, researchers and implementers have given increasing attention to the practical steps needed to improve oxygen systems and achieve real clinical benefits. So we have seen projects that have brought together technology with other aspects, like training and supervision, to actually to see how it is used and what effect it has on clinical outcomes.

The first study that showed the effectiveness of improving oxygen systems is one from PNG. This study ran from 2001 and 2007, and included more than 11,000 children. It showed a 35% reduction in the case fatality rate for hospitalized children under 5 years of age with pneumonia, following the introduction of oxygen concentrators and hospital system improvements.36 This was in five hospitals where it was relatively easy to do it; for example, they had power.

Q: What is the main challenge with using oxygen concentrators in low resource settings?

A: Duke: You need power and many places have either irregular power, with surges that can damage equipment, or the health facility has no power at all. In such settings an alternative source of power is needed. Our current work across many hospitals in Nigeria and PNG is investigating how solar power can get oxygen into places that may have never had it before, and even improve the functioning of the rural health facilities.

Solar power is expensive to install, but solar panels have a life of up to 25 years, so it is a long-term investment for a health service. There are many low-income countries where solar power is being used for lots of industrial and domestic reasons. Because tropical environments usually have many hours of sunlight, it is possible to have sustainable solar power.

Using solar power should not just be about the provision of oxygen, but about improving health system functioning. We should look for the wider benefits such as powering a vaccine refrigerator, a light in the delivery room, a suction machine, and to charge the health workers mobile phone so they can call and refer patients on. Many of the essential day-to-day functions of a health system can benefit from that solar power.

Q: How do costs compare between cylinders and concentrators?

A: Duke: It has been shown many times that it is much cheaper to use concentrators than to use cylinders, and if maintained well they can be more reliable. You can get a good concentrator for USD $600 that can last 5 years, if it is looked after well. So that is cheap. Solar panels are going to last longer than the concentrator, 20-25 years, but are expensive and may cost $20,000. Batteries, accounting for about half of the cost of the system, are necessary when there is no sunlight and they do not last as long as the panels.

Q: Can this become affordable in low resource settings?

A: Graham: The cost was something we had clearly foreseen, as it is always a huge challenge for hospitals and health departments. In places like Nigeria, where it’s a user-pay system, oxygen is also extremely expensive to patients. So one of the elements of our work in Nigeria is helping the hospitals develop financing mechanisms that will make it financially sustainable for hospitals to keep doing it—but also affordable for patients. Fortunately, concentrator-based systems are generally significantly less expensive than cylinder systems. So it really is feasible for hospitals to provide oxygen to patients affordably, typically less than $3 USD per patient.

Q: What are next steps to scaling-up this intervention?

A: Graham: Oxygen therapy itself is a simple, lifesaving therapy. But actually making it available for children is a whole lot more complicated. We cannot say there is a five-step package that can be taken anywhere and applied. But hopefully the work in Nigeria and PNG will give us a much better understanding of how oxygen systems work in different contexts, and enable state governments and hospital boards to say, “Alright, this is what we need to do in our situation; in our context.”

Trevor Duke, MD, is director of the Centre for International Child Health (CICH) at the University of Melbourne, and clinical director of The Royal Children’s Hospital intensive care unit. He heads the WHO Collaborating Centre for Research and Training in Child and Neonatal Health at the Centre for International Child Health. He was also involved in designing the WHO/UNICEF Child Survival Strategy.

Hamish Graham, MBBS, MPH, is a pediatrician at the Royal Children’s Hospital and a research fellow at the Centre for International Child Health at the University of Melbourne, Australia. He is also co-founder of Global Health Gateway, a resource for professionals interested in global health careers.