Hello, and thanks for joining us today. This has been an area of interest in mine because I've always had an interest in new devices. I remember starting as a fellow and being really excited to see a laptop vent, which was back in the day was state of the art. And now we have smaller and smaller devices that can do more things for our patients. So the question that we always get is, how do I get this from a patient? One of the challenges is that we often invent things or come up with new devices before we often have the guidelines or the clear ways to get payment for that. So I definitely don't have all the answers. Feel free to reach out to me if you have further questions. But hopefully I'll give you some help today with thinking about what your patient might need and how to get it. I have no disclosures. I don't have any relationship with any device companies. I play with all the devices. So again, good news and bad news. Good news, there are new devices to help us with patients with severe hypoxia. Especially given our recent pandemic and patients with severe COVID-induced lung damage. I'll tell you, there were definitely days where I was like, I didn't know you could get that hypoxic and still be alive, unfortunately. But patients definitely survived and then you were like, okay, well now what? How do we get you home? How do we get you rehabbing? And so some of those things are important. The bad news again is the pathways for getting these devices are not very clear at times and can be complicated. And I'm gonna disclaimer this portion of the talk, which is this is focused on the United States. For all my friends from Canada and other countries, these devices are available. It's just obtaining them is a little bit different. So factors for getting a device. One of the things to start with is what is the underlying diagnosis? So often for oxygen therapy in this country, there's prescribed list. Usually CMS is the easiest way to go with that is the approved care diagnoses for that. And then getting to sort of the oxygen guidelines and device guidelines. The device guidelines I'm gonna refer to are the RAD device guidelines. And also for ventilators, which we're gonna show you some of these newer ventilators later. Those guidelines have specific parameters that you have to get to achieve in order to qualify for that kind of a device. And then in this country, Durable Medical Equipment is a DME company. And they are typically how a patient actually gets the device. You write the prescription, it goes to the DME. The DME then provides the device. But sometimes though, their insurance can dictate, for example, which DME you can use. And not all DMEs carry the same types of equipment. So sometimes this process can be a little confusing and I'll step through that in a moment with a graphic. But again, also to thinking about once you get this patient a device, then who's gonna follow it. So learning a little bit about these can be helpful as a provider. So I pulled these from CMS.gov. Conditions for which oxygen therapy may be covered. So severe disease such as COPD, diffuse interstitial lung disease, whether of known or unknown etiology, CF bronchiectasis, pulmonary neoplasm, and other conditions such as pulmonary hypertension, congestive heart failure, et cetera. The challenging part for some of these is if patients have multiple conditions because my patients love to not fall into nice neat boxes. You have to remember, though, that our people who are auditing in these things may not understand the complexity of your patient. They may not even really have a medical background. So if you can pick things that are on these lists that are approved, it makes the approval process easier. Conditions in which oxygen is not covered like angina, breathlessness without corpulmonale, probable vascular disease, and terminal illnesses that do not affect the lungs. And then there are lists that you can pull up on CMS.gov relevant to the ICD-10 codes as well. These are just things that will help you put your prescriptions through so that they don't just get triaged and rejected right away. So writing the prescription, this may seem obvious, but you have to write the prescription for the specific device, the specific device settings and interface. So for example, heated high flow can be used via trach or nasal cannula, the special cannulas, so you might need to write that. And also, usually when I write my prescriptions, I write something to the effect of all accessories or tubing or masks or whatever that need to come with them and supplies per insurance coverage. And then writing it out such as this patient is being described device X because he, she, they experience exacerbations of chronic bronchitis, bronchiectasis, COPD, recurrent pneumonia with the inability to clear secretions, for example, and cystic fibrosis, IBF, et cetera. So specifically stating out even in the prescription like why they're getting it can also help you with that as well. And then depending on the specific device, like some of the devices we're gonna show you in a minute, the companies actually will have prescription templates which can help you through this process with some of the verbiage that insurance companies and DMEs are looking for. So again, DME Company is a durable medical equipment company. They're variable in scope of what they carry around the country. I'm at the University of Utah. We cover about six surrounding states. So it's really, there's a huge variety from national companies to local companies, what they carry, what they're gonna provide. So for example, if you identify a particular product that you think might really help one of your patients, you may actually contact the company and say, hey, in this area where this patient lives, do you have a DME that has this, has the providers that can maintain this and understand how to use it? Because as some of the ventilators that we're gonna show you later, those ventilators are continuous rental devices. They're roughly about 1,500 bucks a month, continuous rental, and as part of that, it actually comes with RT service. So the RT comes to the home, helps maintain those things. But in some of our rural areas, like recently we tried to send a patient home to Wyoming and there just wasn't a respiratory therapist available in that region. So sometimes you have to get a little creative in making sure that they're gonna get what they need. And again, does that DME work with this particular patient's insurance company? So there's that part. And then also, not all DMEs cover certain areas. Again, location is also important for patient. And then insurance coverage, because it's not complicated enough. So Medicare, Medicare has CMS guidelines. They're mostly easy-ish to follow. They're at least available. The challenging part is Medicaid is all based on individual states. So if I'm sending a patient home to Nevada, I have to follow Nevada Medicaid rules. And they can choose to go with CMS guidelines or they can choose to do their own thing. And some states, for example, like our high-flow home setup, actually really like it and have found patients go home and stay home on it, great. But other states may have not run into it and it can be challenging sometimes, especially to find the person to talk to that has authorization to approve some of those things. And then private insurance is variable as well. And then self-pay can be really challenging with some of these devices because they are very expensive. And then the other thing to do if you end up in sort of a peer-to-peer scenario is to discuss with them sort of the alternatives. Like often I've got a patient sitting in the hospital and they've been there for a long time and we're like, hey, well, I know this device is expensive, but it's cheaper than the per-day fees in the hospital. So there are ways to kind of help them think through the financial statistics of it in favor for your patient. The other thing I have is a stock template of letter of medical necessity, kind of verbiage and details that insurance companies want to see. And this one in particular, I just pulled out as an example from Aero Fisher Paykel, but a lot of them have this that you can get. Or I've written a lot of my own because I do a lot of work with device with non-invasive ventilation, et cetera. And so I just have a, like if I have to write one for Mr. Jones, for example, I just keep that, pull all the identifying info out and then pull that apart and use it for my next one. So you just sort of save yourself some time in the future. But I go through things like their clinical history. And for example, if I'm saying, well, they really need this device, they've been in and out of the hospital with their interstitial lung disease or their recurrent ammonia, they're hypoxic, and they live at altitude, for example, and they're going home and they've come back three times, this is their fourth hospitalization. It just kind of shows them the severity of this and why this device, the whole goal is to try to get these patients home and to do better. And then the other aspect of that example is to look through things that were not successful. I had a patient who was a chronic trach patient who was just using like the standard trach mask, but in the desert of Utah, that was like not working out super well because it was getting really dried up and having recurrent mucus plugs. And so we were able to argue for the home ervo high flow with the adapter and he's done beautifully with that. But one of the examples of that though is to say we tried the cheaper alternatives, they didn't work, next. And then clinical advantages of the therapy. You know, this is where I kind of keep some of the literature available. Sometimes you can snag this from some of the companies as well, which is data for high flow in the hospital works really well. Like it's not that I'm proposing something really odd, it's just I wanna do it in a different environment. And to say this person needs a real help with secretion clearance because they've come back to the hospital with recurrent mucus plugs, for example. And then I also list, like I liked this portion as well too, the expected outcomes if therapy is not used, which is to say, okay, this person's been to the hospital three times. It works in the hospital, they do great. Like it's being able to show, like can we get this for home environment? We actually think we'd save the insurance company or the public payer money. But again, listing their increased chance for infection, re-hospitalization, et cetera, tends to add weight to that. So just to walk you through the process again, identify the right device for the patient and Dr. Callahan will go through those with some cases. And then you have to have a prescription with a qualifying diagnosis. And sometimes for some of these devices that are newer, that particular qualifying diagnosis is a little vague, depending on the insurance company. But again, being able to list out all of the reasoning behind that and provide clinical notes, et cetera, to support that is important. And then identifying the DME company, where does the patient live, what insurance, what devices do they have? And then going through the insurance authorization process and writing letters of medical necessity if necessary. And then getting the device to the patient and then following up at the end with patient follow-up. Also, with I feel like in medicine, there's a little bit of creativity going on sometimes. One of the things I've noticed with a lot of our interstitial lung disease patients or other patients that were like, for example, extremely debilitated after COVID when their lungs were not doing well is that you really wanna get these people mobile. I really feel like a lot of the times if you watch somebody sit and get debilitated, you're watching them die slowly in front of you because they're not gonna get better, something else will happen. So one of the solutions I've done with some of these mobile ventilators that are battery powered is actually to put the ventilator itself on these rolling walkers, put it on the seat, and then you see the picture here, you can actually secure oxygen tanks to the walker. And then you can actually Y two tanks together into the, with this Christmas tree, Y-shaped oxygen connector. And then putting it with one of the high flow capable ventilators like the Luisa now or likely will also be the Vivo as well. And then keep these patients moving. You know, even if it's in the hospital, if it's in a rehab facility or if it's at home, keep them moving so that they don't develop all the other issues and hopefully, you know, for like our listed transplant patients, you know, we're hoping to keep them functional enough for transplant or just even better quality of life. So these have been some of our creative options and they will continue to come out as we get more devices. But hopefully in the future, I think as these devices get more popular, patients demand them more too, that we'll see more straightforward guidelines. But I'm happy to take any questions, especially after we break up for our small show and tell session. Thanks. Thank you. Okay, great. Thank you, Jeanette. Sorry for going a little bit backwards, but do a quick introduction of everybody. So first from Dr. Brown, who's at the University of Utah where I work as well. My name is Sean Callahan. I'm an ILD and critical care doctor there. And then we have two great respiratory therapists with us today. Jeff Shelton, who works at the University of Utah at the Nielsen Rehab Center and Kimberly Clark, who's at the University of North Carolina, Charlotte. Okay, so general idea of this. This is a new session this year, so we're giving the new session a whirl. So general overview, we're gonna do some patient scenarios and what devices to choose. You've already heard about how you get these paid for, or at least attempt to, which is often a bad reality. And then we're gonna have hands-on time for the second half of the talk with the toys. So the impetus for this is we all have these patients. So really happened during COVID, but even before then, we have these patients who are really sick, they're hypoxic, they're well enough to go home, but their lungs are just really broken and it's hard to get them out of the hospital. This was really accentuated with COVID patients who had bad DVTs, bad fibrotic lung disease afterward. So the goal of the talk today is really to help you identify what your options are, what are the best options for the patient ahead of you and to think creatively like Jeanette's already given you examples of. So I think probably the best way to go through these, talk through the pros and cons of each of the devices we have is to do some patient presentations. These are not stumpers, these are not difficult scenarios, they're just difficult hypoxemic patients. So let's roll through a few. These are all examples that I have in my clinic. These are not their CT scans, but representative images from online. So 62 year old female, advanced COPD, she uses six liters at baseline. She comes in with streptococcus pneumonia infection and is in the ICU and intubated. This is her baseline CT with horrible epizema at baseline. So she comes out the other side even more debilitated. Her bicarbonate level is very high at 39 and she has significant work of breathing just at baseline. She's now requiring eight liters of oxygen to maintain SATs. You can look at her CT now, she has a little bit of basilar fibrosis and a big pneumatic seal. So what would be a good option for her? She would be a good candidate for, sorry guys, we're having lots of technical issues, such as the way of chest and life. She would be a good candidate for high flow nasal cannula. I'm gonna wing this a little bit. The reason for that is you can have humidity, it provides high flow rates, you can achieve high oxygen saturations and can help with dead space washout. It's really good for clearing sputum in these patients with bad COPD. What is it not good for? We all have these patients, inpatient, who just don't like the heat, don't like the flow. So some people are not going to like it. One of the biggest limitations with high flow you guys should be aware of is the amount of oxygen that's needed. So the flow rates are frequently what's touted by companies who promote these and it's true you can get very high flow rates. It's frequently the amount of oxygen that the patients need to get into the units that's the problem. So you end up having to do creative solutions like Dr. Brown's why tanking or why connections getting multiple tanks together. All right so I'll just go through the cases we could talk about pros and cons of each. So Mr. C is a 68 year old man with IPF diagnosed four years ago. He's despite this horrible CT scan on the right doing quite well. He's very active. He's walking three miles a day and working at an office desk job. Two weeks ago he's hospitalized with acute hypoxic respiratory failure thought to be from exacerbation. At discharge he's still quite functional. He's still ambulating doing his normal stuff but now he needs even more oxygen so he's needing seven liters a minute. He'd like to return home to work and walking. A good option for this guy might be an oximizer so he's very ambulatory right. He is motivated. He wants to get out and do stuff. He doesn't really need the humidity so an oximizer is a great option. It's lightweight. It's portable. It's easy for patients to use and you can use your regular oxygen supplies to bleed in and use functionally use less oxygen. The downside of an oximizer is lack of humidity so that's one of the biggest things. So if you have a patient who has a lot of secretions, somebody who's in an air climate like Jeanette and I are in Utah, ends up being not the best option for you. Other things to know about it is they're disposable. They're not permanent so you have to have a supply of them. After I think it's a couple weeks, is that right? A couple weeks you have to dispose of it and get a new one. We have them available that people can put their hands on and touch but they're quite thick too so some people just don't like how thick it is and heavy it is and pulls on them so some people are just like you know it's just too much. This isn't the right option for me. Okay and then patient three, please dismiss my humor with this one, but 40 year old guy and vaccinated COVID surprisingly gets infected. He gets ARDS, intubated for two weeks and undergoes trach. He's decannulated four weeks later. His lungs demonstrate widespread fibrotic changes. So he's discharged from his nursing facility, is quite hypoxic still, not that much better, mainly bedridden, mainly and requires 10 liters of oxygen to maintain SATs. He's not doing much. What would be a good option for this guy? This guy would be a good, a good option for this guy would be one of our large concentrators that we have available you can look at. So they can concentrate oxygen up to 10 liters so maintain the SATs that he needs. They don't require, they're quite heavy. So one thing I would ask you guys when you're looking at these, it wasn't really apparent to me until I actually put hands on this that these are really heavy. I lugged one across the street over here to this conference talk today. They're like 40, 50 pounds. They're big. So if you think of your frail patient after a COVID admission or ILD, if you're really expecting them to be mobile, even though they're on wheels, it's not exactly the easiest thing in the world to get around. They're also quite loud. We have them plugged in, we can turn them on, but they are loud, they make, they vibrate a lot, and then one thing I had included in slides that have not appeared up here is they're very expensive. So something to keep in mind is that these oxygen concentrators burn through energy. There's a good study from things that GM Network opened last year that looked at the cost of running one of these home concentration or concentrators and it's like over $700 for a year in electricity in these concentrators and that's even before like inflation and stuff. So if you have patients who are, you know, financially strapped, one of these devices is going to be far more expensive than like liquid oxygen if they were on an amount of O2 that would be, that would suffice for it. So something to keep in mind. These are good, all these are good options, but they all have pros and cons with it. Because a lot of these slides didn't upload, I will direct you guys, there are handouts available that should be through the app that our RTs have built going through pros and cons of each of these devices, who the optimal patient would be for each thing. What we're envisioning for the next half hour or so would be that people come up, we can, you can put your hands on devices, look at them, we can demonstrate them, turn things on, and actually just get familiar with these. I've not been as familiar with these until doing these sessions and putting my hands on them, so feel free to come up and ask questions. We have lots of staff able to answer things. With that, anything else people want addressed before? I have a great overview in terms of options. I don't have a lot of experience with transtracheal oxygen and or early trach. Is that something that you might consider in any of these patients? For example, the one who had the extensive emphysematous lung disease changes in terms of eliminating dead space ventilation. It's a good question. So we've not done a ton of trans, we've not done transtracheal at Utah. I did some in fellowship. I'd be curious as we're looking at devices if people who have more experience with transtracheal would speak up. My little bit of experience with transtracheal is that it's good for the right patient. So somebody who's motivated is quite apt at caring for it. Something we run into a lot are plugging, so they get plugged up a lot. So putting it in somebody who's just not very active, doesn't have great support, is probably not the best option. So good question. I have a follow-up to that. I'm a pediatrician and I care for a couple of children with transtracheal oxygen after their tracheostomy has been removed. The parent company no longer exists and I was wondering if anyone in the audience knows, is there a source for transtracheal oxygen catheters? I don't know. So they need to be replaced eventually and I'm running out of options. I'm not familiar unless anybody else is. I see Dr. Chan walking up. Okay. I'm at University of Michigan. We used to do transtracheal oxygen and now we're told we send them to Cleveland Clinic that they were the only local area that was doing them and I haven't talked to them about supplies, but that is a real big deal. We used to do a lot, do it fairly frequently. I was very successful in the motivated patient, but because I've post COVID, I had a patient with CVID that was in the hospital for four months because couldn't eliminate it and he's on 15 liters and we couldn't get him home. That was a thought and he's a healthy person just like this. So I had a couple questions because when I'm writing, and I don't know what an oximizer is, that's the first thing. The second thing is heated high flow. I'm familiar with it in the hospital, but not at home. I write, you know, I have this form in my epic and I just put down and I give it to the to the clinic whatever manager and it just goes and I don't know what happens and then I hear about it from the patient, right? That's what happens and then we're saying oh this and because what when we my first question is usually if it's above six liters the ATS suggests liquid oxygen. Now I can't get it. The second issue is if half my patients they're older and they go to Florida and so when they leave they're snowbirds and then they need the oxygen down there. So a local company is different than I think Benson's is nationwide or something or Lendcare, one of those two, so that they can supply it. But these are the things the practical things that I need help with and then when they're over six liters I tried to write for liquid they can't get it and then everybody wants their portable concentrator and every time you tell them it can only go up to five liters and they want an ionogen but it is pulse dose, right? Everyone's been through this pulse dose. I can't and then when I try and change it they don't want you to change it because they don't take away my portable concentrator. I don't want to wear have these tanks. So those are the practical aspects but that if I could get heated high flow at home that would be great. I've never heard of that and just educate me on the Oximizer but those are some of my practical aspects from just basics without getting too fancy. So if you could help me with that, I will. So Kevin, getting them qualified is an issue. You're right the inogen thing people see the cute TV commercials and they're like I want the little thing and then they don't understand they're on too much oxygen pulse dose is not sufficient. So we have a capacity to do that like a walk trial in clinic and show them and prove to them that they can't do pulse dose and so that's a no which is sad. The other aspect is getting an inogen paid for is super painful. Most patients I have are frankly if you're paying for an inogen it's out of pocket. You know some in private insurance will cover it but that's not something your standard Medicare patient is going to be able to get typically unless they have something supplemental and that's really hard. The other thing though is if I'm happy to talk to Kevin about the heated high flow but yeah again part of that is listing all the things that they have failed and saying they require X much oxygen X much flow we've done it they've been successful and then putting together the prescription form and also finding a DME in your area or the patient's area that will get it to them. So those are kind of the steps. And your your question about the Oximizer so we have some over here we can we can look at but for those who aren't familiar with it it's a device that basically serves as a reservoir so oxygen can concentrate in there so you can effectively use less oxygen to keep the the SATs up so it's frequent that we have patients who are on like six liters nasal cannula they use an Oximizer they need like four like they don't need quite as much it's a good tool. I've had success with one person I'll say end of one that we we walk them in clinic with an Oximizer and we're able to write like this is how much this patient needs with Oximizer of four so end of one but that worked so that's something you could try but they need to have it in clinic for the walk. Is that helpful? I don't know about all DMEs but I've never had trouble getting one yeah people are just jerry-rigging stuff. So before we get to toys I do I would like to hear some comments on the the infrastructure problem with the oxygen supplies we have for many areas of the country mine included where you cannot get a liquid system there is not one in the state of Georgia to give to my patients so I can call all the DME companies and they won't fill the prescription because they don't have one and so I think some of these other devices Airvo in particular in our area the only way to get it is one very specific hospice company yes that is correct so so I think part of that and and I'm sure much of this goes back to the payer system in the in the US and the under reimbursement and the fact that you know innovation doesn't get covered in the oxygen space because of that but if you could comment on some of that in your experience where you are I think that would be great thank you. Yeah no the oxygen difficulty personally came down with the competitive bid system liquid oxygen basically went away in a lot of places I can't get liquid oxygen but being able to at least with some of these like 10 liter concentrators plus some of these systems you can actually get a decent amount of O2 plus flow and that's what you lack with just the standard cannulas obviously the oxymizer oxymask is a little different but and sometimes it's just being a little creative like in clinic you know time the oxymizer see what happens you know but it is a really tough and I miss liquid oxygen as well but unless something changes with the way that it's paid for I don't know if that's gonna change. There is a couple of devices where they're looking at kind of like the Inogen style but it it is has the ability to sense flow so if patients sitting breathing comfortably it doesn't need as much flow but if they get up and walk it they do so they are working on some technology I know companies to have something that senses and his ability to change flow dynamically with exercise so that might be something that might help some of those patients. I just had two questions one is clarification is that oxymizer the same as what they call the pendant? Okay yep and the mustache and the second question is the they're starting to advertise some of these almost like a portable BiPAP you know with the with the flow that you can adjust and all that I don't know if that was some of the equipment that you had mentioned or is that something that's not very available either? It's something like like 2000 from Hill Rom it's primarily marketed for like your COPD patients your qualifications are like see PCO2 is to be like greater than 48 etc and that one that one is the exception you actually go through Hill Rom to get the device as opposed to most the time you get a DME to provide it but again it's been a little interesting I have never gotten one for a patient I haven't tried really hard with that one so that is one of those that I think we're waiting to kind of figure out to see if we can get it for patients. Hi I'm Allison at the University of Chicago. The one thing we want to be careful is patients get this point of care devices the pulse oxygen and then they want to use it with their CPAPs and BiPAPs and ventilators and they don't know and they go to Florida and it's tiny and cute and then they're very hypoxic with their ventilators. So one thing to ask the patient the other one I'm having problem getting the Louisa approved for patients with significant ILD hypoxia that may not be hypercapnic and not qualify for NIV. Are you encountering the same? That is one scenario is going to point out with is yes it's still an NIV device and right now the guidelines are based on NIV. That being said you can write a letter of appeal letter of medical necessity and you know go through that process. Yes you're not guaranteed but the other thing that might I think is important is it turns out that Medicaid in California for example pays for the ERVOs at home because they figured out it was a good thing because patients squawked. Patients were advocating and saying I need this device I need to be home and so in some ways we might be better off also talking to our patient organizations and having them pressure the payers and pressure the government to cover them. Okay so let's walk over and see our toys people come up and look specifically things that we have to go through. So we have the oximizers like mentioned so we have pendant and mustache that's why I'm pointing my nose and then an oxy mask which isn't an oximizer but along the same lines. We have a few high flow units and then we have some of the large 10 liter concentrators over there as well so come over let's see stuff let's turn stuff on let's actually put hands on things okay. Also don't forget to fill out your evaluation on your app.

medical devices

patients

guidelines

Durable Medical Equipment

severe hypoxia

portability

patient mobilization