what is oxygen level guideline, before needing supplemental oxygen?

Question

I have just finished testing overnight at home with a portable oxymeter. I have noticed that the level dropped considerably upon resting (84-88) I do have COPD. I found that when I am active the level fluctuates between 91-96. Can someone tell me how normal oxygen level should be? Does anyone know what medi-care guideline is to cover the cost of supplemental home oxygen?

Answer 1

Long-term supplemental oxygen therapy
http://www.intmed.mcw.edu/ClinicConf/UpToDate%AE%20'Long-term%20supplemental%20oxygen%20therapy'.htm

Brian L Tiep, MD
Rick Carter, PhD, MS, MBA

UpToDate performs a continuous review of over 330 journals and other resources. Updates are added as important new information is published. The literature review for version 13.1 is current through December 2004; this topic was last changed on January 16, 2004. The next version of UpToDate (13.2) will be released in June 2005.

INTRODUCTION — Oxygen has been demonstrated to increase survival and improve the quality of life in patients with chronic obstructive pulmonary disease (COPD) (show figure 1 and show figure 2) [1-3]. In the United States, for example, there are currently more than 600,000 patients receiving long-term oxygen therapy (LTOT), most of whom are Medicare recipients with COPD [4].

FINANCIAL ISSUES — Although most physicians and health care professionals consider oxygen to be an important drug for the treatment of hypoxemia, the Center for Medicare and Medicaid Services (CMS; formerly called the Health Care Financing Administration, or HCFA) does not pay for outpatient medications for Medicare recipients. However, CMS classifies oxygen and oxygen delivery equipment as durable medical equipment (DME); this definition allows oxygen to be reimbursed as a form of "medical equipment." As a result, a specific Certificate of Medical Necessity (CMN) called the HCFA–484 must be completed by the physician in order for oxygen therapy to be reimbursed at a level of 80 percent of the Medicare allowable charge. The patient or supplemental insurance is responsible for the remaining 20 percent of the cost.

The requirements for medical necessity established by CMS are also utilized by most third party payers. These requirements are based primarily on the parameters for entry into the multicenter Nocturnal Oxygen Therapy Trial (NOTT) sponsored by the National Institutes of Health [1]. Indications and guidelines for therapy have been further refined by five national consensus conferences on LTOT [5-9]. These guidelines apply not only to hypoxemic patients with COPD, but also to patients whose hypoxemia is due to other disorders, such as chronic interstitial lung disease, chest wall disease, and cardiac disease [10].

Within these guidelines, it is the physician's responsibility to be involved in selection of appropriate equipment and provision of an individualized prescription that must be transmitted to the DME provider (show figure 3). The prescription must contain several required elements including liter oxygen flow and any changes that may be required for sleep, exercise or other condition, duration of need, and/or the issuance of portable oxygen devices. The physician is now instructed not to sign the CMN form (HCFA-484) unless the provider has correctly restated the prescription in Section C (show figure 4A-4B). Periodically, the physician will need to recertify the patient for supplemental oxygen and this recertification must be completed within a specified period of time to ensure that oxygen is provided without interruption.

INDICATIONS — Current indications for continuous long-term oxygen therapy are (show table 1):
bullet Arterial PO2 (PaO2) less than or equal to 55 mmHg or an arterial oxygen saturation (SaO2) less than or equal to 88 percent.

bullet PaO2 between 56 to 59 mmHg or an SaO2 of 89 percent, if there is evidence of cor pulmonale, right heart failure, or erythrocytosis (hematocrit above 55 percent).

Additional Medicare indications for the use of oxygen during sleep or exercise include the following:
bullet Oxygen may be prescribed during sleep if the PaO2 is 55 mmHg or less, the SaO2 is 88 percent or less, or there is a fall in PaO2 of more than 10 mmHg or a fall in SaO2 of more than five percent with signs or symptoms of hypoxemia. The latter indication is defined by CMS as "impaired cognitive process, restlessness, or insomnia."

bullet Oxygen may be prescribed during exercise if there is a reduction in PaO2 to 55 mmHg or less or in SaO2 to 88 percent or less. One of the most important forms of exercise for patients with COPD is walking to perform the activities of daily living.

Documentation of hypoxemia during sleep or exercise is not justification for continuous oxygen therapy if hypoxemia is not present when the patient is awake and at rest. Furthermore, LTOT has not been documented to be effective in patients with milder degrees of hypoxemia. As an example, one study randomized 135 patients with COPD and a PaO2 of 56 to 65 mmHg to either LTOT or standard therapy [11]. No significant differences in survival were noted at one, two, or three years.

REQUIREMENTS — In addition to the PaO2 or SaO2 as indications for LTOT, there are specific requirements that must be fulfilled in order for oxygen to be reimbursed by CMS:
bullet Arterial blood gas analysis or measurement of SaO2 to document the need for outpatient oxygen therapy must be performed by a Medicare qualified laboratory. The intent of this requirement is to prevent the oxygen provider from also being responsible for certifying the medical necessity, since this could represent a conflict of interest.

bullet If oxygen is prescribed at the time of hospital discharge, the arterial blood gas or saturation measurement must be obtained within 2 days of discharge.

bullet Medical management should be optimum when LTOT is prescribed. Short–term oxygen therapy (STOT) may be necessary for some patients with COPD following hospitalization for exacerbation or during periods of acute illness. Lifetime continuous oxygen therapy should be prescribed only when there is evidence of hypoxemia in a clinically stable patient who is receiving appropriate medical management. It is recommended that the arterial blood gas measurement be repeated in one to three months following an acute illness to determine the need for continuous LTOT [7].

bullet The physician or a member of his or her staff must complete the Certification of Medical Necessity (CMN) Form (HCFA–484) (show figure 4A-4B; this can be printed for personal use) and only the physician can sign the form. This requirement is intended to assure the physician's involvement in the prescribing and administration of LTOT.

bullet If the PaO2 is 56 to 59 mmHg or the SaO2 is 89 percent, the blood gas measurement must be repeated in 60 to 90 days in order for oxygen to be continued beyond the initial three months of therapy. This requirement represents a Congressional misunderstanding of the recommendation of the oxygen consensus conference that arterial blood gases should be repeated in one to three months whenever therapy is begun in a clinically unstable patient where the medical management may not be optimal [7].

bullet All patients receiving LTOT must be recertified in 12 months, but retesting of arterial blood gases or oxyhemoglobin saturation is not necessary.

bullet For patients receiving long–term (lifetime) oxygen therapy, renewal of the CMN after the first year is required only when there is a change in the prescription for oxygen. This represents a welcome change in CMS regulations, which previously required yearly recertification with completion of Form HCFA–484 annually. If the oxygen supplier changes, a renewal may also be requested.

bullet Portable oxygen is allowed if the Medicare patient is mobile in the home and regularly goes beyond the limits of a stationary oxygen delivery system with 50 feet of tubing. The CMS does not consider travel outside of the home in making this determination and also does not recognize a distinction between portable and ambulatory oxygen. The distinction made by the Pulmonary Medicine community is that ambulatory oxygen delivery systems should weigh less than 10 lbs (4.5 kg) and be easily carried by the patient [8]. These units should be provided for patients who are highly mobile and active. Portable units, such as a steel cylinder on a two-wheeled stroller, cannot be carried by the patient and are difficult to maneuver on stairs and on public or private vehicles of transportation. Portable units should be prescribed for patients who are less mobile and who leave the home only occasionally.

PRESCRIPTION — The requirement for the physician to sign the CMN was recommended by the Office of the Inspector General of the United States after a five–state survey indicated that the physician's knowledge of home oxygen therapy and involvement in writing the prescription were often inadequate [12]. In many cases, the home oxygen supplier was determining the need for therapy and also supplying the equipment without adequate physician input.

Oxygen is reimbursed on a prospective payment basis by CMS, and there is no Medicare requirement concerning the type of equipment being provided by the home oxygen supplier. CMS considers all oxygen delivery systems to be equal and "modality neutral." For patients who require portable systems, there is a small additional reimbursement for a "portable add on" device.

Responsibilities of the physician — It is extremely important that the physician be actively involved in this process and prescribe the type of equipment that is most appropriate for each patient's needs (show table 2). The CMN no longer serves as the physician's prescription; therefore, a separate oral or written prescription must be provided to the home oxygen supplier when oxygen is ordered and prior to completion of form HCFA-484 (show figure 3).

The physician should also know the DME providers in the area and encourage the use of those providers who are willing and able to provide the best service and to fill the prescription appropriately. For highly active and mobile patients, the physician should order ambulatory liquid oxygen or lightweight, aluminum or fiber–wrapped ambulatory cylinders, both of which may be combined with an oxygen conserving device to substantially increase the functional time and reduce the size and weight of the unit that the patient carries. The DME supplier may not provide patients with the best available technology unless the physician has the knowledge and ability to prescribe it. (See "Oxygen conserving devices").

In addition to determining the medical necessity for home oxygen therapy in patients with COPD, the physician, with the aid of the DME provider, should monitor the use of the oxygen by the patient and the environment in which the oxygen is being used. Patients who continue to smoke while using oxygen represent a hazard to themselves, their families, and other occupants of buildings where they live. Oxygen should not be continued if the patient is unwilling to use it, and advanced ambulatory equipment should not be supplied if the patient is unwilling or unable to be physically active.

Prescription recommendations — Arterial blood gas measurements, rather than the measurement of arterial oxygen saturation alone, should be the standard to document the need for LTOT [7]. No patient should be subjected to a lifetime of continuous oxygen therapy based on the imprecise measurement of SaO2 by an oximeter. Thus, every patient with COPD should have baseline measurements that include the level of PaCO2 and pH as well as PaO2. The arterial blood gas measurements also provide an indication of the correlation of SaO2 with PaO2. In addition, the appropriate oxygen flow rate should be determined for each patient as well as an assessment of exercise desaturation, sleep desaturation, and the potential usefulness of transtracheal oxygen therapy.
bullet The flow of oxygen needed to correct hypoxemia should be determined by measurement of PaO2 or SaO2 when LTOT is initiated (show table 3). The precise PaO2 or SaO2 that optimally improves survival and quality of life is not known. One of the early studies that demonstrated increased survival in patients with COPD who received LTOT raised the mean PaO2 during therapy to 71.3 mmHg [13]. In the NOTT study the investigators attempted to maintain the PaO2 between 60 and 80 mmHg [1]. A PaO2 of 60 to 65 mmHg or an SaO2 of 90 to 92 percent is generally considered to be acceptable. This represents clinically "adequate" correction of hypoxemia for most patients and is unlikely to cause significant CO2 retention. (See "Use of oxygen in patients with hypercapnia").

bullet Approximately 20 to 30 percent of patients with COPD who qualify for LTOT because of hypoxemia at rest show additional desaturation during usual activities of daily living, such as walking. As a result, higher oxygen flows may be necessary during these activities. It is therefore important to determine the exercise oxygen prescription while the patient is walking and to include this information in the oxygen prescription. The difference in oxygen flow necessary to correct hypoxemia at rest and during exercise may be magnified when some of the oxygen conserving devices are being used, especially those that utilize an oxygen pulsing device [14].

bullet Physicians should also determine if higher flows of oxygen are necessary to prevent nocturnal oxygen desaturation. The overall importance of nocturnal desaturation is still unclear, since some persons who have no identifiable disease may demonstrate oxyhemoglobin desaturation during sleep. For example, 30 percent of patients with COPD without daytime hypoxemia have been found to experience desaturation during sleep at night [15,16].

Nocturnal use of oxygen is indicated in two groups of patients:
bullet In those patients who qualify for LTOT because of hypoxemia while awake, it is desirable to adjust the flow rate of oxygen, if necessary, to prevent hypoxemia during sleep. In the NOTT study, for example, oxygen flow was routinely increased by one L/min during sleep [1].

bullet In those patients with COPD who have cor pulmonale, right heart failure, or erythrocytosis without evidence of hypoxemia while awake, any period of prolonged desaturation during sleep may be detrimental. Thus, nocturnal monitoring of hypoxemic events and titration of supplemental oxygen is recommended.

Transtracheal oxygen administration — Transtracheal oxygen appears to impart significant advantages over nasal oxygen delivery by assuring oxygenation and perhaps reducing the work of breathing [17]. Although transtracheal oxygen therapy is a more invasive alternative, patient acceptance has been exceptionally good and compliance with therapy is substantially enhanced [18]. This is a technology that is currently being underutilized, but it does require organization and commitment by the physician and his or her staff. (See "Transtracheal oxygen therapy").

Oxygen adjunctive to exercise training — Hypoxemic patients are prescribed oxygen in order to prevent exertional desaturation as described above. However, a recent double blind study performed on COPD patients, who were not hypoxemic at rest, demonstrated that oxygen during exercise enabled patients to tolerate higher training intensity and increased exercise tolerance [19]. The exact role of oxygen as a rehabilitative adjunct remains to be delineated.

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REFERENCES
1. Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical trial. Nocturnal Oxygen Therapy Trial Group. Ann Intern Med 1980; 93:391.
2. Long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema. Report of the Medical Research Council Working Party. Lancet 1981; 1:681.
3. Eaton, T, Lewis, C, Young, P, et al. Long-term oxygen therapy improves health-related quality of life. Respir Med 2004; 98:285.
4. O'Donohue, WJ Jr, Plummer, AL. Magnitude of usage and cost of home oxygen therapy in the United States. Chest 1995; 107:301.
5. Problems in prescribing and supplying oxygen for Medicare patients. Am Rev Respir Dis 1986; 134:340.
6. Further recommendations for prescribing and supplying longterm oxygen therapy. Am Rev Respir Dis 1988; 138:745.
7. New problems in supply, reimbursement and certification of medical necessity for longterm oxygen therapy. Am Rev Respir Dis 1990; 142:721.
8. Petty, TL, O'Donohue, WJ Jr. Further recommendations for prescribing, reimbursement, technology development, and research in long-term oxygen therapy. Summary of the Fourth Oxygen Consensus Conference, Washington, D.C., October 15-16, 1993. Am J Respir Crit Care Med 1994; 150:875.
9. Petty, TL, Casaburi, R. Recommendations of the Fifth Oxygen Consensus Conference. Writing and Organizing Committees. Respir Care 2000; 45:957.
10. Zielinski, J. Long-term oxygen therapy in conditions other than chronic obstructive pulmonary disease. Respir Care 2000; 45:172.
11. Gorecka, D, Gorzelak, K, Sliwinski, P, et al. Effect of long term oxygen therapy on survival in patients with chronic obstructive pulmonary disease with moderate hypoxaemia. Thorax 1997; 52:674.
12. Office of the Inspector General, Office of Audit Services. Results of national review of the medical necessity for oxygen concentrators. Audit Control No. A048802058, 1990.
13. Neff, TA, Petty, TL. Long-term continuous oxygen therapy in chronic airway obstruction. Mortality in relationship to cor pulmonale, hypoxia, and hypercapnia. Ann Intern Med 1970; 72:621.
14. Tiep, BL, Barnett, J, Schiffman, G, et al. Maintaining oxygenation via demand oxygen delivery during rest and exercise. Respir Care 2002; 47:887.
15. Fletcher, EC, Miller, J, Divine, GW, et al. Nocturnal oxyhemoglobin desaturation in COPD patients with PaO2 above 60 mmHg. Chest 1987; 92:604.
16. Fletcher, EC, Luckett, RA, GoodnightWhite, S, et al. A doubleblind trial of nocturnal supplemental oxygen for sleep desaturation in patients with chronic obstructive pulmonary disease and daytime PaO2 above 60 mmHg. Am Rev Respir Dis 1992; 145:1070.
17. O'Donohue, WJ Jr. Transtracheal oxygen: A step beyond the nasal cannula for longterm oxygen therapy. Nebr Med J 1992; 77:291.
18. Christopher, KL, Spofford, BT, Petrun, MD, et al. A program for transtracheal oxygen delivery: Assessment of safety and efficacy. Ann Intern Med 1987; 107:802.
19. Emtner, M, Porszasz, J, Burns, M, et al. Benefits of supplemental oxygen in exercise training in nonhypoxemic chronic obstructive pulmonary

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Answer 2

I have COPD and am on both oxygen and Medicare. The oxygen company has to have certain documentation from your Pulmonologist in order to supply you with the oxygen and related equipment, and they need a certification from him/her that your saturation is 87 or less. They also need the pulse-oximeter print out that is required by Medicare. No one at the doc's office said it had to be measured while I was at rest. If you are 90 at rest, you most likely will be below 88 just with normal walking. Therefore, you need supplemental oxygen for normal daily activity, even if you're sometimes up to 96. You will especially need oxygen when you sleep. Your and everyone's SAT drops during sleep, even though you're at rest. Normal oxygen level for someone without a lung condition is 95 or above, the top is 100.

Answer 3

I am a nurse and I can tell you that sustained periods of oxygen saturation below 88% are bad. I am thinking that medicare will pay for oxygen supplementation if it is medically documented that you have had such periods of low saturation and with a prescription. Talk to your physician and let him know. The normal oxygen saturation is greater than 98%.

Answer 4

Less than 60 on at least 40% oxygen, or less than 40% on room air. However there are many other contributing factors that contribute to the decision to mechanically ventilate such as a CO2 level higher than 50 and a respiratory rate higher than 35.

Answer 5

Your 02 saturation has to be above 88% to qualify for home oxygen thru medicare with activity or at rest. You qualify. We like to see you above 90% if you are a non smoker and above 88% if you are a COPD c02 retainer. People with emphysema have a high c02 as their drive to breath. If you give the COPD pt too much oxygen, they lose their drive.
I am a hospital nurse in Illinois. I am not sure what all that crap is in the paragraph above me.

Answer 6

Medicare guidelines as I remember is about 86-87% A normal O2 level is somewhere in the high 90's. With COPD it won't be that high, of course. Your numbers that you stated should be in reverse....having a lower O2 sat when you are exercizing. If you play your cards right, you can "qualify"......get my drift????

Answer 7

Needing Oxygen

Answer 8

on a blood gas your po2 has to be below 58, on a sat monitor it has to be below 88% with either resting or active.... if you have lung ca, or certain heart disease the numbers are higher

Answer 9

nurses: that's why we have professionally trained respiratory therapists.

this answer is going to be very long but read it through and you'll be learning something about your condition, oxygen needs, and what is acceptable.

88% is the benchmark, you must be at or below, at rest on room air, to qualify for oxygen, but don't give it no mind. the businesses that dispense home O2 know exactly the questions to ask and the doctors usually know the diagnoses which qualify.

if you are higher than 88% you can still qualify by doing an exercise test. really not much more than walking about five minutes with a pulse oximeter attached. if you fall to 88% or lower you'll qualify for O2 with activity.

your initial qualification may require an ABG (arterial blood gas).
this is a needle stick in the wrist to draw a small amount of blood from an artery. this is the most difinitive way to qualify.

medicare pays for oxygen at home. third party insurers pay for oxygen at home also but within medicare guidelines and according to thier own whimsy policies.

but there is a third condition here: you said you had an oveninght study. this is usually done as a separate test to determine your nocturnal needs. the doctors article though lengthy is the gold standard by which physicans and government have come to recognize the benefits of oxygen for certain patients requiring oxygen.
the NOTT study when looked at in its simplest form says that those who wear nighttime oxygen for more than 12 hours/18hours have a better quality of life, and live longer than those who wear it for 12 hours or less and who needed it in the first place. the details are in the article. the NOTT study has been taking place since the 1980's with well over a 100,000 patients contributing to its outcome.

back to you. the night time study. was it done in conjunction with a sleep apnea test? you don't say. if it was then you were being tested more for sleep apnea related issues and the oximetry was a secondary finding. sleep apnea is a separate diagnosis requiring a different type treatment then just oxygen delivery, but oxygen may be a part of the treatment and if so will qualify under group II guidelines i believe. but it may still be group I.

if you have COPD, you will likely qualify for oxygen at rest at some time in the future if not right now. the guideline for payment of oxygen is fixed regardless of who supplies it, how much, and what device. the medicare allowable i believe at the moment is $230 per month, maybe $200, with another smaller amount per month allowed for portability outside the home. if you dont have medicare then your private insurer will have guidelines for payment of such and they are often equivalent to medicares guidelines for qualification, and for payment.

finalizing your question. it is not unusual for a newly diagnosed COPDer to have reasonably normal saturations-that is greater than 88% at rest, but they find that their saturation drops rapidly, from say 95% to below 88% with exercise or walking. which is why pulmonologists often hear "i can hardly walk to the mailbox and back without getting short of breath". (that statement is another story) but you seem to indicate the opposite which means you likely have the facts reversed. then again you could be missing a piece of evidence. for instance your saturation of 84 to 88 at rest, is that on room air? probably so. but your saturation of 91 to 96 with exercise, is that wearing oxygen? you don't say. if you were not wearing oxygen then i would say the facts are reversed. if you were wearing oxygen then the facts you stated are beliveable.

lastly what is normal oxygen. hang on here this gets a bit medical and scientific but its all provable and correct from the latest medical teaching texts. the respiratory therapist and the nurses are only closely accurate on this one although they are usually the ones to listen to.
a. in all studies conducted on healthy males 20 years old at rest by arterial blood gas, oxygen levels were about 100 to 110mmHg. that is a oxygen pressure measurement of the blood termed PaO2. the corresponding saturation (SaO2) is 97 to 100%. rarely do people sustain 100% saturations on room air.

b. in all studies conducted on healthy males greater than 50 years old the PaO2 expectedly decreases with age, but the oxygen saturation will remain at or about 97%. for you medical people go check your henderson-hasselbach curve of PaO2's versus SaO2. it isnt until the PaO2 gets near 80mmHg on the curve that the SaO2 will begin to demonstrate drops and then it will drop to values above 90%. of course the T, 2-3DPG, and pH must be accounted for but at 7.4 pH what i am saying is accurate.

a basic rule is 40,50,60 of pressure measurement equals 70,80.90 percent saturation measurement. and all this is scientifically proven and irrefutable if you'll check your nursing manual or egans text books.

as for how low oxygen needs to be before it is dangerous well that has many other factors besides low oxygen. when oxygen does get to low, say for instance below 90% then we really want to know why and treat the cause, but the usual treatment is panic and give oxygen to raise the %. when oxygen is lo enough to be of concern it will show up in two ways immediately:

1. an increase in heart rate, which may or may not, and usually not, have irregularities to the rate; we could debate, and we would find many variables, but not now.

2. is an increase in respiratory rate.

these two things are controlled by oxygen sensors in the aorta, carotids, and medulla, plus acidity/alkalinity of the blood. all this sensing changes some for COPDer's depending on how long you have been affected with the condition.

3. an issue for COPD is carbon dioxide retention. i wont go into this but it is a major concern over the years, as it rises, displaces the oxygen on the hemoglobin, changes the pH of the blood and in general cause hell with the patient.

if you would like to learn more, email me at [e-mail]
i can be less wordy and more accurate answering direct questions you may have. this question is so open ended that many an answer is needed.
thanks for letting me in the forum.

Answer 10

they like a 96. however they will repeat test to see if its dropping. if so you will need oxygen if they cant figure it out which in real quick time they will. thanks