Closing gaps in the oxygen supply chain in nations with limited resources.

Oxygen is an essential medication used across all levels of healthcare for conditions such as surgery, trauma, heart failure, asthma, pneumonia, and maternal and child care. Despite its critical importance and inclusion on the World Health Organization's list of essential medicines, many low- and middle-income countries (LMICs) face significant challenges in providing adequate oxygen supplies. These challenges are exacerbated by the COVID-19 pandemic, which has drastically increased global oxygen demand. This paper examines the current challenges and advancements in the oxygen supply chain within LMICs, focusing on availability, infrastructure, and usage. It highlights the innovative solutions being implemented to improve oxygen access and offers strategic recommendations for enhancing oxygen delivery and maintenance in resource-limited settings.

An Oxygen Supply Is Not Enough: A Qualitative Analysis of a Pressure Swing Adsorption Oxygen Plant Program in Ethiopian Hospitals.

BACKGROUND: In response to critical gaps in medical oxygen access, 2 pressure swing adsorption (PSA) oxygen production centers were established using an ecosystem-strengthening strategy in Amhara, Ethiopia, in 2019. A qualitative study was conducted to assess enablers and bottlenecks to oxygen access at the hospital level after installation. METHODS: A variety of hospital staff (clinicians, biomedical professionals, hospital administrators, and procurement teams) across 13 hospitals procuring oxygen from the plants participated in comprehensive, semistructured focus group discussions. A thematic framework analysis approach was used to identify key themes. FINDINGS: A total of 101 individuals participated in 26 focus groups in 2021, 2 years after plants were installed. Primary themes were accessibility of supply, affordability, and hospital readiness. Respondents indicated a substantial increase in their hospital's ability to access lower-cost oxygen, with many attributing this to the locality of plants and reduced transportation barriers. However, other challenges persisted, and the emergence of COVID-19 1 year after plant installation and a civil conflict exacerbated supply shortages. Investments in equipment, supplies, and training optimized clinical utilization of oxygen and were highlighted as a need for ongoing investment. CONCLUSION: To achieve maximum impact, investments in large-scale oxygen systems must be accompanied by strategic plans to transport oxygen, reduce costs to hospitals, and provide support to clinical teams through equipment, supply procurement, and clinical training. These findings support comprehensive ecosystem approaches to strengthening oxygen access for sustainable impact.

Functional availability of medical oxygen for the management of hypoxaemia in Cameroon: A nationwide facility-based cross-sectional survey.

Background: Medical oxygen is essential for managing hypoxaemia, which has a multifactorial origin, including acute and chronic lung diseases such as pneumonia, asthma, and severe malaria. The coronavirus disease 2019 (COVID-19) revealed substantial gaps in the availability and accessibility of safe medical oxygen, especially in low- and middle-income countries (LMICs). This study aimed to assess the availability and sources, as well as the barriers to the availability of functional medical oxygen in hospitals in Cameroon. Methods: This was a nationwide cross-sectional descriptive study conducted from 26 March to 1 June 2021. Using a convenient sampling technique, we sampled accredited public and private COVID-19 treatment centres in all ten regions in Cameroon. Representatives from the selected hospitals were provided with a pre-designed questionnaire assessing the availability, type, and state of medical oxygen in their facilities. All analyses were performed using R. Results: In total, 114 hospitals were included in this study, with functional medical oxygen available in 65% (74/114) of the hospitals. About 85% (23/27) of the reference hospitals and only 59% (51/87) of the district hospitals had available functional medical oxygen. Compared to district hospitals, reference hospitals were more likely to have central oxygen units (reference vs. district: 10 vs. 0%), oxygen cylinders (74 vs. 42%), and oxygen concentrators (79 vs. 51%). The most common barriers to the availability of medical oxygen were inadequate oxygen supply to meet needs (district vs. reference hospitals: 55 vs. 30%), long delays in oxygen bottle refills (51 vs. 49%), and long distances from oxygen suppliers (57 vs. 49%). Conclusions: The availability of medical oxygen in hospitals in Cameroon is suboptimal and more limited in districts compared to reference hospitals. The cost of medical oxygen, delays related to refills and supplies, and long distances from medical sources were the most common barriers to availability in Cameroon.

Hospital Oxygen Supply Overwhelmed Due to COVID-19: When Demand Exceeds Supply.

BACKGROUND: During the first wave of COVID-19, we experienced problems with our hospital oxygen supply system. This study aimed to analyze factors that stressed this system and rethink the design criteria of the gas pipeline system considering the varying oxygen demand. METHODS: A retrospective study was conducted to describe problems that occurred at different stages in the oxygen supply system at our hospital due to increases in oxygen use in general, and the creation of an intermediate respiratory care unit (IRCU) and use of high-flow nasal cannula (HFNC) in particular. Herein, the characteristics and design criteria of the medical gas pipeline system are analyzed, and the steps taken to avoid future problems are outlined. RESULTS: Increases in oxygen use were observed at times of maximum occupancy, and these created vulnerabilities in the oxygen supply due to insufficient capacity in terms of cryogenic tanks, evaporators, and the piping network. The peak consumption was 3 times higher than the peak in the preceding 4 years. The use of HFNC therapy aggravated the problem; IRCU use accounting for as much as two-fifths of the total across the hospital. Steps taken subsequently prevented the recurrence of vulnerabilities. CONCLUSIONS: The design criteria for storage and distribution networks of medical gases in hospitals need to be revised considering new parameters for their implementation and the use of HFNC therapy in an IRCU. In particular, the cryogenic tanks, evaporators, and piping network for hospital wards are critical.

A feasibility study evaluating a reservoir storage system for continuous oxygen delivery for children with hypoxemia in Kenya.

BACKGROUND: Supplemental oxygen is an essential treatment for childhood pneumonia but is often unavailable in low-resource settings or unreliable due to frequent and long-lasting power outages. We present a novel medium pressure reservoir (MPR) which delivers continuous oxygen to pediatric patients through power outages. METHODS: An observational case series pilot study assessing the capacity, efficacy and user appraisal of a novel MPR device for use in low-resource pediatric wards. We designed and tested a MPR in a controlled preclinical setting, established feasibility of the device in two rural Kenyan hospitals, and sought user feedback and satisfaction using a standardized questionnaire. RESULTS: Preclinical data showed that the MPR was capable of bridging power outages and delivering a continuous flow of oxygen to a simulated patient. The MPR was then deployed for clinical testing in nine pediatric patients at Ahero and Suba Hospitals. Power was unavailable for 2% of the total time observed due to 11 power outages (median 4.6 min, IQR 3.6-13.0 min) that occurred during treatment with the MPR. Oxygen flowrates remained constant across all 11 power outages. Feedback on the MPR was uniformly positive; all respondents indicated that the MPR was easy to use and provided clinically significant help to their patients. CONCLUSION: We present a MPR oxygen delivery device that has the potential to mitigate power insecurity and improve the standard of care for hypoxemic pediatric patients in resource-limited settings.

Meeting oxygen requirements of rural India: A self-contained solution.

Addressing oxygen requirements of rural India should aim at using a safe, low-cost, easily available, and replenishable source of oxygen of moderate purity. This may be possible with the provision of a self-sustaining oxygen concentrator (pressure swing adsorption with multiple molecular sieve technology) capable of delivering oxygen at high-flow rates, through a centralized distribution system to 100 or more bedded rural hospitals, with back up from an oxygen bank of 10 × 10 cylinders. This will provide a 24 × 7 supply of oxygen of acceptable purity (~93%) for the treatment of hypoxemic conditions and will enable hospitals to specifically provide for high-flow oxygen in at least 15% of the beds. It may also serve as a facility for a local refill of oxygen cylinders for emergency use within the hospital as well as to subsidiary primary health centers, subcenters, and ambulances, thereby nudging our health-care system toward self-sufficiency in oxygen generation and utilization.

Covid-19 ­ uso racional do gás oxigênio (O2) / Covid-19 - rational use of oxygen gas (O2)

A pandemia do novo coronavírus trouxe grande sobrecarga aos sistemas de saúde de todo o mundo, especialmente aos países de baixa e média renda (BONG CL et al, 2020). O atraso da vacinação tem agravado a situação nestes países, aumentando o índice de novos casos e a mortalidade pela doença (WHO, 2021). Um dos problemas enfrentados tem sido a escassez da oferta de oxigênio (O2) hospitalar. Agências internacionais como Wellcome Trust, Unitaid e MS criaram uma força tarefa em busca de uma resposta emergencial para a situação, estimando a necessidade de um aporte financeiro de cerca de 90 milhões de dólares, a fim de se evitar mortes preveníveis pela falta de oxigênio para o manejo clínico dos pacientes hospitalizados por COVID-19 (USHER AD, 2021).

The pandemic of the new coronavirus has brought great burden to health systems around the world, especially to low- and middle-income countries (BONG CL et al, 2020). The delay of vaccination has aggravated the situation in these countries, increasing the rate of new cases and mortality from the disease (WHO, 2021). One of the problems faced has been the scarcity of hospital oxygen (O2) supply. International agencies such as Wellcome Trust, Unitaid and MS have set up a task force in search of an emergency response to the situation, estimating the need for a financial contribution of about US$90 million in order to avoid preventable deaths from the lack of oxygen for the clinical management of patients hospitalized by COVID-19 (USHER AD, 2021).

Manual básico instalaciones de suministro de oxígeno en EMTs y SAAMs / Basic manual for oxygen supply installations in EMTs and SAAMs

Este documento tiene como objetivo dar las facilitar recomendaciones para asegurar la capacidad de suministro de oxígeno para oxigenoterapia en los módulos asistenciales de los equipos médicos de emergencia (EMT) y en los sitios alternativos de atención médica (SAAM). El documento incluye conocimientos básicos sobre los diferentes tipos de instalaciones de oxigenoterapia, así como las orientaciones para que el personal de apoyo operacional del EMT pueda realizar una adaptación óptima de sus equipos para atender las necesidades clínicas de los pacientes COVID-19.

Randomized controlled trial of 7, 28, vs 42 day stored red blood cell transfusion on oxygen delivery (VO2 max) and exercise duration.

BACKGROUND: Few studies have rigorously assessed the impact of red blood cell (RBC) transfusion on oxygen delivery. Several large trials demonstrated no clinical outcome differences between transfusion of shorter-storage vs prolonged-storage RBCs. These trials did not directly assess functional measures of oxygen delivery. Therefore, it is not clear if 42-day stored RBCs deliver oxygen as effectively as 7-day stored RBCs. STUDY DESIGN AND METHODS: Leukocyte-reduced RBCs were collected by apheresis in AS-3. Thirty subjects were randomized (1:1:1) to receive 2 units of autologous RBCs at either 7, 28, or 42 days following donation. VO2 max testing, using a standardized protocol to exhaustion, was performed 2 days before (Monday) and 2 days after (Friday) the transfusion visit (Wednesday). The primary endpoint was the percent increase in VO2 max between Monday and Friday. The secondary endpoint was the percent change in duration of exercise for the same time points. RESULTS: Hemoglobin levels decreased by 2.8 ± 1.4 g/dL after donation and increased by 2.1 ± 0.6 g/dL after transfusion. This change in hemoglobin was associated with expected decreases (then increases after transfusion) in VO2 max and exercise duration. No differences were observed between 7-day and 42-day RBC transfusion for percent increase in median [IQR] VO2 max (10.5 [0.2-17.3] vs 10.9 [5.7-16.8], P = .41) or for percent increase in exercise duration (5.4 [4.1-6.9] vs 4.9 [2.0-7.2], P = .91), respectively. Results were similar for 28-day RBCs and were consistent across the ITT and per-protocol analysis populations. CONCLUSION: These data indicate that 42-day, 28-day, and 7-day RBCs have similar ability to deliver oxygen.

Improving Hospital Oxygen Systems for COVID-19 in Low-Resource Settings: Lessons From the Field.

Oxygen therapy is an essential medicine and core component of effective hospital systems. However, many hospitals in low- and middle-income countries lack reliable oxygen access-a deficiency highlighted and exacerbated by the coronavirus disease (COVID-19) pandemic. Oxygen access can be challenged by equipment that is low quality and poorly maintained, lack of clinical and technical training and protocols, and deficiencies in local infrastructure and policy environment. We share learnings from 2 decades of oxygen systems work with hospitals in Africa and the Asia-Pacific regions, highlighting practical actions that hospitals can take to immediately expand oxygen access. These include strategies to: (1) improve pulse oximetry and oxygen use, (2) support biomedical engineers to optimize existing oxygen supplies, and (3) expand on existing oxygen systems with robust equipment and smart design. We make all our resources freely available for use and local adaptation.

The development and implementation of an oxygen treatment solution for health facilities in low and middle-income countries.

BACKGROUND: Oxygen reduces mortality from severe pneumonia and is a vital part of case management, but achieving reliable access to oxygen is challenging in low and middle-income country (LMIC) settings. We developed and field tested two oxygen supply solutions suitable for the realities of LMIC health facilities. METHODS: A Health Needs Assessment identified a technology gap preventing reliable oxygen supplies in Gambian hospitals. We used simultaneous engineering to develop two solutions: a Mains-Power Storage (Mains-PS) system consisting of an oxygen concentrator and batteries connected to mains power, and a Solar-Power Storage (Solar-PS) system (with batteries charged by photovoltaic panels) and evaluated them in health facilities in The Gambia and Fiji to assess reliability, usability and costs. RESULTS: The Mains-PS system delivered the specified ≥85% (±3%) oxygen concentration in 100% of 1-2 weekly measurements over 12 months, which was available to 100% of hypoxaemic patients, and 100% of users rated ease-of-use as at least 'good' (90% very good or excellent). The Solar-PS system delivered ≥85% ± 3%) oxygen concentration in 100% of 1-2 weekly measurements, was available to 100% of patients needing oxygen, and 100% of users rated ease-of-use at least very good.Costs for the systems (in US dollars) were: PS$9519, Solar-PS standard version $20 718. The of oxygen for a standardised 30-bed health facility using 1.7 million litres of oxygen per year was: for cylinders 3.2 cents (c)/L in The Gambia and 6.8 c/L in Fiji, for the PS system 1.2 c/L in both countries, and for the Solar-PS system 1.5 c/L in both countries. CONCLUSIONS: The oxygen systems developed and tested delivered high-quality, reliable, cost-efficient oxygen in LMIC contexts, and were easy to operate. Reliable oxygen supplies are achievable in LMIC health facilities like those in The Gambia and Fiji.

Prone positioning in non-intubated patients with COVID-19 associated acute respiratory failure, the PRO-CARF trial: A structured summary of a study protocol for a randomised controlled trial.

OBJECTIVES: To assess the effect of prone positioning therapy on intubation rate in awake patients with COVID-19 and acute respiratory failure. TRIAL DESIGN: This is a two-center parallel group, superiority, randomized (1:1 allocation ratio) controlled trial. PARTICIPANTS: All patients admitted to the Hospital Civil de Guadalajara and Hospital General de Occidente in Mexico for COVID-19 associated acute respiratory failure and in need of supplementary oxygen through high-flow nasal cannula are screened for eligibility. INCLUSION CRITERIA: all adult patients admitted to the COVID-19 unit who test positive for COVID-19 by PCR-test and in need for oxygen are eligible for inclusion. Randomization starts upon identification of requirement of a fraction of inspired oxygen ≥30% for an oxygen capillary saturation of ≥90% Exclusion criteria: less than 18 years-old, pregnancy, patients with immediate need of invasive mechanical ventilation (altered mental status, fatigue), vasopressor requirement to maintain median arterial pressure >65 mmHg, contraindications for prone positioning therapy (recent abdominal or thoracic surgery or trauma, facial, pelvic or spine fracture, untreated pneumothorax, do-not-resuscitate or do-not-intubate order, refusal or inability of the patient to enroll in the study. INTERVENTION AND COMPARATOR: Patients of the intervention group will be asked to remain in a prone position throughout the day as long as possible, with breaks according to tolerance. Pillows will be offered for maximizing comfort at chest, pelvis and knees. Monitoring of vital signs will not be suspended. Inspired fraction of oxygen will be titrated to maintain a capillary saturation of 92%-95%. For patients in the control group, prone positioning will be allowed as a rescue therapy. Staff intensivists will monitor the patient's status in both groups on a 24/7 basis. All other treatment will be unchanged and left to the attending physicians. MAIN OUTCOMES: Endotracheal intubation rate for mechanical ventilation at 28 days. RANDOMISATION: Patients will be randomly allocated to either prone positioning or control group at 1:1 ratio. Such randomization will be computer generated and stratified by center with permuted blocks and length of 4. BLINDING (MASKING): Due to logistical reasons, only principal investigators and the data analyst will be blinded to group assignment. NUMBERS TO BE RANDOMISED (SAMPLE SIZE): With an intubation rate of 60% according to recent reports from some American centers, and assuming a decrease to 40% to be clinically relevant, we calculated a total of 96 patients per group, for a beta error of 0.2, and alpha of 0.5. Therefore, we plan to recruit 200 patients, accounting for minimal losses to follow up, with 100 non-intubated patients in the prone position group and a 100 in the control group. TRIAL STATUS: The local registration number is 048-20, with the protocol version number 2.0. The date of approval is 3rd May 2020. Recruitment started on 3rd May and is expected to end in December 2020. TRIAL REGISTRATION: The protocol was retrospectively registered under the title: "Prone Positioning in Non-intubated Patients With COVID-19 Associated Acute Respiratory Failure. The PRO-CARF trial" in ClinicalTrials.gov with the registration number: NCT04477655. Registered on 20 July 2020. FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol. The study protocol has been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines (Additional file 2).

COVID 19 and the oxygen bottleneck.

The COVID 19 pandemic is exposing an important weakness in health systems: medical oxygen production and delivery. Tatum Anderson reports.