RTs have a responsibility to provide oxygen at levels that allow their obese patients to increase their activity abilities

It is often assumed that patients on oxygen have brought the need for this therapy upon themselves simply by choosing to smoke. Respiratory care professionals know that this is not always the case and that there are many possible reasons a patient might need oxygen therapy. One can easily extend this line of thinking to other conditions as well, however. For example, have obese people brought their need for therapy upon themselves by eating? Or is it really just possible that the junk food industry has laced its products with some addictive drug and created a nationwide addiction to fatty foods? Or is it the fault of the convenience industry, which has created a wide array of shortcuts to exercise, allowing patients to never have to lift a finger during activities of daily living? There always seems to be some outside factor on which to place the blame for one’s poor health, yet almost always the bottom line is that it comes down to the patient’s choice of whether or not to work to prevent acquiring a preventable disease.

Right now we have a sort of race going on regarding which preventable disease will take the lead as the primary cause of death in Americans. COPD is currently “ahead” with the preventable aspect being that the patient has the choice of whether to smoke or to not smoke. Obesity is right behind COPD in this race, with the preventable part being the choice to overeat and not get exercise or to both eat and exercise responsibly. Both of these diseases have a tremendous impact on a patient’s quality of life, and an even greater impact on the overall cost of health care due to the collateral effects of these diseases.

According to the Centers for Disease Control and Prevention (CDC) Web site,1 being overweight increases the risk of diseases/disorders:

• hypertension
• dyslipidemia (for example, high total cholesterol or high levels of triglycerides)
• type 2 diabetes
• coronary heart disease
• stroke
• gallbladder disease
• osteoarthritis
• sleep apnea and respiratory problems
• some cancers (endometrial, breast, and colon)

Many of these complications are also associated with COPD.

Data from the National Center for Health Statistics2 (NCHS) show that 30% of US adults 20 years of age and older—more than 60 million people—are obese. The American Thoracic Society (ATS) estimates that 30 million Americans have COPD, with this number growing consistently over the past few years. On their own, these conditions are invariably challenging to treat, but treating an obese patient diagnosed with COPD is an even bigger challenge for the respiratory professional.  

There are many ways to determine whether a patient is obese—the simplest is putting the patient on a scale. Many times, simple observations can reveal that the patient is not at an ideal weight. While COPD is not as easy to diagnose, relatively simple screening tools can provide the clinician with enough information to predict the presence of COPD.

The compounding effects of obesity and COPD often make it difficult to determine the root cause of the symptom. For example, obesity adds a restrictive component to COPD. The additional weight around the chest and the pressure on the diaphragm prevent full lung expansion. Additional weight on a person also means more oxygen is required to support the extra body mass. At rest, the patient will consume more oxygen just to maintain proper oxygenation. One example of early clinical research revealed that approximately 25% to 40% of COPD patients desaturated at night and required supplemental oxygen therapy.3 Many of these patients may have been overweight and had not had full polysomnographic studies, which might have revealed that the patient actually had obstructive sleep apnea (OSA), possibly due to their weight. In this case, oxygen therapy for obstruction would not have treated the problem; CPAP would be the therapy of choice for OSA. There are other such clinical studies that draw conclusions that might have been different if the patient’s weight, and complications due to the weight, were taken into consideration.

Long-term oxygen therapy (LTOT) is the therapy of choice for chronically hypoxic patients. Considering that 30% of the adult population is obese, it is no surprise that many patients prescribed LTOT are also overweight. These patients, in addition to dealing with issues relating to the use of LTOT, must deal with the same problems that any other overweight individuals deal with, including overeating and exercising little. The goal of LTOT is to provide  patients with oxygen systems that allow them to comfortably complete activities of daily living. But if the patient is also obese, these daily activities are often limited. For patients, this can create a spiral into sedentary living where the less patients do, the less they can do, until eventually they are in a situation where they cannot be mobile and require mobility assistance. For the home care provider, this creates ample opportunity to provide equipment. Oxygen therapy for a stationary patient is the easiest and most profitable form of therapy. The availability of power wheelchairs, lifts, and other products developed to assist patients who cannot take care of themselves unassisted has grown with the growing obese population. Treating the symptom and not the cause is a short-term solution, however. The complications of a sedentary life ultimately progress to a point where the patient succumbs to one or several compounding diseases. The quality of life for the patient—and the cost to the health care system—is disastrous.

Options for Therapy
LTOT patients want lightweight, long-lasting portable oxygen systems. They also want a fashionable, comfortable system. The oxygen industry has responded, and there are currently several options available to consumers for portable oxygen therapy systems, yet due to economic issues, the choices actually offered to the patient are often limited. In addition, many of the patients selecting a system are not well versed on the performance differences of portable oxygen systems and will take form over function when given the opportunity. The home care provider needs to intervene and help patients find systems that meet their needs and are able to maintain the patients’ oxygen levels during activities of daily living. These are more than simple resting prescriptions for LTOT. With activity, many patients are not able to maintain proper saturation and will experience serious desaturation. This results in shortness of breath, fatigue, and dizziness. When patients experience these symptoms, they usually stop what they are doing and sit down until they feel comfortable.

For an obese patient, complications due to obesity often prevent exercise, even if the oxygen system is providing adequate oxygen delivery. Osteoarthritis, back pain, swollen ankles, and overall poor muscle conditioning create challenges that can keep the patient from exercising. The challenge for the respiratory therapist is not only to determine the appropriate oxygen system to use with the obese patient, but to monitor the oxygen levels during activity that the patient is capable of completing. Pulmonary rehabilitation clinicians, exercise physiologists, and other heath professionals can help determine the exercise capabilities of obese patients and help motivate them to exercise to their capacities with a focus on achieving progress in their active abilities. If this is done properly, patients will begin to see progress and ideally will feel more comfortable about being more active. Once there is an understanding that the patient can actually exercise with oxygen, small steps can be taken to increase the workload equal to the patient’s capabilities. Over time, the patient might even start to lose weight and improve exercise capacity.

Moving Forward
With approximately 127 million adults in the United States being overweight and 60 million obese, weight-related health issues will be with us for a long while. There are currently 1.5 million patients receiving LTOT, and this number is expected to increase to 4 million by 2020.4 This means that many of the patients who will be receiving LTOT will be overweight and experiencing the complications associated with both obesity and oxygen therapy. Titrating oxygen to the patient’s needs and continually monitoring appropriate oxygen delivery and effect is the reason respiratory therapists are needed in the home and rehabilitation facilities. The respiratory therapist providing oxygen therapy in patients’ homes must determine how to oxygenate the patients and keep them active at the same time. It would be inappropriate to adapt an oxygen program to an obese patient’s current activity level, as this would encourage a sedentary lifestyle. Portable systems that allow for activity need to be available to these patients and should be promoted as often as possible. Many new portable oxygen systems support a low single dose and a low maximum dose capability. This direction in product development is in response to demand by consumers to provide lighter weight, long-lasting portable oxygen systems. If an obese patient cannot maintain proper oxygenation with exercise, they simply will not be able to maintain an active lifestyle. Encouraging a patient to exercise at low oxygen saturation will provide only negative effects and consequences related to hypoxemia. The obese patient might initially need a slightly heavier portable oxygen system with high dose capabilities to begin an exercise program. As progress is made, however, the patient might lose weight; and so they will require less oxygen with activity. This will allow for the potential of being able to use a lighter weight portable oxygen system.

Most of America is aware of the problems related to being overweight. Diet programs, diet books, exercise programs, and health clubs are everywhere. For LTOT patients—obese or not—there is the added consideration of supplemental oxygen needs. If respiratory therapists do not monitor and maintain proper oxygen levels while patients are active, the patients will likely cease being active and begin the downward spiral into a sedentary lifestyle. An inactive LTOT patient will not survive for long. Estimates are that LTOT patients survive for approximately 2 years after starting LTOT. Is this in part because we do not give them enough oxygen to be active? A goal of every respiratory therapist should be to have their LTOT patients survive for many more years by being active and healthier and enjoying an improved quality of life. For therapists treating an obese patient on LTOT, this is an even greater challenge. Are we up to it?

Robert McCoy, BS, RRT, FAARC, is managing director, Valley Inspired Products Inc, Apple Valley, Minn.

1. How does obesity affect a person’s health? Available at: www.cdc.gov/nccdphp/dnpa/obesity/faq.htm#how Accessed August 25, 2006.

2. Prevalence of overweight and obesity among adults: United States, 1999-2002. Available at: www.cdc.gov/nchs/products/pubs/pubd/hestats/obese/obse99.htm Accessed August 25, 2006.

3. O’Donohue WJ Jr, Bowman TJ. Hypoxemia during sleep in patients with chronic obstructive pulmonary disease: significance, detection, and effects of therapy. Respir Care. 2000;45:188-91.