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Supplemental Oxygen Therapy
Doctors prescribe supplemental Oxygen therapy to increase the amount of Oxygen a person receives with every breath. Some medical conditions make it difficult for the lungs to extract the body’s required amount of Oxygen from room air, resulting in Oxygen levels dropping to dangerous levels. Supplemental Oxygen allows the patient to maintain acceptable levels of Oxygen in their bloodstream. Since medical Oxygen is categorized by the FDA as a “drug”, the production, storage and delivery of Oxygen contents is regulated by federal and state entities to ensure that only pure and uncontaminated Oxygen is delivered to Patients. Any user of Oxygen should choose a high quality control provider like Landmark. Among other things, a provider of Oxygen must receive the proper licensure, certification and accreditation.
Oxygen Concentrators are medical devices about the size of carryon luggage. They intake room air (approximately 21% Oxygen) and filter out Nitrogen to deliver a flow of air to the Patient that is greater than 90% Oxygen. The unit is fitted with a length of hose, attached to a nose cannula, and plugged into a 110 volt standard electrical outlet. Standard concentrators can be set to run continuously without running out of charge. Concentrators should be used when not ambulating in order to save gas or liquid Oxygen contents. Typical Oxygen concentrators weigh about 30 pounds and have caster wheels to enable easy movement across the floor. Landmark maintains a fleet of company-owned Oxygen concentrators. Our on staff technicians are available in the middle of the night, if needed, to provide technical support, perform repairs, and exchange equipment.
Portable aluminum oxygen cylinders are filled with pure compressed Oxygen contents under pressure. Most people have seen someone receiving supplemental Oxygen from a tank while out on errands, eating at a restaurant, or just enjoying their day. With multiple sizes in carrying bags and carts, these cylinders are frequently used for supplemental Oxygen, mostly for their portability, reliability, and convenience. With the Oxygen in these cylinders under pressure, no electrical power is required, making them the go-to backup solution in power outages or on road trips. Most customers have a primary Oxygen system, such as a concentrator, and use some cylinders as a portable solution or backup. Landmark works with our customers to configure the proper number of cylinders and sizes depending on customer need.
Many providers use third parties to refill Oxygen cylinder contents for their customers. Landmark owns a 3,000 gallon bulk liquid Oxygen tank that allows us to transfill our own cylinders. We use our own specially equipped vehicles to deliver Oxygen. We store, fill and deliver concentrated Oxygen using our highly trained Oxygen technicians. Every week, our technicians are delivering to homes and facilities across North Texas.
Oxygen Content Tank Refill Programs—Liquid and Gas Cylinders
Landmark maintains a proprietary Liquid Oxygen bulk storage tank and its own gas transfilling system. We do not use third parties for this critical part of our operation, but have many thousands of company-owned gas and liquid Oxygen cylinders we fill, track, and service. Our Oxygen transfilling Quality Assurance Program establishes a uniform method of ensuring:
Our production of Oxygen gas meets established assay/purity guarantees,
Our cylinders are processed and packaged to avoid contamination during storage and delivery,
Our Oxygen is offered in a suitable container, manufactured and maintained in accordance with safety standards, and in compliance with all applicable inspections and requalification tests, and
Our cylinders are properly identified with labels that state clearly what the product is and associated hazards.
We run regular routes so wait times for deliveries are minimal. We also take the time to place cylinders where the customer desires as opposed to just dropping off at the front door. We offer our customers free exchanges of empty Landmark gas cylinders at any of our branches.
Oxygen Hardware, Supplies and Accessories
Our Oxygen programs are complimented by complete hardware offerings, including regulating and conserving devices. Some Oxygen users can qualify for conserving devices, which release a bolus of Oxygen only during inhalation, thus dramatically increasing the amount of time a Patient can use a portable Oxygen tank. Users interested in using a conserving device must have a prescription from their Physician. Landmark carries all related supplies for Oxygen therapy, including hoses, nasal cannulas, face masks, filters, and humidification chambers. We ship fresh supplies to our customers upon demand or customers can drop by one of our branches to refresh supplies. Landmark carries portable accessories, such as tank racks and cylinder carriers, including over the shoulder bag carriers and personal wheeled tank carts and dollies. We offer oximeter testing devices, which test the amount of Oxygen saturation in the blood. For broader respiratory conditions, Landmark provides a wide range of home respiratory products from nebulizers to ventilators.
Ventilation and Airway Maintenance
A home ventilator, also known as a respirator, is a mechanical device used to move air in and out of the lungs and perform respiration, which is the exchange of Oxygen for Carbon Dioxide. Home Ventilators are used when ventilator Patients are able to maintain enough consistency in their condition to allow for home discharge. A ventilator can be stationary or portable depending on the Patient’s need. Ventilators may be used all the time or only partially, and have many different settings to accommodate unique conditions. Landmark’s team of Respiratory Therapists meets with Patients in the hospital prior to discharge in order to begin the training process, and then in their home on the day of discharge. It is essential for a qualified Respiratory Therapists to provide training and be present for in-home set up of the equipment and home acclimation. As a full service provider, we also take care of supplies and related equipment the Doctor may prescribe, including supplemental equipment, custom breathing circuits, and tracheostomy kits. Our highly experienced Respiratory Therapists regularly maintain equipment and supplies, provide retraining to Patient and caregivers, and create proactive communication.
The cough assist is a mechanical insufflator-exsufflator device designed to help Patients clear bronchopulmonary secretions when they are unable to cough for themselves. The device uses gradually increasing positive inhalation pressure followed by a rapid shift to negative pressure that produces expiratory flow and simulates a cough. It can be used in trached or non-invasive Patients. The machine can be set to perform pressure changes manually or on a timed basis.
The trachea is the area on the front of the neck below the throat and the Adam’s Apple. It’s also called the windpipe. A tracheostomy is a surgical procedure to create a hole in the windpipe into which a trach tube is inserted to facilitate breathing and the removal of bronchopulmonary secretions. Trach tubes come in many different styles and sizes, such as: fenestrated, cuffed, balloon cuffed, foam cuffed, cuffless, low profile and extra long. A different type of tube may be used depending upon whether the Patient needs a ventilator, has complicating tracheal issues, or is having difficulty using a speaking valve. A trach tube typically consists of an outer cannula, inner cannula, and neck plate. There are also additional components to trach kits, including: collars, speaking valves, heat moisture exchanger (HME), cleaning kits, tubing, water traps, connectors, suction ports, Oxygen adapters, collars, and ties.
Stationary and Portable Suction Machine / Aspirator
Suction machines are primarily used to remove excess secretions. A suction machine is also called an aspirator. A suction machine may be used either with a suction catheter or oral suction device. The suction machine has tubing that connects to a filter and canister, which connects to the catheter or oral suction device. A suction device produces negative pressure to remove excess secretion and deposit it in a canister.
50 PSI Compressor
A 50 PSI is used for Patients who require airway humidification or need to receive medication under higher flow and pressure than a standard nebulizer.
Acapella / Flutter Valve
A device designed to improve clearance of secretions by facilitating the opening of airways in patients with lung diseases such as COPD, asthma, and cystic fibrosis.
A device used to encourage deep breathing by providing visual feedback about inspiratory volume. Incentive spriometry reduces the risk of atelectasis and pulmonary consolidation.
BiLevel Device (BiPAP or VPAP)
BiPAP and VPAP machines are both BiLevel Positive Airway Pressure (BPAP) devices, also called NIPPV or non-invasive positive pressure ventilation machines. BPAP is used when Patients have specific respiratory conditions benefitting from BiLevel therapy such as:
Intolerance to pressure on exhalation
Need to improve the exchange of Oxygen and Carbon Dioxide
Need to decrease the amount of energy required by the body to perform the mechanics of breathing
A BiLevel machine has two pressure levels, one for inhaling (IPAP) and one for exhaling (EPAP). On BiLevel, a person with trouble breathing out does not have to exhale against the machine’s higher inhalation pressure setting. A BiLevel machine will either: 1) push air in under a higher inhalation pressure (IPAP) on timed preset intervals, often expressed in Breaths per Minute (BPM), or 2) spontaneously deliver higher inhalation pressure on inhalation, after the device detects the beginning of inspiration and until a preset pressure is reached. The user can be custom fitted from the same nasal and full face masks available to CPAP users.
BiLevel S, ST, SV and ASV
A BiLevel device may also be used as a ventilation device if the Physician wishes to avoid endotracheal intubation. A person is not trached while using a BiLevel device, instead using either a nasal or full face mask interface.
S means Spontaneous, which means the machine detects the user breathing in with sensors and will deliver pressure at IPAP pressure upon detecting the user’s inhalation. The machine then reverts back to the EPAP pressure for exhalation.
ST means Spontaneous Timed, which is a backup feature that monitors a user’s breathing. If breath is not taken within a scheduled time period, the device provides a burst of air that will kick start breathing again. The IPAP and EPAP pressure are separately adjusted. An ST will typically monitor breathing at a BPM rate to determine if a breath is needed.
SV means Servo Ventilation, which maintains a user’s pressure levels. With an SV, if breath falls below a certain pressure while inhaling or exhaling, the device provides a burst to accelerate to the proper pressure. A Servo Ventilation machine shares some ST functions, but has more settings than a Spontaneous Timed machine.
ASV means Adaptive Servo-Ventilation. It is designed to treat complicated breathing patterns and apnea conditions. The ASV also provides pressure support, delivering ventilations if the user inspiration rate drops below a set rate.
IPPB stands for Intermittent Positive Pressure Breathing and is used to assist in the delivery of aerosol medications, and aid in the expansion of the lungs in Patients whom are unable to breathe deeply without assistance. Patients use a mouthpiece or mask that is attached to the IPPB device. Positive pressure is introduced when the machine senses inhalation, or through a manual button, continuing until a set pressure is met, and then automatically ceasing until next inhalation.
IPV stands for Intrapulmonary Percussive Ventilation. IPV is similar to IPPB in that the user receives pressurized air through a mouthpiece or mask. The difference with IPV is that the user receives multiple short, high flow bursts that make up one breath. This process serves to not only hydrate and loosen secretions, but also assists in actually removing the secretions from the lung.
Sleep Therapy Devices
Sleep Apnea is a form of sleep disorder that involves temporary suspension of the body’s mechanics of breathing during sleep either due to obstruction in the airway, or for neurological reasons. The Greek word “apnea” means “without breath.” During Obstructive Sleep Apnea, the airway in the back of the throat closes due to upper airway obstruction. Central Sleep Apnea is when the brain sends improper signals to the muscles that control breathing during sleep. Complex Sleep Apnea is a combination of Obstructive Sleep Apnea (“OSA”) and Central Sleep Apnea. When oxygen is cut off for too long, the brain responds defensively, bringing the body out of deep sleep stages up into shallower stages. The person may become almost awake, in order to move the body and reestablish breathing.
Dangers of Long Term Apnea
A person with Sleep Apnea may not even remember waking up because they don’t become fully awake, only rising from deep stages of sleep into shallow stages where the body can wake up enough to move and correct the apnea. It’s the deep stages of sleep that fully recharge the body, yet remain elusive when continually awakened by apnea events. Often, the only clue may be fatigue or daytime drowsiness despite normal hours at sleep. Sleepiness while driving and otherwise staying alert at work may also be a sign the body is not receiving the benefits of full rest from deep-stage, uninterrupted sleep.
Even temporary suspension of breath causes harm. Cutting off the air supply drops the amount of oxygen in the blood, causing blood pressure to rise. When happening multiple times a night, the nervous system also remains under pressure from systematically pulling the body out of sleep. The brain works harder to regulate proper levels of oxygen, and internal organs do not receive full rest. The chronic changes in blood oxygen levels and underlying fatigue from Sleep Apnea may worsen the prognosis for certain conditions. Increasingly, there are links between Sleep Apnea and identified health problems:
High Blood Pressure
Coronary Heart Disease
Type 2 Diabetes: Sleep deprivation can cause insulin resistance
Mood and Anxiety
A Physician may evaluate symptoms and prescribe a Polysomnography, or sleep study, in order to determine if Sleep Apnea exists. Sleep studies are either performed in a sleep lab or at the home, depending upon insurance or preference. Some Patients and their Doctors want an in-home study, yet others elect a study performed in a sleep lab. An at-home sleep test measures oxygen level, air flow, heart rate and other items, while a test performed in a sleep lab will measure additional items such as brain waves, EKG and other vitals. Sleeping in a lab is monitored by lab personnel. At-home tests are usually cheaper than lab tests, but some Physicians recommend Patients be tested in a lab setting for additional data capture. Often, an initial test in the lab is followed by a second night sleeping in the lab in order to titrate the Patient, or establish what the pressure setting should be while receiving PAP treatment. Some Physicians may simply prescribe an ‘Auto’ device that dials in pressure without the need for a second sleep study. Patients should check costs, convey their personal preference, and seek the advice of their treating Physician.
Different Types of Treatment Options
Once a diagnosis of Obstructive Sleep Apnea has been made, Physicians may recommend either a therapy device or other treatment options, such as losing weight to help mitigate the apnea. Unfortunately, weight loss is difficult for some and challenging to maintain. Others may recommend surgery, although this may be considered a major procedure. An Ear, Nose and Throat (ENT) or other specialist should evaluate and recommend options. Another treatment option is a dental appliance that realigns the jaws to keep tissue from constricting the airway. The appliance is fitted and worn at night and has shown positive results in some users, but others have problems tolerating an appliance in the mouth while trying to sleep. Treatment of Central Sleep Apnea may include adjusting medication and treating underlying medical conditions, receiving supplemental oxygen, or using a positive airway pressure therapy device.
The most heavily prescribed treatment for Obstructive Sleep Apnea is a Continuous Positive Airway Pressure (CPAP) Device. CPAPs deliver a continuous stream of air through a tube, and into a mask interface. The stream of air flows through the mouth or nose and creates an ‘air-splint’ in the pharynx to keep the airway open in the back of the throat. The air splint allows for the free flow of air into the lungs, preventing apnea events, since the brain does not need to pull the body out of deep stage sleep to correct breathing. People that use CPAP therapy can notice substantial improvement in lifestyle. Once accustomed, users notice a difference in energy level, usually within the first month of continual use. Blood pressure may be reduced and there may be a reduction of risk from cardiovascular or stroke events. Snoring is mitigated, which means good news for any sleeping partners. Long term users of CPAP therapy recognize a difference between being on or off CPAP therapy, improvements in lifestyle, and a desire to continue CPAP therapy.
BiLevel Devices (BiPAP or VPAP Machines)
BiPAP and VPAP machines are both BiLevel Positive Airway Pressure (BPAP) devices, and are also known as NIPPV, which stands for non-invasive positive pressure ventilation. A CPAP machine produces continuous pressure, which is often a challenge for people with conditions that cause difficulty exhaling. A BiLevel machine has two pressure levels, one for inhaling (IPAP) and one for exhaling (EPAP). BPAP is used when Patients either have specific respiratory conditions benefitting from BiLevel therapy, or have trouble tolerating CPAP pressure on exhalation. On BiLevel, a person with trouble breathing out does not have to exhale against the pressure of a CPAP machine. A BiLevel machine will either: 1) push air in under a higher IPAP on timed preset intervals, often expressed in Breaths per Minute (BPM), or 2) spontaneously deliver higher pressure on inhalation, after the device detects the beginning of inspiration, and until a preset pressure is reached. The user will typically be fitted with the same nasal and full face masks available to CPAP users.
Auto CPAP & BiPAP Machines
A basic positive pressure device blows pressure at a constant rate, while an Auto PAP device changes pressure on a breath by breath basis. If intake pressure is too low, then the pressure on the APAP will automatically increase, while high pressure causes the opposite to occur. The main advantage of using an Auto PAP is the user can require different amounts of pressure in different stages of sleep. Auto PAP devices can function either in standard or automatic mode. Other than the machine, all the other components, such as mask and hose, are the same with Auto therapy.
Success with positive pressure therapy can be greatly increased with a properly fitted mask. Equipment providers need to have quality control and a thorough setup process. Our main goal with Landmark masks is to ensure a comfortable fit. Loose or tight fitting masks can cause leaks, which can make sleep difficult for the patient. We carry most makes, models and sizes. We allow customers to try on multiple masks until finding the right fit. We also take the time to train properly. This involves thoroughly explaining the proper placement of the mask on the face, cleaning procedures, and how to make minor adjustments as the mask and headgear ages. Since each mask is different, the equipment provider should know the proper fitting and adjusting techniques for many masks. Landmark’s mask setup process ensures not only maximum comfort, but full training on the correct way to use and adjust each mask.
Apnea Monitors are a device that continuously monitors heart rate and breathing in a pediatric Patient. If the heart rate falls or rises above a certain rate, or if breathing does not take place after timed period, the machine will alarm, informing the caregiver.
Common Challenges with PAP Therapy
Sleeping with a mask, hose and machine takes some getting used to; it’s very common to have challenges becoming acclimated to CPAP therapy. Challenges are normal when implementing personal therapy devices, but especially while trying to sleep. CPAP users report varying acclimation periods, some quick, others much longer. Proper training and setup is essential to become accustomed to a device. New users should expect:
to be uncomfortable at first trying to sleep with a mask on their face, especially if not fitted properly,
to be initially unfamiliar with the pressure in their throat from the machine, especially if pressure changes are needed,
to introduce new machine noise into the sleeping environment, and
to look different with a mask on their face.
Successful Sleep Therapy Using a CPAP Machine
Spending money on a CPAP therapy machine, but not getting benefits does not make sense. It takes a month or longer to become use to CPAP. New users sometimes become discouraged and quit CPAP. Sleeping with a mask, hose and machine running takes getting used to. It is therefore essential for new CPAP users to be fitted properly, setup thoroughly, and be fully trained. Equally important is: 1) setting expectations for the challenges of sleeping with a machine, and 2) fully supporting the new users during the critical stage of acclimation. Often, pressure settings require technician adjustment, and a new Physician order.
New users should commit to overcoming the challenges becoming acclimated to CPAP therapy before even agreeing to receive a CPAP machine. They should anticipate certain issues and oblige themselves to work through these problems with their Physician and an Equipment Provider such as Landmark, whom is highly experience with CPAP, training, mask fit and compliance. Once committed, a new user should work to follow their Physician’s Plan of Care. If CPAP is received, these three rules should be followed for Successful Sleep Therapy:
Get a Good Fit! A properly fitted mask is most critical, as everyone’s face is different. All users should be custom fit by an expert and exposed to multiple models and sizes to ensure proper fit. This is best done in person, as one mask does not fit all.
Communicate! New Sleep Therapy users should not miss their follow up appointments with Physicians, and should stick to the Physician’s Plans of Care, communicating any issues promptly. Equipment Providers need be readily available for issues with the use, device, or mask interface. Often, dialing in the proper pressure settings requires technician adjustment, and positive pressure machines have a wide range of settings to adjust. Remember, only a Physician can order a change in pressure, but the Equipment Provider should take the lead and push the process along to complete any changes rapidly. Effective communications between Patient, Physician and Equipment Provider are essential.
Remain Committed! The health and lifestyle benefits of a full night’s rest are worth repeating often. The new user and their sleeping partner should remember the benefits of CPAP therapy, especially when encountering minor difficulties such as dealing with white noise in the bedchamber, or overcoming the strangeness of wearing a sleep mask.
Satisfying these rules involve not only Patient commitment, but choosing a quality Equipment Provider that can provide top notch equipment, custom-fit sleep masks, and is readily available to trouble-shoot settings, mask issues, and provide continue training. Quick follow up and coordination by the Equipment Provider with the Patient and Physician office is essential to shorten acclimation periods and increase long term therapy compliance. The Equipment Provider should quickly follow up with the customer and communicate challenges to the Physician office, as the Doctor may need to issue a new prescription for setting changes. Each additional day without a proper mask fit or incorrect settings may decrease the likelihood of compliance and benefits of therapy.
Importance of Sleep Resupply
Patients that have remembered the benefits of CPAP therapy and consistently worked to become compliant should be eligible for mask or mask resupply every 6 months. Resupply is critical to preserving the integrity of therapy compliance because masks do wear out over time, eventually leaking or having fit issues. These nighttime annoyances do create a reluctance to receive CPAP therapy. Cushions and pillows should be replaced every 3 months. Cushions and pillows are the portion of the mask interface that form the seal and are directly in contact with the skin. Humidification water chambers should get replaced every six months. Humidification is provided to increase comfort by eliminating the dryness of compressed air. The chamber, especially when using tap water, will eventually become stained with residue. Tubing should be replaced every three months. Tubing typically retains moisture after humidified use. Over time, fresh tubing is required to preserve cleanliness and avoid unwanted smells. Our programs have both a 3 and 6 month resupply kit.
Success with positive pressure acclimation can be greatly increased with a properly fit mask. Equipment Providers need to have quality control and a thorough setup process. Our main goal with Landmark masks is ENSURE A COMFORTABLE FIT. Loose fitting masks can cause leaks, which can keep a person up all night in annoyance. Tight fitting masks can also cause leaks, and skin irritations that make sleeping worse. Our highly experienced sleep therapy team has fitted thousands of faces with sleep therapy devices. We carry all makes, models and sizes to find the right fit. We allow customers to try on multiple masks until finding a comfortable fit. We do not force any particular mask on them.
We also take the time to train properly. This involves thoroughly explaining the proper placement of the mask on the face, cleaning procedures, and how to make minor adjustment as the mask and headgear ages in order to maintain fit. Since each mask is different, the equipment provider should know the proper fitting and adjusting techniques for many masks. Landmark’s mask setup process ensures not only maximum comfort, but full training on the correct way to use and adjust each mask. As always, we back all of our purchases with ongoing support from real people at actual locations. Sleep Right to Work and Play Right.
CPAPs that are not cleaned properly are crawling with germs. Mask should be cleaned daily, with remaining components cleaned at least once per week. To clean a mask, simply wipe it down daily with a baby wipe. Make sure the baby wipe does not have alcohol in it, as alcohol will work to dry the mask and make it stiff. Wiping the mask with a baby wipe after each use will help eliminate dirt, oil, makeup or other substances. Wash at least once per week with baby soap or basic baby wash. In all cases, use a gentle cleaning agent, with no alcohol. Make sure to wash the whole mask, including the headgear. User must also make sure to wash the hose and water chamber once per week. If distilled water is not used in the humidification chamber, then use 1 part vinegar to 3 parts water and soak the water chamber for a few hours—while not in use—and then wash with a non-scented soap, finishing with a thorough rinse. It is typically not advisable to wash the filters, just obtain new ones.
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Landmark provides Infusion Therapies & Home Medical Equipment directly to Patients in homes and facilities across North Texas, including IV drugs, equipment, supplies, nursing and administration services.
We work with our Patients' Doctors to develop individual IV treatment plans that maximize the effectiveness of Home Infusion Therapy, and our staff is expert at orchestrating complex Infusion Therapies in the home.
Our sterile medications and nutrition are prepared in USP-797 Cleanrooms under stringent requirements, compounded by highly trained Infusion Technicians, and supervised by experienced Clinical Infusion Pharmacists.
We fully manage Patient orders from intake, through delivery, and all the way to the end of therapy. Our signature Landmark Level of Service means we are available 24 / 7 to coordinate with our Patient & Referral Customers to help achieve the best possible outcome for their Plan of Care.
Our four main Customers we serve:
Clinical Care Management
Medical Equipment and Supplies
Infusion Pumps & IV Supplies
Enteral Pumps & Formula
Negative Pressure Wound Therapy Pumps
Home Medical Equipment
the Patient receiving the Equipment or Infusion, and their Caregivers,
Prescribing Physicians, and their Clinical Staff,
Other Integrated Care Providers involved in managing the care of our Patients, and
Health Insurance Payers seeking quality homecare providers.
Landmark Healthcare, Inc. was formed in 1999 and has processed over 340 thousand orders for over 84 thousand Patients in North Texas (as of August 2020). Our mission is to help discharge Patients to their homes on a timely basis, and provide ongoing home support for their Physician's plan of care. We fully coordinate our orders with clinical referrals, home health, Patients, and Caregivers. Our USP 797 sterile compounds are prepared under the supervision of experienced Clinical Pharmacists, and we set up medical equipment at the home or facility setting. We provide full training and support for our products 24 / 7 / 365.