Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Reviews
Year : 2023 | Month : January | Volume : 17 | Issue : 1 | Page : OE01 - OE05 Full Version

Oxygen Therapy and Associated Risk Factors for Home Isolated COVID-19 Patients: A Review


Published: January 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/59430.17342
Pradeep Kumar Yadav, Rajiv Ratan Singh

1. Assistant Professor, Department of Forensic Medicine, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. 2. Professor, Department of Emergency Medicine, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.

Correspondence Address :
Dr. Pradeep Kumar Yadav,
647/37A/468, Sita Vihar Colony Jankipuram Extension Lucknow- 226031, Uttar Pradesh, India.
E-mail: dctrprdp@gmail.com

Abstract

During the second wave of the viral pandemic, hospitals were overcrowded by the escalation of Coronavirus Disease-2019 (COVID-19) cases. To effectively address the drastic escalation of the COVID-19 pandemic, innovative solutions are warranted. The rising demand for critical-care services burdens hospitals; hence, to alleviate the burden on the healthcare system, asymptomatic patients or those with mild symptoms can be treated at home through continuous monitoring and care. Affected patients are at risk of hypoxia, which urgently requires oxygen therapy. Depending on the extent of oxygen demand, patients can boost their oxygen levels by making use of a nasal cannula, face mask, oxygen cylinder, and/or oxygen concentrator. Several risk factors are associated with the augmented probability of COVID-19 progression to severe status due to increased oxygen requirement, and they include advanced age, obesity, glucose intolerance, hypertension, and cardiovascular disease. A close monitoring of oxygen saturation (SpO2) along with other clinical investigations like complete and differential blood counts, serum electrolytes, random blood sugar, liver function tests, coagulation profile (Prothrombin Time (PT), activated Partial Thromboplastin Time (aPTT) and International Normalized Ratio (INR)), renal function test, C-reactive protein (CRP), D-dimer and ferritin level are mandatory for patients receiving home-based oxygen therapy. An awareness of safety considerations such as perfectly fitting, proper sized mask, availability of ventilation, knowledge of caregiver about danger signs and good functioning of fire alarm system at home are of prime importance before setting up oxygenation devices at home, and this further mandates a comprehensive evaluation of home-based management and treatment of mildly symptomatic patients with COVID-19.

Keywords

Coronavirus disease-2019, Home remedy, Oxygen devices, Safety measures

Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2) is deadly zoonotic virus which multiply profusely. During the second wave of this viral pandemic, hospitals were overcrowded (1),(2). Moreover, due to an increased demand for critical-care services, the pressure on Intensive Care Unit (ICU) bed facilities, mechanical ventilators, personal protective equipment, and healthcare personnel poses a threat to the excellence and safety of healthcare management (1),(2). Nonetheless, self-care under home quarantine is recommended for asymptomatic and mildly symptomatic patients. Patients with COVID-19 exhibit a broad spectrum of symptoms that affect multiple systems, among which the respiratory system is the most commonly affected, and home-based management of patients with respiratory disorders is challenging; hence, different strategies need to be formulated for the treatment of these patients (3). A proportion of mild COVID-19 patients recover with medication while in home isolation; however, a subset requires supportive therapy, such as subcutaneous heparin and oxygen supply management in the home-based-care setting (4). These provisions potentially mitigate the necessity of hospital admission. Oxygen supplementation can be provided at home, though it requires proper monitoring.

Therefore, this review summarises the mechanisms and side-effects of commonly used oxygen-therapy measures or techniques for patients with COVID-19, thus availing comprehensive information that may help maximise oxygen-therapy benefits, minimise risk, and hopefully, reduce mortality in patients with COVID-19.

Cause of Oxygen Requirement at Home during the COVID-19 Pandemic

Stable patients with SpO2 of 92% at rest should be referred for oxygen therapy. Due to the incapacitation of local healthcare systems, particularly the limited availability of hospital beds during the peak of pandemic situation (5),(6). Patients with mild symptoms opt to stay at home with home based care provided by government (7). Rapid clinical deterioration signs like dyspnoea (shortness of breath) and/or cyanosis, (when the body is deprived of adequate oxygen supply at the tissue level); fever, cough, including low SpO2 (<92%) etc., may arise in the preliminary phase of the disease due to the development of silent and unpredictable arterial hypoxaemia, even without an associated increase in exertion related to breathing (8).

Home-based Monitoring of Oxygen Status

Telemedicine has played an important role in providing guidance to patients as well as caregivers who can understand advice given by a physician over the phone. Their temperature, SpO2, and pulse measurements are monitored daily at home. The clinical progression of COVID-19 is unpredictable; hence, one should be cautious to monitor and document the patient’s signs and symptoms to identify initial signs of deterioration that potentially occur to an inconsequential extent in patients opting for home isolation, as mild symptoms may not require hospital admission at an early stage (9),(10),(11). After testing positive with the Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) test, continuous self-monitoring of SpO2 , heart rate beats per minute (bpm), and body temperature at home is mandatory. Certain tests, such as 6-minute walk tests, can indicate the need for oxygen therapy in patients receiving home isolation whose SpO2 levels are within normal limits (i.e., SpO2 levels of 92% or higher at rest under normal room air conditions) (12),(13),(14),(15). It is recommended that such patients walk across the room for approximately six minutes at a normal pace and remeasure their oxygen level. A decline in oxygen level after the walk indicates early hypoxia and the requirement for oxygen. The minimum normal SpO2 level is reportedly 92% (12),(13), while other studies have reported this value to be between 93% and 94% [15,16]. The pulse oximeter is a potentially useful device for measuring patient SpO2 (where ‘p’ refers to a pulse-oximetry measurement) and bpm levels. It has a finger disposable wireless sensor enabling continuous SpO2 monitoring. The user-friendliness and affordable cost of pulse oximetry renders it a preferable alternative for detecting problems at an early stage; however, one should be wary of its accuracy, particularly when SpO2 levels fall below 90%. When monitoring the SpO2 level at home using a pulse oximeter, individuals should take several precautionary measures (17):

i) Before taking a measurement, the patient must be relaxed and breathing calmly without talking for some time.
ii) Measurements should be taken indoors, with the device placed firmly on either the middle or ring finger.
iii) Nail paint (if any) should be removed.
iv) Cold extremities must be warmed prior to monitoring.
v) The person should patiently observe the readings for 30-60 seconds to identify the most precise value associated with a strong pulse signal.
vi) The SpO2 level should be measured several times a day to precisely estimate the trend in arterial oxygenation.
vii) Individuals should take care of themselves and make appropriate decisions promptly if their SpO2 level exhibits a declining trend over a time.

Oxygen monitoring can also be performed using spirometry. Conventional spirometry measures lung function that can be performed during normal tidal breathing. With this technique, one must breathe into a device that reflects how effectively their lungs are working (18).

Oxygen Sources that can be made Available at Home

SARS-CoV-2 causes severe injury to the lungs, thus adversely affecting respiratory function. The alveolar-capillary membrane that exchanges oxygen and carbon dioxide is affected, thus causing oxygen deficiency, which must be remedied by external oxygen-administration devices. Low tissue oxygenation/hypoxia potentially occurs due to system failure in terms of oxygen transport and circulation. Hypoxia indicates the need to initiate oxygen therapy, which is a potentially life-saving intervention; nevertheless, it should be administered upon proper evaluation and constant assessment; otherwise, it is potentially disadvantageous to the patient’s health (19). Several oxygen sources can easily be made available at home. The selection of oxygen-delivery devices depends on the extent of oxygen requirement, degree of patient acceptance, device efficiency and consistency, and ease of therapeutic application. The clinical evaluation, performance, and design of the device ultimately determine which oxygen-delivery device and mode of administration should be preferred (20),(21). The percentage of oxygen delivered can be inconsistent or precise, depending on the device and mode of administration selected. Oxygen can be delivered via low- or high-flow systems, with or without humidity, and with or without a reservoir. The monitoring of oxygen-delivery effectiveness entails arterial blood-gas analyses, SpO2 monitoring, and clinical assessment (21).

Delivery Devices

Although oxygen therapy cannot instantaneously boost oxygen levels or restore them to normal in patients with COVID-19. The primary form of treatment in moderate cases is oxygen therapy: the goal is to achieve 92-96% SpO2 or 88-92% in patients with Chronic Obstructive Pulmonary Disease (COPD) by following means (22),(23):

Nasal cannula: Nasal cannulas are the most common devices for oxygen delivery. The device comprises a low-flow system, with flow rate ranging from 1 to 6 L/min. It supplies 24-44% inspired oxygen at a rate exceeding 4 L/min. It consists of a flexible tube that is placed under the nose. The tube includes two prongs that enter the nostrils. Oxygen transported to the nasopharynx via a nasal cannula combines with room air; therefore, oxygen concentration in the nasal cannula varies depending on the patient’s respiratory rate, tidal volume, oxygen flow rate, and degree of mouth breathing (14). Hence, nasal cannulas are suitable for patients with COVID-19 experiencing low respiratory distress primarily because they are less intrusive than other devices and allow a person to eat and speak freely.

Disadvantages

a) The nasal cannula potentially causes discomfort due to mucous-membrane dryness.
b) It can also cause nasal bleeding due to continuous irritation and breach of tissue (22).

Face masks: Simple face mask- The simple, or ‘low-flow’, face mask is used when an increased delivery of oxygen is required for short periods (i.e., <12 hours). Oxygen is delivered at a flow rate of 2-10 L/min and is transported at a concentration of 35-60%. The device covers the nose and mouth and has vents on its sides that allow room air to enter via several entry points, thereby diluting the source oxygen and supplementing it with air drawn into the mask during breathing. The SpO2 achieved cannot be predicted as it depends on the rate and depth of the patient’s breathing (22),(24).

Disadvantages

a) The simple face mask, including the accompanying nasal tube, is expensive.
b) A face mask is uncomfortable for patients while eating or talking.
c) Inflammation of skin due to continuous use is likely to occur.
d) It is difficult to position over the nose and mouth.
e) To deliver a high concentration of oxygen, a tight seal is necessary.

Non rebreathing face mask: The non rebreathing face mask is indicated for acute oxygen-desaturation conditions. It provides the highest concentration of oxygen (upto 90%) at a flow rate of 10-15 L/min via a reservoir mask and is recommended for short-term use in patients who are critically ill. The reservoir bag must be filled with oxygen before use and the mask well positioned to ensure a close fit on the patient’s face. Two one-way valves prevent exhaled air from entering the bag. When the patient exhales, the one-way valve closes and all the expired air is deposited into the atmosphere, not the reservoir bag. Therefore, the patient does not rebreathe any of the exhaled gas (24). Oxygen via a reservoir mask cannot be humidified, and patients tend to be more comfortable if their oxygen levels can be maintained within target range on a humidified system once they are more stable. This mask is appropriate for patients with COVID-19 who are breathing spontaneously and severely hypoxaemic, as it delivers the highest possible oxygen concentration.

Disadvantages

a) Its major drawback is that the mask must be tightly sealed on the face, which is uncomfortable and has a drying effect.
b) It is considerably expensive.
c) Malfunction can be a source CO2 accumulation.
d) It is impractical in cases of long-term oxygen therapy (22).

Venturi/Air entrainment mask: This is a high-flow device that delivers a fixed oxygen concentration of 24-54%. It utilises a flow metre to provide a constant, precise, and preset oxygen level. It of a sterile water bottle, ridged tubing, drainage bag, air/oxygen ratio nebulising system, and masks that work with corrugated tubing. The mask maybe an aerosol face mask, tracheotomy mask, T-piece, or face tent. The key is that oxygen flow exceeds the patient’s peak inspiratory flow rate, with a slight chance of the patient inhaling air from the room. The device is commonly used to control a person’s carbon dioxide retention and supply supplemental oxygen. Hence, this device is apt for patients with COVID-19 who have a hypoxic drive to breathe but also require supplemental oxygen. It delivers humidified oxygen without drying mucous membranes, hence proving comfortable for patients (22).

Disadvantages

a) The mask potentially causes discomfort as it can be hot and confining for patients and also cause interference while talking and eating.
b) A properly fitting mask is required.
c) In added instances, respiratory therapists/nurses may be accountable for regulating and monitoring the high-flow systems.

Oxygen cylinders: An oxygen cylinder is a storage container made with reinforced metal. It is filled with compressed oxygen under high pressure, which is safely and gradually released via its regulator tap, and the oxygen is supplied to the patient through a surgical mask via nasal cannula. The water flask or humidifier that accompanies the cylinder must be filled with normal tap water up to the marked level. Oxygen is moistened as it passes through it to prevent the mucous membranes of the respiratory tree from drying, and the humidifier is connected to a flow metre that regulates oxygen flow in L/min. A reduction gauge displays the residual amount of oxygen in the tank. Setting up an oxygen cylinder requires technical assistance, which can be sought from the service provider (22). To distinguish them from devices carrying other medical gases, oxygen cylinders are colour coded with a white exterior. The cylinders come in various capacities, and the appropriate cylinder must be selected, depending on the patient’s oxygen requirement; moreover, when the cylinder’s supply is exhausted, it should be refilled before use. A larger, freestanding cylinder can be used in the home as a back-up source in the event of power failure. A portable cylinder is designed to use even outside and it can be attached to a walker, wheelchair, or can be carried in a backpack (25).

Disadvantages

a) Proper attention is required when checking the cylinder’s oxygen level.
b) Awareness of duration is required (25).

Oxygen concentrators: Oxygen concentrators, also referred to as oxygen generators, are electrically powered devices that purify ambient air and redirect nitrogen back into the air, thus providing filtered oxygen to the patient through a cannula. Atmospheric air contains 21% oxygen, 78% nitrogen, and 1% other gases. The purified air supplied to the patient is approximately 90-95% pure. By means of a pressure valve, oxygen supply can be adjusted to flow rates ranging from 1 to 10 L/min. In the context of COVID-19, the use of transportable/portable oxygen concentrators at flow rates ≤4 L/min is recommended (15). The supply should be set according to the patient’s clinical requirement. Unlike oxygen cylinders, concentrator’s require uninterrupted power supply for their operation. Even a brief power cut could adversely affect the patient. Concentrators can be either stationary at home or portable with the patient (26),(27),(28). A portable oxygen concentrator includes its own power supply; furthermore, it is a compact, lightweight machine that is designed formability and can be carried around outside the home (29),(30),(31). Home concentrators require installation and regular maintenance by specialised expertise. In the context of the COVID-19 pandemic, this is not ideal since it potentially increases exposure risk of infection.

Disadvantages (20),(32)

a) Concentrators require a continuous supply of electrical power to function; this may entail the setting up of a backup power generator in the home.
b) Patients should change the filters weekly, and timely service of stationary oxygen concentrators is required.

Natural Boosting: Several exercises, yoga, and other similar activities can be used to boost oxygen levels naturally at home, apart from oxygen-supply devices and resources. During hypoxia, patients with COVID-19 are advised to sleep in the prone position, in which they lie on their chest with pillows placed under their neck, shins, and chest. Patients can also lie on their sides. In addition, having a nutritious, iron-rich diet that improves lung function is said to be beneficial. According to doctors, lying on one’s tummy when suffering from a respiratory infection like this is potentially advantageous. Some patients have been reported to recover or exhibit improvements in their health by prone positioning alone (33).

Assessment of Risk Factors Associated with Home-based Oxygen Therapy

During the COVID-19 pandemic, several clinical factors and laboratory findings have been reported to be associated with disease progression, ultimately leading to severe illness or mortality. Major factors include advanced age, obesity, glucose intolerance, hypertension, and cardiovascular disease. These constitute independent host risk factors for oxygen requirement in patients with COVID-19.

Advanced age: As confirmed by several studies, advanced age emerges as one of the risk factors for oxygen requirement in patients with COVID-19 globally (34),(35). This is potentially attributable to a less rigorous immune response in advanced age (35). Notwithstanding to date, the reason underlying old age-related susceptibility remains unclear.

Obesity: Obesity is another risk factor reportedly associated with the augmented probability of COVID-19 progression toward severity (36). Disease progression is reportedly seven times higher in patients with obesity (37). Patients with obesity and concomitant lung diseases (asthma and COPD) may experience an excessively high percentage of total body oxygen consumption as well as a decline in functional residual capability and expiratory volume (18). Additionally, people with obesity are at a higher risk of developing pulmonary emboli/aspiration pneumonia (38), and these secondary pathophysiologies may exacerbate pneumonia in patients with COVID-19, resulting in progression to severe infirmity. However, the precise mechanisms underlying the association between obesity and COVID-19 progression remains unclear. Promoting a healthy diet to sustain nutritional requirements has become increasingly essential in the battle against COVID-19.

Glucose intolerance: Diabetes mellitus, the most common metabolic disease worldwide, weakens the immune system (39) and is reportedly another risk factor for disease severity or mortality in COVID-19 (40),(41). Hyperglycaemia, even in patients with undiagnosed diabetes, has also been reported to be a predictor of poor clinical outcome and mortality (42). People with diabetes mellitus have been reported to be three times more likely to progress to severe disease or death from COVID-19 (43), and this trend is likely to be worse in patients with uncontrolled diabetes (44). Hyperglycaemias were seen in non diabetic patients because of steroid use and catecholamine surge due to stress (45). A study observed hypoglycaemia in COVID-19 patients related to decrease oral intake or in sepsis (46).

Hypertension: Hypertension is known to be a genetic condition that is worsened by external factors, such as lifestyle, stress, and diet. With the progression of age, blood pressure rises due to a disorder in the blood vessels, such as atherosclerosis, thus affecting lung function and impairing oxygen delivery; moreover, it is a potential cause of high mortality among patients with COVID-19 (34),(40),(47).

Cardiovascular disease: Patients with co-morbid cardiovascular disease are more susceptible to COVID-19 (34),(41),(47). The reason behind this phenomenon maybe associated with angiotensin-converting enzyme 2 (ACE2) expression in vascular fibroblasts and myocytes (48). The presence of SARS-CoV-2 in cardiovascular cells potentially aggravates the disease. Body mass index, low lymphocyte count, glucose intolerance, and dyslipidaemia are reportedly significant risk factors for oxygen requirement (49).

Safety Considerations before Setting up a Home-based Oxygen-delivery System

Despites its benefits, several safety considerations should be followed before setting up an oxygenation device at home (22):

a) A perfectly fitting, proper-sized oxygen mask, including an accompanying nose clip and tightened strap, should be used to avoid leakages or gaps in/and around the nose and minimise oxygen-supply interruptions.
b) Due to an inadequate resource supply, many cannulas and concentrator machines are borrowed/shared among users; therefore, caregivers and patients with COVID-19 should ensure that equipment, devices, cannulas, and masks are well sanitised before use.
c) Sufficient ventilation and open windows must be available in the room while using an oxygen concentrator, as this will allow eliminated nitrogen to escape freely.
d) Caregivers should be aware of the dangers of using home oxygen in the presence of a naked flame, such as that from cookers and candles. Oxygen cylinders could cause an explosion; hence, they should be ≥5 feet away from naked flames, a heat source, or electrical devices. Smoking cessation must be advocated.
e) Fire alarms and smoke detectors should ideally be installed in the home and consistently being in good working order.
f) Documented training should be availed to patients/caregivers before ordering home oxygen (35).
g) Oxygen supply should be immediately turned off when not in use, and the nasal prongs or mask should never be left under or on bed coverings or cushions whilst oxygen is being supplied.
i) Aerosol sprays and petroleum products/by-products (e.g., petroleum jelly/Vaseline) must not be used whilst using oxygen.
j) Oxygen cylinders must be secured to prevent them from falling over and stored upright, either chained or secured in appropriate holders.

Conclusion

The appropriate selection of home-based oxygen-therapy devices and delivery systems for patients with COVID-19 depends on the extent of hypoxaemia, existing indication for the patient’s fundamental diagnosis, and predilection. Caregivers should possess a consolidated knowledge of all devices and delivery systems for them to devise appropriate and individualised patient-based plans for home-based oxygen therapy. An awareness of potential harm and safety considerations is of paramount importance, and this further mandates a comprehensive evaluation of home management and treatment of COVID-19 patient with mild symptoms.

Acknowledgement

Authors would like to express their heartfelt gratitude to all of the co-authors for their invaluable contributions and assistance in bringing this article to fruition.

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DOI and Others

DOI: 10.7860/JCDR/2023/59430.17342

Date of Submission: Aug 01, 2022
Date of Peer Review: Sep 19, 2022
Date of Acceptance: Nov 08, 2022
Date of Publishing: Jan 01, 2023

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? NA
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Aug 03, 2022
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• iThenticate Software: Nov 07, 2022 (20%)

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