HQAA’s Equipment List is the vehicle organizations use to disclose what products and supplies they provide to their customers. It looks a lot like a Medicare form (the 855-S), which serves a similar role for companies providing care to Medicare recipients and it's very important that the information on the 855-S matches up with HQAA’s equipment list. The list is three pages long, and broken up into categories. One of the categories is respiratory equipment, which includes oxygen, ventilators, and CPAP, along with some other less common therapy modalities that utilize pressure to treat various respiratory disorders.
The use of pressure as a therapy is part of a rich history that led to the development of the respiratory therapy profession. In fact, the discovery that pressure could be therapeutic in treating breathing problems would give birth to the profession. Because positive pressure and oxygen were both used to treat respiratory disorders, the oxygen orderlies working in hospitals began to deliver the machines to the hospital rooms and hook people up to them. This led to “inhalation therapy” departments in hospitals which eventually became respiratory therapy. It all started with the humble IPPB…..
IPPB (intermittent positive pressure breathing) treatments were the “meat and potatoes” of respiratory therapy departments in the hospital. IPPB machines were fairly simple mechanical machines with pressure valves and a power source –usually either compressed air or electricity. The machines interfaced with patients via a plastic or rubber circuit fit with a mouthpiece or facemask. The concept was simple: the patient would initiate a breath (breath in) and the machine was triggered by the negative pressure of inspiration. When triggered, the machine would deliver a push of air which essentially forced the patient to take a much deeper breath than they normally would. The device proved to be an excellent post-operative therapy to encourage deep breathing. Post-surgical patients often breathe shallow, because of pain or simply because they aren’t active. This shallow breathing can cause atelectasis, alveoli in the lungs collapsing, which can lead to pneumonia. An IPPB treatment lasted about ten to fifteen minutes and three or four of these treatments a day seemed to do the trick and helped countless patients prevent pneumonia.
IPPB also proved a good way to deliver aerosol medications. Using an IPPB machine rather than an inhaler would help deliver the medication deeper into the lungs which was better for the patient. It didn’t take long to figure out that this therapy was good for chronic conditions and could be useful at home. Bennett (later Puritan Bennett) and The Bird Corporation both developed machines that could be used in the home to treat COPD, certain restrictive lung disorders, and Black Lung disease.
The therapy was over utilized in the hospitals and at home as well and third-party payment for the devices declined in the 1990’s. However, the therapy still exists and is useful in some very specific (but admittedly rare) cases. There is still a billing code for the devices and IPPB still enjoys a place on the equipment list.
CPAP (Continuous Positive Airway Pressure) is a much newer and more common therapy. Developed for commercial use in the 1990’s, this device uses positive pressure applied to a patient’s airway via a facemask to splint the airway and prevent it from collapsing. CPAP is used to treat obstructive sleep apnea (OSA) and worn at night during sleep. When sleeping, OSA patients experience “sleep apnea” which is the cessation of breathing for short but frequent periods of time. This prevents them from sleeping effectively and causes a whole host of problems over time. OSA is diagnosed with sleep testing, usually performed when patients (or their spouses) complain of snoring, frequently waking up, and not feeling rested after a night’s sleep. PAP therapy is relatively easy to use and inexpensive compared to the cost of treating the myriad problems associated with OSA. CPAP has become a mainstay of home respiratory care and many DME organizations exist primarily to provide PAP. BiPAP is a type of CPAP. CPAP has one pressure, while BiPAP has two levels of pressure which is more comfortable and more therapeutic for some patients. AutoPAP is another newer therapy. It is CPAP that is constantly titrated to the patient’s needs.
Respiratory Assist devices (RADs) are very similar to BiPAP devices. They have an added feature: a back up rate. Thus, they are essentially BiPAP devices that can be used as a ventilator. Typically, a patient escalates to RAD therapy by trying CPAP, BiPAP, and finally RAD. If CPAP and BiPAP don’t work, RAD comes into play. RAD will offer the positive pressure that the other PAP therapies offer, but has the added bonus of kicking into ventilator mode and delivering breaths at a given rate (prescribed by the physician). Often, the settings are titrated to a patient’s comfort and pulmonary function, so these devices typically require a respiratory therapist to evaluate and titrate them using clinical services. There are several manufacturers and while the devices have additional and more complex internal features, they often look almost identical to the other PAP devices. Besides the sleep testing, RAD’s usually require additional medical necessity documentation such as evidence that they failed PAP.
Mechanical In-Exsufflation devices are a twist on the concept of positive pressure being used to inflate the lungs for therapeutic reasons. These devices are used to assist patients in coughing. In fact, they often referred to as “cough assist” devices. They provide patients with positive pressure (which causes a deep breath) following by a rapidly applied negative pressure as the patient begins to exhale. This negative pressure helps patients cough. These devices are typically rented by Medicare or insurance for a specified period (13 months for Medicare patients) after which the device’s ownership converts over to the patient. They are manufactured by several companies; typically, companies that manufacture other respiratory therapy equipment.
Intrapulmonary Percussive Ventilation devices: Finally, we have the Intrapulmonary Percussive Ventilation (IPV) devices. These are very similar to the cough assist devices described above. They provide bursts of pneumatic, oscillating pressure to a patient which is designed to expand the lungs, and loosen mucus. The oscillation utilizes principles of physics to bypass blockages deep into the lungs. The therapy is appropriate for several different types of patients, but are most commonly used for cystic fibrosis patients. Insurance coverage is a possibility but only in very specific cases.
All these therapies use positive pressure to inflate the lungs and cause the patient to take a deep breath. All are used today, though it is becoming more and more unusual to see IPPB in use. Today, simple aerosol generators can turn liquid medication into a fine mist to inhale. Most patients can inhale deeply on their own without an assistive device. But respiratory therapists of a certain age remember the IPPB treatments fondly and homecare companies of a certain age remember building clinical programs that kept a generation of COPD-ers out of the hospital.
Newer, more sophisticated therapies and equipment have replaced the IPPB including inhalers (not DMEPOS), cough assists (DMEPOS), and IPV (DMEPOS). But a dose of pressure can still be used therapeutically to help patients with respiratory disease. And our homecare companies are still on the frontlines providing that equipment and that care.
