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Annals of Tropical Paediatrics (2010) 30, 87–101

Oxygen concentrators: a practical guide for clinicians and


technicians in developing countries

T. DUKE*{, D. PEEL*{, S. GRAHAM*1, S. HOWIE**, P. M. ENARSON1 &


R. JACOBSON{{

*Centre for International Child Health, University of Melbourne Department of Paediatrics, MCRI, Royal
Children’s Hospital, Parkville, Victoria, Australia, {School of Medicine & Health Sciences, University of
Papua New Guinea, {Ashdown Consultants, United Kingdom, 1International Union Against Tuberculosis &
Lung Disease, **Medical Research Council Laboratories, The Gambia and {{AirSep Corporation, Buffalo,
New York, USA

(Accepted February 2010)

Abstract Hypoxaemia is a common problem causing child deaths in developing countries, but the cost-effective
ways to address hypoxaemia are ignored by current global strategies. Improving oxygen supplies and the detection
of hypoxaemia has been shown to reduce death rates from childhood pneumonia by up to 35%, and to be cheaper
per life saved than other effective initiatives such as conjugate pneumococcal vaccines. Oxygen concentrators
provide the cheapest and most consistent source of oxygen in health facilities where power supplies are reliable. To
implement and sustain oxygen concentrators requires strengthening of health systems, with clinicians, teachers,
administrators and technicians working together. Programmes built around the use of pulse oximetry and oxygen
concentrators are an entry point for improving quality of care, and are a unique example of successful integration of
appropriate technology into clinical care. This paper is a practical and up-to-date guide for all involved in
purchasing, using and maintaining oygen concentrators in developing countries.

Introduction Therefore, it is likely that there are at least


1.5–2.7 million cases of hypoxaemic pneu-
Every year nearly 2 million children die from monia each year. Furthermore, 40% of the
pneumonia or other acute respiratory infec- almost 9 million annual child deaths result
tions.1 Hypoxaemia is the major fatal from neonatal conditions such as birth
complication of pneumonia and is a major asphyxia, sepsis and low birthweight,4 and
risk factor for death. The global burden of all of these are commonly associated with
hypoxaemia is very large. It is estimated that hypoxaemia.
at least 13% of children with severe pneu- Despite the huge global burden of hypox-
monia requiring hospital admission have aemia in sick children, treatment for hypox-
hypoxaemia.2 It is also estimated that, aemia, i.e. oxygen, is not available to a large
annually, 11–20 million children are proportion of patients admitted to hospital
admitted to hospital with pneumonia.3 in developing countries. This is particularly
true for children with pneumonia present-
ing to peripheral health centres and small
Reprint requests to: Professor Trevor Duke, Centre for district hospitals. A recent study from Papua
International Child Health, University of Melbourne
Department of Paediatrics, Parkville, Victoria,
New Guinea reported a 35% reduction in
Australia. Fax: z61 39 345 6667; email: trevor.duke pneumonia-related case-fatality rate in
@rch.org.au infants and children (2–59 months of age)
# W. S. Maney & Son Ltd 2010
DOI: 10.1179/146532810X12637745452356
88 T. Duke et al.

following the introduction of pulse oximetry with unreliable power supplies are dis-
to detect hypoxaemia and oxygen concen- cussed. Some of the published experiences
trators as a reliable source of oxygen.5 in different countries are outlined in the
Oxygen concentrators were first devel- Appendix.
oped for military use in the 1950s. In
developed countries in the 1970s, they
began to be used to provide long-term home How Does an Oxygen Concentrator
oxygen therapy for adults with chronic lung Work?
disease. Their use has been extended over
the past 35 years; concentrators are now Air is 21% oxygen, 78% nitrogen and 1%
successfully supplying oxygen needs in other gases. Oxygen concentrators take air
hospitals in developing countries through- from the environment and separate the
out the world, including Egypt,6 Malawi,7 oxygen and nitrogen by means of a
Papua New Guinea,8,9 The Gambia,10 pressure swing adsorption (PSA) process.
Nigeria11 and Nepal.12 Concentrators have Room air is passed through a sieve bed or
been used successfully to supply oxygen to column filled with a regenerative, synthetic
anaesthetic machines.13–15 zeolite molecular sieve which is a beaded,
This article reviews oxygen concentrators inert, ceramic material. This sieve material
and their use in paediatric care in develop- allows the oxygen to pass through freely
ing countries: how they work, the various while the nitrogen is retained under pres-
types which are available, installation and sure. The cycle alternates typically between
maintenance requirements, difficulties two sieve beds (some concentrators have
encountered when using concentrators, more sieve beds), allowing one bed to make
and what has been necessary to sustain their oxygen while the other is depressurised,
use over many years. Some solutions to the freeing the nitrogen to exit the system
problem of using concentrators in hospitals through the exhaust muffler. The oxygen

FIG. 1. Delivery of oxygen from a portable oxygen concentrator to two children at once.
Oxygen concentrators 89

is collected while the bed is pressurised. oxygen to multiple patients, depending on


Nitrogen is released through the exhaust patient size and oxygen requirements.
muffler when the bed is depressurised, Appropriate technical specifications are
allowing the sieve bed to regenerate. The listed in Textbox 1. A recent survey docu-
cycle of alternating pressure allows the mented the available models suitable for
continuous production of oxygen. The bedside use in tropical countries.13
system has four main components: an air Oxygen concentrators are available in a
compressor, valve(s), sieve bed(s) and variety of voltages and frequencies to match
circuit board. Most concentrators supply the power supplies of the countries in which
oxygen at a concentration of 90–96%, they are to be operated. Power incompat-
although .85% is quite adequate for ibility renders concentrators unusable very
clinical requirements. quickly.14 Voltage transformers alone will
not render power supplies compatible if a
frequency difference remains. Concen-
Bedside Oxygen Concentrators trators require a continuous AC power
source, most commonly a reliable mains
The concentrators most commonly used in electricity source and a back-up generator in
developing countries weigh about 25 kg and case of power failure. The economics of
produce oxygen at a rate ranging from 5 to various systems, including sizes, costs and
10 L/min (Fig. 1). They provide a reliable payment can be discussed with the manu-
source of oxygen for many years with facturer of the oxygen concentrator and
minimal service and maintenance. With local suppliers of alternative power sources.
appropriate mechanisms to divide the flow Solar power systems will need to include
from the concentrator, they can supply solar panels, batteries, a charge controller

TEXTBOX 1. Key technical points and specifications for oxygen concentrators suited for use in a district hospital ward.
N The concentrator should achieve .85% oxygen concentration at a flow rate of up to 10 L/min.
N The concentrator should operate at a voltage and frequency suitable for the local power supply; this differs
between countries.
N For energy efficiency the power requirements should be close to 350 W for units providing 5 L/min, 410 W for
8-L/min units, and 600 W for 10-L/min units.
N The concentrator should have one or two outlets with individual flow controls and flow indicators.
N Outlet pressure should be no less than 55 kPa for units providing 5 L/min and 138 kPa for 8- and 10-L/min
units.
N Weight should not exceed 25 kg.
N An hour meter should record total hours of unit operation.
N Maximum operating altitude should be not less than 2000 m, with not less than 85% oxygen concentration at
maximum flow.
N Maximum operating temperature should be not less than 40uC.
N Maximum operating humidity should be not less than 95% relative humidity.
N A list of all spare or replacement parts and their costs for 40,000 hours of operation (e.g. compressor, sieve beds
and valve spares kits) should be provided.
N The concentrator should comply with ISO 8359:199620 and IEC 60601-121 and carry a CE marking.
N The concentrator should be fitted with an oxygen monitor which gives an audible/visual alarm when the product
gas is below 82% oxygen concentration
N A user manual intended for hospital use and a service manual with a troubleshooting guide should be provided.
N There should be a 60-month parts warranty at a defined cost.
N The unit should include either a 4-way flow splitter, together with all nozzles and blanking plugs, which can
deliver flows of 0.5, 1.0 and 2.0 L/min (Fig. 4), OR a flow meter stand (Fig. 2). Each flow meter should be
continuously adjustable with an accurate low flow scale acceptable for patient care, such as from 0.1 to 2 L/min (or
higher flow as appropriate).
90 T. Duke et al.

and an inverter. Their capital costs are alternative source of power, and they are
high but they are cheap to run and can expensive.
be cost-effective if properly designed and
maintained.
Installation and Maintenance of
Bedside Oxygen Concentrators
Limitations of Oxygen Concentrators
Oxygen concentrators are usually supplied
Absence of a reliable power supply is a with user manuals and maintenance infor-
common reason for failure of oxygen con- mation explaining how the apparatus works,
centrators. In the Solomon Islands, limita- its limits of performance and what regular
tions in power meant that effective use of maintenance is required. There will be
oxygen concentrators was possible only in instructions on how to unpack and install
hospitals in the major centres.15 In Sierra the concentrator. It is important to check
Leone, where concentrators were the only that the voltage shown on the packing list is
oxygen source, supply was frequently inter- correct for the power supply and that the
rupted by lack of mains power and by the plug fits the mains power socket.
high cost of fuel for generators.16 A concentrator should be positioned close
In The Gambia, because of power limita- to a mains power outlet in a cool part of the
tions, only two of 12 hospitals surveyed were ward, not in direct sunlight, with a good air
suitable for concentrators; in these settings, supply. The ward should be well ventilated
oxygen cylinders were preferred.10 In one and there must be good air circulation
remote rural hospital in The Gambia, around the concentrator itself: clearance
concentrators were run using solar power.17 on all sides should be in accordance with
However, there are important limitations to
the manufacturer’s instructions. The con-
current solar technology. Recent estimates
centrator should be in the shade and at least
are that the capital cost of solar panels is
1.5 m away from any source of heat.
$25,000, plus the cost of batteries, charger
and inverter, merely to run a concentrator
which costs less than $1000.
The use of batteries to supply 24-hour Dividing Flow to Multiple Patients
power to a concentrator from only 4 hours
of mains electricity supply is currently being There are two ways to divide the flow from a
explored (Bradley et al., unpublished data, bedside concentrator to multiple patients. In
personal communication, David Peel). This the past, most concentrators used a flow
would be sufficient for the majority of splitter, which allows a fixed flow of oxygen
district hospitals throughout the world, (0.5 or 1 L/min) through fixed-size orifices.
which typically have some mains power. If not used properly, however, they are liable
Many details of a battery system are still to to deliver extremely low flows to patients.
be evaluated but initial testing is encoura- If a flow splitter is to be used, it must be
ging. ensured that all four ports have either
A universal power supply (UPS) can be oxygen tubing or a blanking plug so that
useful in settings where power surges are oxygen does not escape through unused
common and interruptions of power brief. nozzles. It is important that a blanking plug
However, it is important to note that UPS be applied to any unused port of the flow
provides power for only a few minutes after splitter to avoid wasting oxygen and to
mains power goes off. UPS may buy time to ensure that the correct flow is delivered.
switch to an alternative power source, such At least one manufacturer of concentra-
as a generator, but is not in itself an effective tors now has a flow meter stand as an
Oxygen concentrators 91

FIG. 2. A flow stand which provides oxygen to up to five patients at once.

alternative to a flow splitter. This has the With the oxygen-delivery system in place,
advantage of being more familiar to clinical the power supply cable should be connected
staff who are used to using flow meters on to the concentrator and then plugged into
cylinders. The flow is simply dialled up for the main power socket. An extension cable
each patient, as long as the aggregate flow should not be used. After the concentrator is
does not exceed the flow from the concen- switched on, it is normal for a continuous
trator. A concentrator can deliver oxygen to alarm to sound for up to 1 minute. If there is
one or more patients requiring low flow at a no power supply or other problems arise, an
time if it is equipped with a flow meter alarm will sound; in such cases, the user
stand (Fig. 2). Table 1 shows the equip- manual should be consulted.
ment needed to administer oxygen from an Once the concentrator is running, the flow
oxygen concentrator to up to five patients. rate should be adjusted to the required L/min
flow range by turning the control knob of the
TABLE 1. Equipment for the administration of oxygen flow meter anti-clockwise. Flow-rate mark-
to multiple patients from an oxygen concentrator.
ings are read at the centre of the ball. In flow
Description Quantity meters equipped with backlines, the proper
viewing angle is achieved when the two lines
Oxygen concentrator 1 appear as one. It can take up to 5 minutes for
Flow meter stand or 1 the concentrator to stabilize at or above the
flow splitter specified minimal performance of 85% O2.
Nozzles of 0.5 and 1 4 each
L/min if using flow spitter
There is no harm in using the unit while it is
Blanking plugs if using 3 building concentration, and most units reach
flow splitter therapeutic levels in less than 2 minutes.
Plastic tubing, 5-mm Up to 15 m64
internal diameter
Conduit to mount plastic Up to 15 m64
tubing on wall Testing After Installation
Non-crush plastic oxygen 8m
delivery tubing After all delivery tubing has been attached,
Prongs (or catheters) 4 the concentrator should be tested for flow
Back-up cylinder with 1
regulator and flow controller delivery and monitored for the oxygen
concentration produced.
92 T. Duke et al.

FIG. 3. Simple flow testing for an oxygen concentrator.

The flow is tested (a) by submerging the sing the tube under water. The difference in
oxygen catheter in water, or (b) by using an bubbling rate should be observed when the
in-line flow indicator. Assessing flow under flow is adjusted to between 0.5 and 1 L/min
water is a simple bedside test. Nasal prongs (Fig. 3). In-line indicators test flow from
are attached to each tubing outlet and the each concentrator orifice, but are rarely
flow from the prongs is checked by immer- used.

FIG. 4. An oxygen concentration status indicator or oxygen monitor. Note: The lights indicate adequate or below
normal oxygen concentration; a flow meter is shown to the left.
Oxygen concentrators 93

Monitoring the Function of an Oxygen For more precise measurement of oxygen


Concentrator concentration, an oxygen analyser can be
used. However, these do not come with the
It is vital that concentrators are fitted with concentrator and cost about US$150–400;
an oxygen concentrator status indicator they are therefore mostly used by biomedi-
(OCSI, or what some manufacturers call cal engineers.
an ‘oxygen monitor’). The oxygen monitor
is the most important indicator of function
and is particularly important where engi- Other Types of Concentrator
neering support is poor. An oxygen monitor Very lightweight portable oxygen concentrators
or OCSI is required to meet ISO 8359
specifications ‘to indicate by visual and/or There is now a class of smaller portable
audible alarm when the oxygen produced is oxygen concentrators, known as POCs.
at low concentration’. One example is a These miniaturised oxygen concentrators
coloured light display (Fig. 4). The indica- have been available since 2002. Because of
tor shows a green light to indicate normal their small size, they enhance ambulation
operation and a concentration of oxygen and travel for oxygen-dependent patients.
greater than 85% by volume. A yellow light POCs can weigh less than 2 kg and operate
indicates that the oxygen concentration is on multiple power sources: internal battery,
between 70% and 85% by volume. A red external battery, AC or DC power. When
light indicates that the oxygen concentration the unit operates on mains power, its battery
is below 70% by volume in which case a is recharged. These devices utilise a built-in
continuous alarm will sound. The most oxygen conserving device which allows a
usual causes of low oxygen product con- measured amount of oxygen to flow only
centration and the appropriate remedies are during the beginning of the patient’s inhala-
listed in Table 2. tion phase. They are much more expensive
There are differences in the alert limits than bedside portable oxygen concentrators
and indicators provided by different manu- and because they cannot deliver oxygen to
facturers for the oxygen monitoring device, multiple patients at the same time are
e.g. coloured lights, digital display indicat- unsuitable for use in hospitals in developing
ing concentration. Unfortunately, some countries.
manufacturers sell concentrators without
any form of oxygen monitor; although
Large oxygen generators
these are cheaper than other models, they
are not up to standard and are not recom- Larger concentrators are often referred to as
mended. oxygen generators and work on the same

TABLE 2. Causes of low oxygen concentration delivered by a concentrator (as indicated by the oxygen monitor)
and their remedies.

Cause Remedy

Dirty filters Wash or change filters


Low voltage Use a voltage regulator
Flow exceeding maximum Reduce flow if safe to do so
capacity (depending on concentrator specifications)
High ambient or operating temperatures Improve airflow around the unit,
reduce ambient temperatures, or reduce flow
94 T. Duke et al.

principle as bedside concentrators. They


provide higher capacities of both oxygen
output and oxygen outlet pressure: up to
450 kPa (65 psi). They can have several
uses: supplying oxygen to anaesthesia
machines, ventilators and other medical
devices; supplying an
entire hospital; or refilling oxygen cylinders.
Large oxygen generators can be custom-
designed to supply all or part of a hospital’s
oxygen requirements when connected to the
medical oxygen pipeline. However, the capi-
tal cost of pipelines is considerable and they
need maintenance. If the pipeline is not
maintained, much of the gas will leak;
leakages of 50–75% have been recorded from
poorly maintained pipelines. The main
source of leak is at the wall outlets, which
have a spring-loaded connection sealed with
a rubber O-ring. With time and friction of FIG. 5. The external, large-pore filter on a concen-
screwing and unscrewing oxygen flow-meters trator which should be removed and cleaned each
from the wall outlets, the O-rings wear out. week.
These have to be checked regularly and
replaced when worn. Leakages can also occur
2 m of the device or any of the oxygen-
at the manifold, if such a system is used.
carrying accessories. Oil, grease and petro-
Oxygen generators can also be used to
leum-based products should not be used on
refill oxygen cylinders. These systems can
or near the unit. The unit should be
fill 2–200 cylinders per day, to 15,000 kPA,
positioned away from curtains or drapes,
with additional oxygen compressors. This
hot air registers, heaters and fireplaces
may be of some value if a central hospital
and should be placed so that all sides are
supplies oxygen cylinders for small health
at least 30 cm away from a wall or other
centres without power.
Typically, the power consumption for obstruction.
oxygen generators is approximately 1 kilo- When not in use, nasal catheters or
watt hour to produce 1000 litres of oxygen. prongs should not be left in contact with
Hospital administrators, engineers and bed sheets or blankets; this is an infection
equipment suppliers should review the hazard and also a fire hazard if the con-
requirements of the facility to properly select centrator is turned on as the oxygen will
or construct an economical oxygen system. make the bedding material inflammable.
Where an oxygen generator is selected as a The concentrator power switch should be
source, the size and the design of the oxygen set to ‘off’ when not in use. Firebreak
system should meet the guidelines of ISO connectors are recommended to stop the
standard 10083.18 oxygen flow in the event of fire.
To avoid nosocomial infection, face
masks, nasal prongs and oxygen tubing
Safety Procedures should be cleaned with soap and water,
soaked in dilute bleach solution, rinsed in
Oxygen can promote fire. Smoking and water to remove chlorine residues, and
naked flames are not permitted within allowed to dry before re-use.
Oxygen concentrators 95

Maintenance to the outlet. The flow meter should be


Weekly maintenance by clinical staff turned to the maximum capacity of the
concentrator and allowed to operate for a
Most portable oxygen concentrators have an period of at least 5 minutes for the unit to
external, coarse, cabinet air filter over the air stabilise before readings are taken. If the
inlet which is often at the back of free- unit’s oxygen monitor is indicating a low
standing or portable concentrators (Fig. 5). oxygen concentration, an independent test
As this filter becomes dirty, less air can pass such as the above is valuable to determine if
through it. If the filter is left to occlude, the monitor has failed or the oxygen con-
oxygen production can be reduced and the centrator is in need of service. If the unit is
unit may eventually shut down as a result of performing below the manufacturer’s speci-
elevated internal temperatures. This filter fications, service is required.
must be washed in detergent at least once a All oxygen concentrators have an internal
week, rinsed in clean water, dried and fine particle filter. These should be
replaced. A spare filter should be inserted inspected and replaced at intervals accord-
if the concentrator continues to run during ing to the manufacturer’s instructions.
cleaning. When dirty, some internal filters can cause
The exterior of the oxygen concentrator the unit to perform below specifications
should be cleaned with a mild disinfecting because of diminished airflow to the com-
cleaning agent or a diluted solution of pressor and a resultant decrease in oxygen
bleach (5.25% sodium hypochlorite). A production.
solution in the range of 1 : 100 to 1 : 10 of Oxygen concentrators commonly have
bleach to water can be used effectively, four major components, outlined below.
depending on the amount of organic mate- An understanding of each of these and their
rial present. Allow the solution to remain on function greatly enhances the technician’s
the surface for 10 minutes and then rinse off ability to properly maintain, diagnose and
and dry. repair a concentrator. A log-book should be
kept to record all maintenance activities for
each concentrator, including weekly filter
Maintenance by the hospital engineer or service changes by clinical staff.
technician
Oxygen concentrators have an alarm to
The compressor
signal power failures. Where a battery is
used for alarm activation, it should be tested The compressor is the ‘pump’ within the
and maintained every 6 months, or as oxygen concentrator that pushes room air
necessary. Testing involves disconnecting into the sieve beds and allows oxygen to flow
the oxygen concentrator from its power out. The two aspects of the compressor
source and turning the power switch to which can cause concern are output and
‘on’. For models which use a capacitor to noise levels. Output is how much com-
power the alarm, the unit may need to be pressed air the compressor can produce and
operated for a period of time to provide a depends on the model, its stroke size, bore
charge to the capacitor. size and cup seal condition. The cup seals
The oxygen concentrator should be tested form the seal between the piston and the
at regular intervals to confirm that the cylinder wall. As the cup seals wear, the
oxygen concentration is within specifica- compressor’s output gradually decreases
tions. If humidification is used, the humidi- and there is a slight increase in sound
fier should first be removed from the line caused by air leaking around the seal. This
and a calibrated oxygen analyser connected reduced output means less air is sent into
96 T. Duke et al.

the sieve beds and less oxygen produced. oxygen and argon to pass through freely.
When there is a measurable decrease in the As well as nitrogen, the sieve material has an
unit’s oxygen production or the operating attraction for water molecules. Water in the
system pressure, the compressor will require feed air is contained within a water zone of
rebuilding or replacement. the sieve bed and, on depressurisation,
The condition of the compressor’s bear- is released along with the nitrogen as part
ings also determines sound level. There are of the purge gas. A controlled amount of
four bearings in the compressor which allow sieve is intentionally exposed and allowed
the inner components to rotate. As the to ‘contaminate’ with water molecules form-
bearings become worn, the noise level ing the water zone. In a well designed
increases noticeably and service is required. and properly operating PSA system, the
water zone remains constant even when
exposed to high humidity and ambient
Valves temperatures.
Sieve material within the sieve bed can
The valves, or valving system, control the
become contaminated in a number of ways.
PSA process within the oxygen concentra-
A leak in the system, especially on the
tor. They control the pathway of the
product side, allows water molecules in
compressed air which feeds and pressurises
room air to come in contact with and
one sieve bed while the other sieve bed is
contaminate the sieve material. The sieve
allowed to depressurise and purge the
material needs to be tightly packed and
nitrogen through the exhaust muffler.
contained within the sieve bed. Most
Many types of valves (4-way, 3-way, 2-
manufacturers use a spring-loaded piston
way, rotary, spool and sleeve, diaphragm,
design which keeps pressure on the sieve to
and poppet) are found within different
prevent it from shifting. If the material
models of oxygen concentrators. Some
moves or migrates, the contaminated sieve
valves can be opened and serviced, but
in the water zone will move throughout
others are sealed. The type of valve in the
the bed.
concentrator will directly influence the
If the alternating PSA cycle of feeding
need for filtration. Owing to particulates,
and purging the beds is interrupted,
dust, dirt, smoke and surface corrosion
the beds can become contaminated. A
caused by humidity, highly sensitive valves
failure to cycle could be caused by a
with extremely small tolerances are very
defective valve or printed circuit board
susceptible to sticking. They therefore
(PCB) which controls the valves. This could
require a high degree of filtration. Two-
result in one bed being fed room air
way poppet valves have been designed and
continuously. This introduces more water
demonstrated to operate reliably in very
molecules than the water zone can contain,
humid climates with elevated tempera-
expanding the water zone into the active
tures. It is important that the oxygen
part of the bed. Care should be taken to
concentrator has a valving system proven
thoroughly leak-test a unit and repair any
to be suitable to the conditions in which the
leaks which can result in sieve bed failure.
unit is to be operated. To detect leaks, a solution of soapy water
should be sprayed or applied to all fittings
and connections, from the air compressor to
Sieve beds
the oxygen outlet.
The sieve beds hold the molecular sieve Argon, along with the oxygen, passes
material where gas separation takes place. freely through the sieve material and is
The material is regenerative and stores allowed to concentrate, so the maximum
nitrogen under pressure while allowing oxygen concentration obtainable will be
Oxygen concentrators 97

TABLE 3. Troubleshooting guide for the hospital engineer or service technician.

Problem Probable cause(s) and solution(s)

Oxygen concentrator No mains power


does not turn on Inspect and check power cord, electrical connections,
circuit breaker (if equipped), internal fuse (if equipped,
sometimes located on the PCB), on/off switch, PCB
Oxygen concentrator operates but the Check cabinet filter, cabinet fan, capacitor for the
compressor shuts down intermittently compressor, cabinet thermal switch (if equipped), valve(s), PCB
Compressor may have a faulty thermal switch
Oxygen concentrator’s Inspect and check electrical connections to the
compressor does not turn on compressor, capacitor, PCB, valve(s), compressor
Oxygen concentration is within Pressure regulator needs to be adjusted, repaired, or replaced
specifications but flow fluctuates
Oxygen concentration is Tubing to oxygen monitor is kinked,
within specifications faulty oxygen monitor
but the oxygen monitor
indicates low concentration
Oxygen concentrator runs but For these situations it is very useful to test the system’s operating
oxygen concentration is low cycle pressures for determining which component is in need of repair
or replacement; refer to service manual for instructions on
how to test system pressure
Low system pressure can indicate a restriction to the
intake of the compressor, a leak, a worn compressor, valve, PCB
High system pressure can indicate contaminated sieve beds,
restriction in the exhaust muffler, valve, PCB

PCB, printed circuit board.

95.5%, the remainder being argon and a on historical reliability data. Many manu-
small amount of nitrogen. facturers provide technical training, either at
their facility or on-site.
To be able to properly support the oxygen
Printed circuit board (PCB)
concentrators in a facility, an inventory of
The PCB is the electronic control for spare parts needs to be maintained and
operating the valve(s) and alarm system. If should include the major components,
it fails, the unit may not cycle properly or components which wear and most, if
may not operate at all. Some systems have a not all, electrical components. Items to
lighting and diagnostic system on the PCB consider include compressors, compressor
to aid troubleshooting. mounts, sieve beds, valves, PCBs, on/off
Table 3 provides a guide to troubleshoot- power switches, power cords, hour meters,
ing some of the more common problems circuit breakers, fuses, cabinet fans and
with oxygen concentrators. Consult the ser- tubing, fittings and filters. This inventory
vice manual for additional troubleshooting of parts should be adjusted according to
suggestions. the number of concentrators being sup-
Regular contact with the manufacturer’s ported. This is where the manufacturer can
technical support department should be be of great assistance in recommending
maintained. This can be done via email quantities and parts commonly used.
and will allow receipt of updates on equip- These parts should be included in the initial
ment and service manuals. Technical sup- purchase contract. Concentrators will not
port offers troubleshooting assistance and run without regular maintenance and repla-
recommends spare parts inventories, based cement of parts.
98 T. Duke et al.

Regulatory Requirements to Support dependent medical equipment in health


Oxygen Concentrators facilities with no mains or unreliable power.
Another challenge likely to be met in the
Regulatory requirements need to be brought near future is concentrators which require
into line with rational clinical needs. In minimal maintenance for an extended per-
some countries, companies selling bottled iod of time, such as 5 years.
gas have promoted regulations requiring
99% oxygen for hospital use. The cost of
making a concentrator which produces 99% Acknowledgments
oxygen is markedly increased. They are
available but require an additional PSA We thank David Woodroffe, David
separation system which uses black carbon Woodroffe Digital Illustration for Figs 1,
sieve material to remove argon (the major 2, 3 and 5. The Centre for International
gas remaining, apart from oxygen, when Child Health is a World Health
nitrogen is removed from air). Processes to Organization Collaborating Centre for
remove argon greatly increase the overall Research and Training in Child and
cost of the system and the power require- Neonatal Health, and is supported by
ments. 85% oxygen is perfectly adequate for AusAID as part of the Knowledge Hubs
patient care. Such regulations increase the for Women’s and Children’s Health, and by
costs of PSA systems and make them less the R. E. Ross Trust (Victoria).
viable. This is to the detriment of efforts to
make appropriate technology available in
developing countries at an affordable price. References
The WHO Essential Medicines programme
1 UNICEF, World Health Organization. Pneumonia:
lists oxygen as an essential drug.19 WHO The Forgotten Killer of Children. Geneva: WHO,
should specify the concentration to be 85% 2006.
or more, and national regulations should 2 Subhi R, Adamson M, Campbell H, et al. The
reflect this to ensure that concentrators prevalence of hypoxaemia among ill children in
remain an option for providing oxygen in developing countries. Lancet Infect Dis 2009; 9:219–
27.
all health facilities.
3 Rudan I, Tomaskovic L, Boschi-Pinto C, Campbell
H, WHO Child Health Epidemiology Reference
Group. Global estimate of the incidence of clinical
Future Trends in Oxygen Concentrator pneumonia among children under five years of age.
Technology Bull WHO 2004; 82:895–903.
4 World Health Organization. Global Burden of
Disease. http://www.who.int/healthinfo/global_bur-
There continue to be improvements in the den_disease/GBD_report_2004update_part2. Ac-
design and manufacture of oxygen con- cessed December 2009.
centrators, resulting in smaller, lighter, 5 Tin W, Gupta S. Optimum oxygen therapy in
quieter, more power-efficient and less preterm babies. Arch Dis Child Fetal Neonatal Ed
expensive models. New models of oxygen 2007; 92:F143–7.
6 Dobson M, Peel D, Khallaf N. Field trial of oxygen
concentrators appear every year. However, concentrators in upper Egypt. Lancet 1996;
within a hospital or health service, stan- 347:1597–9.
dardising to one model helps ensure 7 Enarson P, La Vincente S, Gie R, Maganga E,
continuity of spare parts, maintenance Chokani C. Implementation of an oxygen concen-
and training. trator system in district hospital paediatric wards
throughout Malawi. Bull WHO 2008; 86:344–8.
A challenge for oxygen concentrators is in
8 Duke T, Wandi F, Jonathan M, et al. Improved
the use of alternative, renewable or hybrid oxygen systems for childhood pneumonia: a multi-
sources of power to solve the problem of hospital effectiveness study in Papua New Guinea.
running concentrators and other electricity- Lancet 2008; 372:1328–33.
Oxygen concentrators 99

9 Matai S, Peel D, Jonathan M, Wandi F, Subhi R, APPENDIX. Various countries’ experiences


Duke T. Implementing an oxygen programme in
of oxygen concentrators.
hospitals in Papua New Guinea. Ann Trop Paediatr
2008; 28:71–8.
10 Howie SRC, Hill S, Ebonyi A, et al. Meeting oxygen
Egypt
needs in Africa: an options analysis from the
Gambia. Bull WHO 2009; 87:763–71. The earliest large-scale field trial
11 Mokuola OA, Ajayi OA. Use of an oxygen
concentrator in a Nigerian neonatal unit: economic In 1993, a project was set up to introduce
implications and reliability. Ann Trop Paediatr 2002; oxygen concentrators in upper Egypt.6 This
22:209–12. involved installing oxygen concentrators in
12 Litch JA, Bishop RA. Oxygen concentrators for the
delivery of supplemental oxygen in remote high-
district hospitals, training technicians in
altitude areas. Wilderness Environ Med 2000; installation and maintenance, making reg-
11:189–91. ular inspections, servicing and repairing the
13 Peel D, Howie SRC. Oxygen concentrators for use equipment and setting up a reporting system
in tropical countries: a survey. J Clin Engineering that would closely inspect the performance
2009; Oct/Dec:205–9.
14 Howie SRC, Hill SE, Peel D, et al. Beyond good
and usefulness of the machines. A team and
intentions: lessons on equipment donation from an an overall co-ordinator were appointed to
African hospital. Bull WHO 2008; 86:52–6. carry this out. One year after installation,
15 Auto J, Nasi T, Ogaoga D, Kelly J, Duke T. two concentrators of a total 22 had faults
Hospital services for children in Solomon Islands: and both were repaired. The training of staff
rebuilding after the civil conflict. J Pediatr Child
Health 2006; 42:680–7.
was successful and the day-to-day running
16 Kingham TP, Kamara TB, Cherian MN, et al. of the programme was predominantly done
Quantifying surgical capacity in Sierra Leone. Arch by the local team.
Surg 2009; 144:122–7.
17 Schneider G. Oxygen supply in rural Africa: a
personal experience. Int J Tuberc Lung Dis 2003;
5:524–6.
Papua New Guinea
18 International Organization for Standardization. ISO Proving effectiveness: impact of better detection
10083: Oxygen Concentrator Supply Systems for Use of hypoxaemia and improved oxygen supply
with Medical Gas Pipeline Systems, 2006. http://
www.iso.org/iso/iso_catalogue/catalogue_tc/catalo- After studies showed that hypoxaemia was a
gue_detail.htm?csnumber532061. Accessed De- major child health problem and that the
cember 2009.
19 World Health Organization. WHO Model List
supply of oxygen was a major problem in
of Essential Medicines, 16th edn. http://www Papua New Guinea,22,23 pulse oximeters and
who int/selection_medicines/committees/expert/17/ oxygen concentrators were introduced in five
sixteenth_adult_list_en Accessed December 2009. hospitals in 2005. Nurses, doctors and hospi-
20 International Organization for Standardization. ISO tal technicians were provided with training in
8359: Oxygen Concentrators for Medical Use – Safety
Requirements, 1996. http://www iso org/iso/iso_cata-
the use, maintenance and repair of the
logue/catalogue_tc/catalogue_detail htm?csnum- equipment. The technology, training and
ber522625 ongoing monitoring and support formed the
21 International Electrotechnical Commission. Medical oxygen programme in Papua New Guinea.9
Electrical Equipment – Part 1: General Requirements In the following 2.5 years, there was a
for Basic Safety and Essential Performance, 2005.
http://www nssn org/search/DetailResults aspx?docid
highly significant reduction in hospital mor-
5277847&selnode. Acessed September 2007. tality rates for pneumonia. In the years before
22 Laman M, Ripa P, Vince J, Tefuarani N. Can the system was introduced, there were 356
clinical signs predict hypoxaemia in Papua New deaths from 7161 admissions for pneumonia
Guinean children with moderate and severe pneu-
(case fatality rate 4.97%). In the 2.5 years
monia? Ann Trop Paediatr 2005; 25:23–7.
23 Duke T, Frank D, Mgone J. Hypoxaemia in
after the system was introduced, there were
children with severe pneumonia in Papua New 115 deaths from 3538 admissions (case
Guinea. Int J Tuberc Lung Dis 2000; 5:511–19. fatality rate 3.2%). The risk of a child with
100 T. Duke et al.

pneumonia dying in the hospitals after the and very dusty conditions. The cost of
system was introduced was 35% lower than treating one patient for 1 year using the
before (risk ratio 0.65, 95% confidence concentrator was 27% that of using cylin-
interval 0.53–0.80, p,0.0001).5 The cost of ders. Greater savings could have been
the programme was estimated to be $51/child achieved by using a flow splitter on the
treated, $50 per DALY averted, and $1670/ concentrator in order to treat several
additional life saved. The programme has patients at once. The use of the concen-
now been extended to 17 hospitals. trator was limited by interruptions to the
power supply. During power cuts, a portable
generator was used to power the concen-
Malawi trator.
A large national Child Lung Health programme
Malawi was one of the first countries with Nepal
limited resources to implement a national
Oxygen concentrators at high altitude
oxygen programme, beginning in 2002. This
was part of a highly successful National Child Oxygen demands are high at Kunde
Lung Health Project. Case fatality rates from Hospital, located near Mount Everest,
pneumonia have consistently fallen since the 3900 m above sea level. Oxygen is required
introduction of the programme. In 2007, an for childbirth, neonatal resuscitation, surgi-
evaluation of 15 hospitals using oxygen cal procedures and management of cardio-
concentrators showed that this technology pulmonary illness and altitude sickness (e.g.
had been successful in reducing hospital high altitude pulmonary or cerebral
mortality for pneumonia. Many units of one oedema). It is a 10-day walk from the
particular model which claimed to comply nearest road, and transport of cylinders is
with international standards were not work- difficult. In 1997, oxygen concentrators
ing. This emphasised that cheaper equip- were installed and connected to power
ment is not always the most cost-effective in supplied by a hydro-electric system with a
the long term, and that manufacturers claims petrol generator as back-up.12 An additional
need to be tested in the field. One challenge two concentrators are kept as back-up. No
was high staff turnover which made it equipment failures occurred over 3 years
difficult to sustain adequate staff skill levels. and the concentrators have replaced oxygen
Another challenge to optimal success was cylinders and portable hyperbaric chambers.
user fees; making hospital care free for
children in one hospital markedly increased
demand and access compared with hospitals The Gambia
where fees were charged.7 Donations and options where power is limited
In 2000, a teaching hospital in The Gambia
Nigeria received a donation of oxygen concentra-
tors.14 Unfortunately, all the equipment
Oxygen concentrators in a neonatal unit
very quickly stopped working. The main
Oxygen concentrators were introduced to a problem was lack of compatibility of fre-
neonatal unit in Nigeria in 1993 to over- quency: machines constructed for use with
come the limitations of cylinder oxygen.11 A 110 V 60 Hz electrical supply did not
model that met international standards was function with the 230 V 50 Hz local elec-
purchased and installed. It ran for 18 hours trical supply. The concentrators were sec-
a day for 3 years without breaking down, ond-hand and, although they had been
despite high daily temperatures (30–32uC) serviced before donation, there was not the
Oxygen concentrators 101

expertise in The Gambia to maintain the In remote district hospitals without reg-
equipment and the donor did not assess ular electricity, oxygen concentrators have
whether the electrical frequency was com- a limited role.10 In one such hospital in
patible. This emphasises the need for better The Gambia, oxygen concentrators were
planning, management and local participa- run successfully on solar power. Despite
tion around donations of equipment to a high initial outlay, running costs were
developing countries. It is also important small. Such a set-up requires a high level of
to ensure that any new equipment, either technical expertise.17 In The Gambia, the
given or bought, is supported by sufficient use of batteries to supply 24-hour power
technical expertise. Following this experi- to a concentrator from only 4 hours of
ence, the hospital organised a committee to mains electricity supply is currently being
oversee all donations, working with a non- developed (B. Bradley, et al., unpublished
government organization partner. data, personal communication, David Peel).