Evaluation of oxygen concentrators for use in countries with limited resources

An Oxygen Supply Is Not Enough: A Qualitative Analysis of a Pressure Swing Adsorption Oxygen Plant Program in Ethiopian Hospitals

BACKGROUND

In response to critical gaps in medical oxygen access, 2 pressure swing adsorption (PSA) oxygen production centers were established using an ecosystem-strengthening strategy in Amhara, Ethiopia, in 2019. A qualitative study was conducted to assess enablers and bottlenecks to oxygen access at the hospital level after installation.

METHODS

A variety of hospital staff (clinicians, biomedical professionals, hospital administrators, and procurement teams) across 13 hospitals procuring oxygen from the plants participated in comprehensive, semistructured focus group discussions. A thematic framework analysis approach was used to identify key themes.

FINDINGS

A total of 101 individuals participated in 26 focus groups in 2021, 2 years after plants were installed. Primary themes were accessibility of supply, affordability, and hospital readiness. Respondents indicated a substantial increase in their hospital's ability to access lower-cost oxygen, with many attributing this to the locality of plants and reduced transportation barriers. However, other challenges persisted, and the emergence of COVID-19 1 year after plant installation and a civil conflict exacerbated supply shortages. Investments in equipment, supplies, and training optimized clinical utilization of oxygen and were highlighted as a need for ongoing investment.

CONCLUSION

To achieve maximum impact, investments in large-scale oxygen systems must be accompanied by strategic plans to transport oxygen, reduce costs to hospitals, and provide support to clinical teams through equipment, supply procurement, and clinical training. These findings support comprehensive ecosystem approaches to strengthening oxygen access for sustainable impact.

Technology to improve reliable access to oxygen in Western Uganda: study protocol for a phased implementation trial in neonatal and paediatric wards

INTRODUCTION

Oxygen is an essential medicine for children and adults. The current systems for its delivery can be expensive and unreliable in settings where oxygen is most needed. FREO₂ Foundation Australia has developed an integrated oxygen system, driven by a mains-powered oxygen concentrator, with the ability to switch automatically between low-pressure oxygen storage device and cylinder oxygen in power interruptions. The aim of this study is to assess the clinical impact and cost-effectiveness of expanding this system to 20 community and district hospitals and level IV facilities in Western Uganda.

METHODS AND ANALYSIS

This will be a phased implementation with preintervention and postintervention comparison of outcomes. Standardised baseline data collection and needs assessment will be conducted, followed by implementation of the FREO₂ Oxygen System in combination with pulse oximetry in 1-2 facilities per month over a 16-month period, with a total 23-month data collection period. The primary outcome will be the proportion of hypoxaemic children receiving oxygen pre and post oxygen system. Secondary outcomes will assess clinical, economic and technical aspects. Pre and post oxygen system primary and secondary outcomes will be compared using regression models and standard tests of significance. Useability will be quantitatively and qualitatively evaluated in terms of acceptability, feasibility and appropriateness, using standardised implementation outcome measure tools.

ETHICS AND DISSEMINATION

Ethics approval was obtained from Mbarara University of Science and Technology (MUREC 1/7) and the University of Melbourne (2021-14489-13654-2). Outcomes will be presented to the involved facilities, and to representatives of the Ministry of Health, Uganda. Broader dissemination will include publication in peer-reviewed journals and academic conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12621000241831.

Cost implication of CPAP use in low resource settings, surmounting the oxygen administration challenge

PURPOSE

Newborn respiratory support using Bubble Continuous positive airway pressure (bCPAP) has become acceptable in Nigeria as many centers are increasingly reporting its usefulness. There is increasing access to CPAP devices although the use of 100% oxygen for bCPAP administration is on the rise as oxygen/air blenders are not commonly available or insufficient. The cost of oxygen has become a significant contributor to hospital bills. The oxygen concentrator driven bCPAP device with blending capacity is expected to save lives and reduce cost of care.

OBJECTIVE

To compare the cost saving benefit of the use of oxygen concentrator bCPAP devices for CPAP administration to oxygen based devices in a resource limited setting.

METHODS

This prospective cross sectional study was done between February and December 2019. The oxygen use by CPAP devices-Improvised (IbCPAP), Fisher and Paykel and T-piece were quantified, costed, documented and compared with the same duration of use of concentrator CPAP-Diamedica.

RESULTS

CPAP services was accessed by 357 babies, 154 males and 203 females of GA range from 22 to 42 weeks and Birthweights range from 264 to 4400 grams. The main indication for CPAP was respiratory distress syndrome 201(56.3%). Oxygen supply were by oxygen pipeline 250 (70%), cylinders 39 (10.9%), concentrator CPAP 44 (12.3%) mixed source 24 (6.7%). Mean duration on the CPAP devices was 5.4 days, mean cost ₦37,645 ($104) or ₦6,971 ($20)/day, highest with IbCPAP, non-existent with concentrator bCPAP.

CONCLUSION

The high running cost implication of CPAP use in low resource settings could deter transitioning to quality devices hence the need for non-oxygen dependent devices.

The LeVe CPAP System for Oxygen-Efficient CPAP Respiratory Support: Development and Pilot Evaluation

Background: The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has placed a significant demand on healthcare providers (HCPs) to provide respiratory support for patients with moderate to severe symptoms. Continuous Positive Airway Pressure (CPAP) non-invasive ventilation can help patients with moderate symptoms to avoid the need for invasive ventilation in intensive care. However, existing CPAP systems can be complex (and thus expensive) or require high levels of oxygen, limiting their use in resource-stretched environments. Technical Development + Testing: The LeVe ("Light") CPAP system was developed using principles of frugal innovation to produce a solution of low complexity and high resource efficiency. The LeVe system exploits the air flow dynamics of electric fan blowers which are inherently suited to delivery of positive pressure at appropriate flow rates for CPAP. Laboratory evaluation demonstrated that performance of the LeVe system was equivalent to other commercially available systems used to deliver CPAP, achieving a 10 cm H2O target pressure within 2.4% RMS error and 50-70% FiO2 dependent with 10 L/min oxygen from a commercial concentrator. Pilot Evaluation: The LeVe CPAP system was tested to evaluate safety and acceptability in a group of ten healthy volunteers at Mengo Hospital in Kampala, Uganda. The study demonstrated that the system can be used safely without inducing hypoxia or hypercapnia and that its use was well-tolerated by users, with no adverse events reported. Conclusions: To provide respiratory support for the high patient numbers associated with the COVID-19 pandemic, healthcare providers require resource efficient solutions. We have shown that this can be achieved through frugal engineering of a CPAP ventilation system, in a system which is safe for use and well-tolerated in healthy volunteers. This approach may also benefit other respiratory conditions which often go unaddressed in Low and Middle Income Countries (LMICs) for want of context-appropriate technology designed for the limited oxygen resources available.

Technical results from a trial of the FREO2 Low-Pressure Oxygen Storage system, Mbarara Regional Referral Hospital, Uganda

Increased access to reliable medical oxygen would reduce the global burden of pneumonia. Oxygen concentrators have been shown to be an effective solution, however they have significant drawbacks when used in low-resource environments where pneumonia burden is the heaviest. Low quality grid power can damage oxygen concentrators and blackouts can prevent at-risk patients from receiving continual oxygen therapy. Gaps in prescribed oxygen flow can result in acquired brain injuries, extended hypoxemia and death. The FREO2 Low-Pressure Oxygen Storage (LPOS) system consists of a suite of improvements to a standard oxygen concentrator which address these limitations. This study reports the technical results of a field trial of the system in Mbarara, Uganda. During this trial, oxygen supplied from the LPOS system was distributed to four beds in the paediatric ward of Mbarara Regional Referral Hospital. Over a three-month period, medical-grade oxygen was made available to patients 100% of the time. This period was sufficient to quantify the ability of the LPOS system to deal with blackouts, maintenance, and an unscheduled repair to the LPOS store.

Implementing bubble continuous positive airway pressure in a lower middle-income country: a Nigerian experience

Bubble CPAP (bCPAP) is used for respiratory distress (RD) in neonates. The leading causes of neonatal mortality can lead to severe RD. Many neonatal deaths are preventable using evidence-based interventions like bCPAP as part of a comprehensive approach. The study aimed to assess the implementation of a multi-center, comprehensive hospital-based bCPAP program in a low-middle-income country using a low-cost bCPAP device. Seven established hospitals in three Nigerian States were selected using purposive sampling. A respiratory support program was developed and implemented using the Pumani® bCPAP. Neonates <28 days old with severe RD, birth weight >1000g and breathing spontaneously, were eligible. The program lasted 22 months. Focus group discussions and in-depth interviews of healthcare workers and hospital administrators were used in program assessment. Content analysis of qualitative data completed. The staff reported that the bCPAP device was easy to use and effective. All staff reported comfort in eligible patient identification, effective set up and bCPAP administration. All study sites experienced varying degrees of electric power interruption and oxygen availability and affordability. Staff training, staffing disruptions, data collection challenges and use of improvised bCPAP contributed to low enrollment. Advocacy, direct program support, and innovation using locally available resources improved enrollment. Professional organization collaboration, competency-based training and peer mentoring contributed to program success. Thorough pre-program assessment, with comprehensive understanding of all aspects of the existing system within the local context which are likely to impact the introduction of a new program is important to implementation success.

Ventilators are not the answer in Africa

The treatment of severely ill coronavirus disease 2019 (COVID-19) patients has brought the worldwide shortage of oxygen and ventilator-related resources to public attention. Ventilators are considered as the vital equipment needed to manage these patients, who account for 3% – 5% of patients with Covid-19. Most patients need oxygen and supportive therapy. In Africa, the shortage of oxygen is even more severe and needs equipment that is simpler to use than a ventilator. Different models of generating oxygen locally at hospitals, including at provincial and district levels, are required. In some countries, hospitals have established small oxygen production plants to supply themselves and neighbouring hospitals. Oxygen concentrators have also been explored but require dependable power supply and are influenced by local factors such as ambient temperature and humidity. By attaching a reservoir tank, the effect of short power outages or high demands can be smoothed over. The local and regional energy unleashed in the citizens to respond to the COVID-19 pandemic should now be directed towards developing appropriate infrastructure for oxygen and critical care. This infrastructure is education and technology intensive, requiring investment in these areas.

Providing oxygen to children and newborns: a multi-faceted technical and clinical assessment of oxygen access and oxygen use in secondary-level hospitals in southwest Nigeria

Background

Oxygen is an essential medical therapy that is poorly available globally. We evaluated the quality of oxygen therapy in 12 secondary-level Nigerian hospitals, including access to oxygen equipment, equipment functionality, healthcare worker knowledge and appropriateness of use.

Methods

We conducted a three-part evaluation of oxygen access and use involving: (1) facility assessment (including technical evaluation of oxygen equipment), (2) clinical audit (children and neonates admitted January 2014–December 2015) and (3) survey of healthcare worker training and experience on the clinical use of oxygen (November 2015).

Results

Oxygen access for children and newborns is compromised by faulty equipment, lack of pulse oximetry and inadequate care practices. One hospital used pulse oximetry for paediatric care. Eleven hospitals had some access to oxygen supplies. Testing of 57 oxygen concentrators revealed two (3.5%) that were ‘fit for use’. Overall, 14.4% (3708/25 677) of children and neonates received oxygen some time during their admission; 19.4% (1944/10 000) of hypoxaemic children received oxygen; 38.5% (1217/3161) of children who received oxygen therapy were not hypoxaemic.

Conclusions

Oxygen access for children in Nigerian hospitals is poor, and likely results in substantial excess mortality. To improve oxygen access for children globally we must focus on actual provision of oxygen to patients—not simply the presence of oxygen equipment at the facility level. This requires a systematic approach to improve both oxygen (access [including equipment, maintenance and affordability]) and oxygen use (including pulse oximetry, guidelines and continuing education).

Bubble CPAP devices for infants and children in resource-limited settings: review of the literature

Background: Early management of respiratory distress is critical to reducing mortality in infants and children in resource-limited settings. Bubble continuous positive airway pressure (bCPAP) can offer effective and affordable non-invasive respiratory support. Objective: To determine the best physical components of bubble CPAP circuits for respiratory support of children in low-resource settings. Methods: Using PubMed, CINAHL and LILACS, studies of any design in any language published before June 2017 which examined the physical components of bCPAP circuits were identified and reviewed. Results: After screening, the review included 45 articles: 17 clinical trials, 11 literature reviews, 10 technical assessments of bCPAP components, three reports of real-world implementation in low-resource settings, three cost analyses and one case report. There is no ideal bCPAP circuit for all settings and patients, but some choices are generally better than others in designing a circuit for low-resource settings. Oxygen concentrators are usually the best source of oxygen. As yet, there is no affordable and accurate oxygen blender. Nasal prongs are the simplest patient interface to use with the fewest complications but are not the cheapest option. Expiratory limbs should be at least 1 cm in diameter. Home-made pressure generators are effective, safe and affordable. Conclusion: This narrative review found many studies which evaluated the real clinical outcomes with bCPAP in the target population as well as technical comparison of bCPAP components. However, many studies were not blinded or randomised and there was significant heterogeneity in design and outcome measures. Abbreviations: bCPAP, bubble continuous positive airway pressure; CPAP, continuous positive airway pressure; FiO₂, fractional oxygen concentration; HFNC, high-flow nasal cannula; HIC, high-income countries; LMIC, low- and middle-income countries; NP, nasopharyngeal; O₂, oxygen; PEEP, positive end-expiratory pressure; PICO, Population, Intervention, Comparison and Outcome.

Healthcare-provider perceptions of barriers to oxygen therapy for paediatric patients in three government-funded eastern Ugandan hospitals; a qualitative study

Background

This study aimed to assess on-the-ground barriers to the provision of oxygen therapy for paediatric patients in three government-funded Eastern Ugandan district general hospitals (DGHs).

Methods

Site visits to DGHs during March 2017 involved semi-structured interviews with medical officers, clinical officers, paediatric nurses and non-clinical staff (n = 29). MAXQDA qualitative data software was used to assist with response analysis.

Results

The healthcare professionals reported that erratic electricity supplies, few and/or malfunctioning oxygen cylinders and concentrators, limited or no access to pulse oximetry, inadequate staffing and lack of continued professional training were key barriers to the delivery of oxygen therapy. Local populations were reportedly fearful of oxygen therapy and reluctant to consent for oxygen therapy to be administered to their children.

Conclusion

According to healthcare providers in three Eastern Ugandan DGHs, numerous barriers exist to oxygen therapy for paediatric patients. Healthcare professionals reported lack of facilities and training to effectively deliver oxygen therapy. Quality improvement work prioritising oxygen therapy in government-funded district general hospitals should focus on oxygen supply and delivery issues on a site-specific level and sensitizing communities to the potential benefits of oxygen.

Assessment of a storage system to deliver uninterrupted therapeutic oxygen during power outages in resource-limited settings

Access to therapeutic oxygen remains a challenge in the effort to reduce pneumonia mortality among children in low- and middle-income countries. The use of oxygen concentrators is common, but their effectiveness in delivering uninterrupted oxygen is gated by reliability of the power grid. Often cylinders are employed to provide continuous coverage, but these can present other logistical challenges. In this study, we examined the use of a novel, low-pressure oxygen storage system to capture excess oxygen from a concentrator to be delivered to patients during an outage. A prototype was built and tested in a non-clinical trial in Jinja, Uganda. The trial was carried out at Jinja Regional Referral Hospital over a 75-day period. The flow rate of the unit was adjusted once per week between 0.5 and 5 liters per minute. Over the trial period, 1284 power failure episodes with a mean duration of 3.1 minutes (range 0.08 to 1720 minutes) were recorded. The low-pressure system was able to deliver oxygen over 56% of the 4,295 power outage minutes and cover over 99% of power outage events over the course of the study. These results demonstrate the technical feasibility of a method to extend oxygen availability and provide a basis for clinical trials.

Solar powered oxygen systems in remote health centers in Papua New Guinea: a large scale implementation effectiveness trial

BACKGROUND

Pneumonia is the largest cause of child deaths in Papua New Guinea (PNG), and hypoxaemia is the major complication causing death in childhood pneumonia, and hypoxaemia is a major factor in deaths from many other common conditions, including bronchiolitis, asthma, sepsis, malaria, trauma, perinatal problems, and obstetric emergencies. A reliable source of oxygen therapy can reduce mortality from pneumonia by up to 35%. However, in low and middle income countries throughout the world, improved oxygen systems have not been implemented at large scale in remote, difficult to access health care settings, and oxygen is often unavailable at smaller rural hospitals or district health centers which serve as the first point of referral for childhood illnesses. These hospitals are hampered by lack of reliable power, staff training and other basic services.

METHODS

We report the methodology of a large implementation effectiveness trial involving sustainable and renewable oxygen and power systems in 36 health facilities in remote rural areas of PNG. The methodology is a before-and after evaluation involving continuous quality improvement, and a health systems approach. We describe this model of implementation as the considerations and steps involved have wider implications in health systems in other countries.

RESULTS

The implementation steps include: defining the criteria for where such an intervention is appropriate, assessment of power supplies and power requirements, the optimal design of a solar power system, specifications for oxygen concentrators and other oxygen equipment that will function in remote environments, installation logistics in remote settings, the role of oxygen analyzers in monitoring oxygen concentrator performance, the engineering capacity required to sustain a program at scale, clinical guidelines and training on oxygen equipment and the treatment of children with severe respiratory infection and other critical illnesses, program costs, and measurement of processes and outcomes to support continuous quality improvement.

CONCLUSIONS

This study will evaluate the feasibility and sustainability issues in improving oxygen systems and providing reliable power on a large scale in remote rural settings in PNG, and the impact of this on child mortality from pneumonia over 3 years post-intervention. Taking a continuous quality improvement approach can be transformational for remote health services.

Implementation and 8-year follow-up of an uninterrupted oxygen supply system in a hospital in The Gambia

SETTING: A 42-bed hospital operated by the Medical Research Council (MRC) Unit in The Gambia.

OBJECTIVE: To devise, test and evaluate a cost-efficient uninterrupted oxygen system in the MRC Hospital.

DESIGN: Oxygen cylinders were replaced with oxygen concentrators as the primary source of oxygen. An uninterruptable power supply (UPS) ensured continuity of power. Hospital staff were trained on the use of the new system. Eight years post-installation, an analysis of concentrator maintenance needs and costs was conducted and user feedback obtained to assess the success of the system.

RESULTS: The new system saved at least 51% of oxygen supply costs compared to cylinders, with savings likely to have been far greater due to cylinder leakages. Users indicated that the system is easier to use and more reliable, although technical support and staff training are still needed.

CONCLUSION: Oxygen concentrators offer long-term cost savings and an improved user experience compared to cylinders; however, some technical support and maintenance are needed to upkeep the system. A UPS dedicated to oxygen concentrators is an appropriate solution for settings where power interruptions are frequent but short in duration. This approach can be a model for health systems in settings with similar infrastructure.

Improving oxygen therapy for children and neonates in secondary hospitals in Nigeria: study protocol for a stepped-wedge cluster randomised trial

BACKGROUND

Oxygen is a life-saving, essential medicine that is important for the treatment of many common childhood conditions. Improved oxygen systems can reduce childhood pneumonia mortality substantially. However, providing oxygen to children is challenging, especially in small hospitals with weak infrastructure and low human resource capacity.

METHODS/DESIGN

This trial will evaluate the implementation of improved oxygen systems at secondary-level hospitals in southwest Nigeria. The improved oxygen system includes: a standardised equipment package; training of clinical and technical staff; infrastructure support (including improved power supply); and quality improvement activities such as supportive supervision. Phase 1 will involve the introduction of pulse oximetry alone; phase 2 will involve the introduction of the full, improved oxygen system package. We have based the intervention design on a theory-based analysis of previous oxygen projects, and used quality improvement principles, evidence-based teaching methods, and behaviour-change strategies. We are using a stepped-wedge cluster randomised design with participating hospitals randomised to receive an improved oxygen system at 4-month steps (three hospitals per step). Our mixed-methods evaluation will evaluate effectiveness, impact, sustainability, process and fidelity. Our primary outcome measures are childhood pneumonia case fatality rate and inpatient neonatal mortality rate. Secondary outcome measures include a range of clinical, quality of care, technical, and health systems outcomes. The planned study duration is from 2015 to 2018.

DISCUSSION

Our study will provide quality evidence on the effectiveness of improved oxygen systems, and how to better implement and scale-up oxygen systems in resource-limited settings. Our results should have important implications for policy-makers, hospital administrators, and child health organisations in Africa and globally.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12617000341325 . Retrospectively registered on 6 March 2017.

A Low-Pressure Oxygen Storage System for Oxygen Supply in Low-Resource Settings

BACKGROUND

Widespread access to medical oxygen would reduce global pneumonia mortality. Oxygen concentrators are one proposed solution, but they have limitations, in particular vulnerability to electricity fluctuations and failure during blackouts. The low-pressure oxygen storage system addresses these limitations in low-resource settings. This study reports testing of the system in Melbourne, Australia, and nonclinical field testing in Mbarara, Uganda.

METHODS

The system included a power-conditioning unit, a standard oxygen concentrator, and an oxygen store. In Melbourne, pressure and flows were monitored during cycles of filling/emptying, with forced voltage fluctuations. The bladders were tested by increasing pressure until they ruptured. In Mbarara, the system was tested by accelerated cycles of filling/emptying and then run on grid power for 30 d.

RESULTS

The low-pressure oxygen storage system performed well, including sustaining a pressure approximately twice the standard working pressure before rupture of the outer bag. Flow of 1.2 L/min was continuously maintained to a simulated patient during 30 d on grid power, despite power failures totaling 2.9% of the total time, with durations of 1-176 min (mean 36.2, median 18.5).

CONCLUSIONS

The low-pressure oxygen storage system was robust and durable, with accelerated testing equivalent to at least 2 y of operation revealing no visible signs of imminent failure. Despite power cuts, the system continuously provided oxygen, equivalent to the treatment of one child, for 30 d under typical power conditions for sub-Saharan Africa. The low-pressure oxygen storage system is ready for clinical field trials.

Providing oxygen to children in hospitals: a realist review

OBJECTIVE

To identify and describe interventions to improve oxygen therapy in hospitals in low-resource settings, and to determine the factors that contribute to success and failure in different contexts.

METHODS

Using realist review methods, we scanned the literature and contacted experts in the field to identify possible mechanistic theories of how interventions to improve oxygen therapy systems might work. Then we systematically searched online databases for evaluations of improved oxygen systems in hospitals in low- or middle-income countries. We extracted data on the effectiveness, processes and underlying theory of selected projects, and used these data to test the candidate theories and identify the features of successful projects.

FINDINGS

We included 20 improved oxygen therapy projects (45 papers) from 15 countries. These used various approaches to improving oxygen therapy, and reported clinical, quality of care and technical outcomes. Four effectiveness studies demonstrated positive clinical outcomes for childhood pneumonia, with large variation between programmes and hospitals. We identified factors that help or hinder success, and proposed a practical framework depicting the key requirements for hospitals to effectively provide oxygen therapy to children. To improve clinical outcomes, oxygen improvement programmes must achieve good access to oxygen and good use of oxygen, which should be facilitated by a broad quality improvement capacity, by a strong managerial and policy support and multidisciplinary teamwork.

CONCLUSION

Our findings can inform practitioners and policy-makers about how to improve oxygen therapy in low-resource settings, and may be relevant for other interventions involving the introduction of health technologies.

Improved oxygen systems in district hospitals in Lao PDR: a prospective field trial of the impact on outcomes for childhood pneumonia and equipment sustainability

BACKGROUND

Hypoxaemia is a common and potentially fatal complication of many childhood, newborn and maternal conditions but often not well recognised or managed in settings where resources are limited. Oxygen itself is often inaccessible due to cost or logistics. This paper describes implementation of oxygen systems in Lao district hospitals, clinical outcomes after 24 months and equipment outcomes after 40 months postimplementation.

METHODS

A prospective field trial was conducted in 20 district hospitals, including 10 intervention hospitals that received oxygen concentrators and 10 control hospitals. Equipment outcomes were evaluated at baseline, 12, 24 and 40 months. Clinical outcomes of children under 5 years of age with pneumonia were evaluated using a before-and-after controlled study design with information retrospectively collected from medical records.

RESULTS

Fourteen (37%), 7 (18%) and 12 (34%) of 38 concentrators required repair at 12, 24 and 40 months, respectively. The proportion of children discharged well increased in intervention (90% (641/712) to 95.2% (658/691)) and control hospitals (87.1% (621/713) to 92.1% (588/606)). In intervention hospitals, case fatality rates for childhood pneumonia fell from 2.7% (19/712) preintervention to 0.80% (6/691) postintervention with no change in control hospitals (1.7% (12/713) preintervention and 2.3% (14/606) postintervention).

CONCLUSION

Medium-term sustainability of oxygen concentrators in hospitals accompanied by reduced case fatality for childhood pneumonia has been demonstrated in Lao PDR. Significant local engineering capacity to address multiple causes of equipment malfunction was critical. The ongoing requirements and fragile structures within the health system remain major risks to long-term sustainability.