The provision of Home Care Services is currently the fastest growing sector for the industrial gases companies. However, this is one area that was not included in the traditional industrial gases portfolio until recently.

Home Care Services is very fragmented in structure. Currently over 50 per cent of the business is supplied by small companies, but it is exhibiting strong growth of between 15 \\$quot;“ 20 per cent per annum in Europe and in some other regions such as South America. This growth is mainly due to the rise in the demographics of an aging population, prevalence of respiratory diseases, mobility \\$quot;“ quality of life and lower cost to service patient (home vs. hospital).

Home Care markets vary widely among countries, based on the medical services provided and health insurance systems. Also the services and equipment offerings provided vary considerably.

Home Care \\$quot;“ what is it?
Home Care is the care of patients that reside at home rather than in a hospital, clinic or hospice. The service provides patients and relatives with psychological benefits by allowing patients to be treated at home. Additionally, this service also has a cost benefit for national and regional health authorities, private institutions and insurance companies. The facts are clear;
it is significantly cheaper to treat a patient at home rather than in a hospital.

Home Care provision is the supply of medical care services to patients that were formerly only available in hospitals \\$quot;“ such as respiratory therapy, dialysis,
drug infusion, nutritional support and nursing care. As equipment becomes more sophisticated and the ability to monitor the equipment from remote locations
improves, more services are being rolled out from hospitals to homes.

Home Care Services and gas companies
Traditionally, and currently in many parts of the world, Home Care Services were provided by specialised companies as it is essentially a localised business.
Home Care companies need to not only supply the service but also needed to supply associated equipment,gases, nutrients and drugs. If the patient needs
oxygen for respiratory use, the Home Care provider would have a relationship with a gas producer who would fill their cylinders or liquid dewars. In the past
the Home Care provider was the customer of the gas company.

However, supplying gas and services is what gas companies are all about and have developed over the past 100 years. Some gas companies recognised this and started to enter into the Home Care market with the supply of oxygen. Yet, there is more to Home Care than just supplying oxygen and there is a wider selection of respiratory requirements for patients being developed all the time. This has attracted the industrial gas companies in recent years \\$quot;“ driven by the high growth in Home Care Services, high gas pricing and high profitability from variety of other services.

Respiratory Home Care market - care for patients with repiratory diseases
The respiratory therapy side of Home Care is the sector of most interest to our industry. Respiratory therapy is a health care specialty that offers a set of challenges in the areas of prevention, treatment, management, and rehabilitation of people with diseases such as Chronic Obstructive Pulmonary Disease (COPD),
Obstructive Sleep Apnoea (OSA) or asthma.

Some of the major respiratory diseases, which are often treated in hospitals with patients taking up valuable bed space, could be treated at home. Respiratory
Home Care therapies include Long Term Oxygen Therapy (LTOT) for COPD, Obstructive Sleep Apnoea(OSA) Therapy, CPAP and Aerosol therapy.

Respiratory Home Care products in use
Currently, COPD is under diagnosed and under treated, in many cases due to lack of knowledge of the disease and availability of treatment solutions. It is estimated that four million patients receive oxygen supplementation at home in the United States. This could be as high as 450,000 patients in Europe on LTOT (Europe is definitely a smaller but faster growing market).

There are several primary types of oxygen delivery systems used in LTO therapy. They include oxygen concentrators, liquid oxygen systems, cylinders (gaseous),
oxygen-conserving devices, humidifiers, nebulizers and disposable equipment (cannulas, venturi masks and long extension tubing).

Concentrators
Concentrators (electrical) are the most frequently used oxygen supply devices in the home. There are many brands of concentrators that work on the same principle - the extraction of oxygen from room air. Most oxygen concentrators deliver up to five litres per minute at 85 per cent concentration.

Due to their ease of use and lack of requirement for regular deliveries, oxygen concentrators are the preferred method of oxygen delivery in the home.
Disadvantages of the concentrator include lack of portability, inability to fill portable equipment from the concentrator, higher electric bills related to an increase in electricity consumption, and a need for a back-up source of oxygen in the event of electrical failure.

Liquid Oxygen Systems (LOS)
LOS are the second most common method of oxygen delivery within the home. Use of the liquid system is usually reserved for patients who maintain an active
lifestyle, are not homebound, or who require higher flow rates of oxygen. Liquid cylinders consist of an inner and an outer steel shell, separated by a vacuum
similar in construction to a large thermos bottle. Conversion of the liquid to a gaseous state is performed through vaporization.

Advantages of the liquid system in the home include higher flow rates, easier patient maintenance, and lack of an electrical supply requirement. The main
disadvantage is the possibility of loss of oxygen by evaporation through a pressure relief valve that automatically opens when cylinder pressure increases.
This pressure causes loss of oxygen into the air, which then relieves pressure within the cylinder. When using portable systems, the patient must plan activities in advance and is restricted to specified time frames related to the limited supply of oxygen. Most portable systems can supply two to eight hours of oxygen.

Cylinders (gaseous)
Cylinders are the least utilized method of in-home oxygen administration. Originally this system was used for the supply of oxygen to patients on home mechanical ventilation, which requires a gaseous driving device. This problem has been solved by the invention of smaller, electrically driven home mechanical ventilation systems. Smaller cylinders serve as backup or portable systems for patients using concentrators as their primary source of oxygen.

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Advantages of compressed gas cylinders include portability, small size, and the lack of an electrical source requirement. Disadvantages include the need to stabilize or anchor the cylinder, regulator use difficulties, application of regulators to the cylinder, lack of aesthetic appeal, and cylinder supply limitations that include a need for delivery and a time restraint of
usage.

Other systems in use
There are also a number of other services in use. Some oxygen-conserving devices are used in the home care setting, but are not always encountered in the acute care facility. Demand-delivery devices and reservoir cannulas, which provide oxygen to the patient only during inspiration, allow the patient to use less oxygen. These devices are particularly helpful for patients who are on limited supply liquid systems or gaseous systems.

There are also humidifiers, which are used where patients require augmentation of their oxygen. Both disposable humidifiers and non-disposable humidifiers can be utilized in the home care environment.

Nebulizers are used to give medicine in a mist form. They are an effective way to give medications for breathing problems such as asthma.

Disposable equipment such as nasal cannulas, venturi masks and other types of oxygen-delivery disposables are also used in the home just as they are in the hospital setting.

Sleep Apnoea and Long Term Respiratory Care
Due to the growing trend of sleep disorder diagnosis, more people are being prescribed CPAP and BiPAP therapy for treatment. Home health personnel provide
services to the sleep apnoea patient by providing education in implementing CPAP and BiPAP instruction in use of CPAP, BiPAP-related equipment; Sleep Apnoea
Diagnostics and Monitoring Devices (CPAP/BiPAP)and Home Mechanical Ventilation Devices (inc. masks, circuits and others).

CPAP and BiPAP therapies that provide constant pressure to the airways. CPAP is delivered to the patient through a mask placed over the nose during sleep. Pressure from an air blower (small compressor) forces air into the nasal passages. This constant and continuous pressure keeps the throat and upper airways from collapsing during sleep, but apnoea episodes return when CPAP is stopped or not used properly.

With the growing trend of sleep disorder diagnosis, more people are being prescribed CPAP and BiPAP therapy for treatment.

Home Mechanical Ventilation (HMV) is the most acute service provided in the home. Provision of this mode of care requires extensive coordination and planning prior to patient discharge to the home environment. Attentive discharge planning should include those involved in the acute care of the patient and those who will provide home services.The family must be taught how to operate ventilator, suction and oxygen equipment. Cardio-pulmonary resuscitation measures.

Additional equipment needed by the patient includes humidification systems, manual ventilation bags with masks, extra ventilator circuits, battery-powered suction
equipment, and replacement tubes and cleaning equipment for the tracheotomy.

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