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Belluscura plc (UK)…Confirmation of Issue Price for Placing on the AIM market of the London Stock Exchange

24 May 2021
NOT FOR RELEASE, PUBLICATION OR DISTRIBUTION, IN WHOLE OR IN PART, DIRECTLY OR INDIRECTLY, IN OR INTO OR FROM, THE UNITED STATES OF AMERICA, AUSTRALIA, CANADA, JAPAN, NEW ZEALAND OR SOUTH AFRICA OR ANY OTHER JURISDICTION WHERE IT IS UNLAWFUL TO DISTRIBUTE THIS ANNOUNCEMENT.

This announcement is an advertisement and not an admission document or a prospectus. This announcement is not and does not constitute or form part of, and should not be construed as, an offer of securities for subscription or sale in any jurisdiction nor a solicitation of any offer to buy or subscribe for, any securities in any jurisdiction, nor shall it or any part of it, or the fact of its distribution, form the basis of, or be relied on in connection with, any contract or commitment whatsoever. This announcement does not constitute a recommendation regarding any securities. Prospective investors should not subscribe for or purchase any securities referred to in this announcement except in compliance with applicable securities laws and regulation and on the basis of the information in the final admission document (“Admission Document”) intended to be published by Belluscura plc (“Belluscura” or the “Company”), and any supplement thereto, in connection with the placing of ordinary shares of £0.01 each (“Ordinary Shares”) and the proposed admission of the entire issued and to be issued ordinary share capital of the Company to trading on AIM, a market operated by the London Stock Exchange plc.

Belluscura PLC

(“Belluscura” or the “Company”)

Confirmation of Issue Price for Placing

Designer and manufacturer of FDA cleared, lightweight and portable oxygen concentrators
to raise £17.5 million, with an expected pre-money market capitalisation of £50.96 million

LONDON, U.K. AND PLANO, TX, U.S. (24 May 2021). Belluscura plc (AIM:BELL), a leading medical device developer focused on lightweight and portable oxygen enrichment technology, announces that it has received very strong levels of support for the placing and subscription. First day of dealings will commence on Friday 28 May.

Key Fundraising Statistics:

Total Fundraising Size¹: £17.5 million
Issue Price per Belluscura Share: 45 pence
Number of Existing Belluscura Shares: 74,351,847
Number of VCT/EIS Placing Shares: 14,192,554
Number of General Placing Shares: 24,051,890
Number of Subscription Shares: 644,444
Enlarged issued share capital on Admission: 113,240,735
Market capitalisation at the Issue Price²: £50.96 million

Notes:

¹ Before estimated commissions, fees and expenses payable by the Company of approximately £1.4 million.
² The market capitalisation of the Company at any given time will depend on the market price of the Ordinary Shares at that time.
There can be no assurance that the market price of an Ordinary Share will equal or exceed the Issue Price.

Belluscura focuses on novel oxygen-based treatment platforms that can be adapted and applied in a wide range of
markets beyond those traditionally applicable to a single product or product line.Its range of portable products will
be lighter / more adaptable / have higher O₂ capacity by weight than existing oxygen enrichment products in their
respective class. Whilst potentially useful for recovering COVID patients, it has a wide range of use for sufferers of
pneumonia / COPD (i.e. asthma/ emphysema /chronic bronchitis) and other respiratory illnesses. It received 510(k)
clearance from the US Food & Drug Administration (FDA) in March 2021 for its X-PLO₂R range of oxygen
concentrators, which will be launched in 2021.

The Company has a registered office in the UK. Its subsidiary, Belluscura LLC, is based in Plano, Texas, USA. The USA
is the Company’s main country of operation.

Admission Document

The Admission Document (when published) will be made available on the Company’s website shortly, at
belluscura.com/investors.

Further announcements will be made as appropriate.

For further information please contact:

Belluscura plc

Robert Rauker, Chief Executive Officer                                                                                                           www.belluscura.com
Anthony Dyer, Chief Financial Officer                                                                                                               via Walbrook PR

SPARK Advisory Partners Ltd (NOMAD)   

Neil Baldwin                                                                                                                                                 Tel: +44 (0)20 3368 3550

Dowgate Capital Ltd (Broker & Bookrunner)

James Serjeant / Nicholas Chambers                                                                                                      Tel: +44 (0)20 3903 7715

Walbrook PR Ltd (Media & Investor Relations)                         Tel: +44 (0)20 7933 8780 or belluscura@walbrookpr.com

Paul McManus / Sam Allen                                                                             Mob: +44 (0)7980 541 893 / +44 (0)7748 651 727

About Belluscura plc (www.belluscura.com)
Belluscura is a UK medical device company focused on developing oxygen enrichment technology spanning broad
industries and therapies. Our innovative oxygen technologies are designed with a global purpose: to create
improved health and economic outcomes for the patients, healthcare providers and insurance organisations.

Background & history
Belluscura was established in the UK in December 2015 with the object of commercialising intellectual property in
the medical device space. The Company is currently focused on devices and treatments involving enriched oxygen.

The Company has raised approximately $11.7 million since 2018 in a number of fundraising rounds in order to
develop and commercialise the Company’s product portfolio.

In February 2017, Belluscura entered into a co-exclusive license and development agreement with Separation
Design Group LLC (“SDG”) of Waynesburg, Pennsylvania, to jointly develop and commercialise the X-PLO₂R™
portable oxygen concentrator, a device that weighs less than 1.5kg, yet can deliver up to 800ml per minute of pulse
dose enriched oxygen to a patient prescribed long term oxygen therapy. This agreement was updated in March
2021 to be an exclusive licence and development agreement.

SDG owns patents and patent applications covering novel oxygen enrichment technologies and treatment devices
and methods. Through joint development efforts with SDG and the licence, Belluscura now either owns or
exclusively licenses a total of 26 patents and applications relating to oxygen enrichment devices and treatments.

The Belluscura and SDG development relationship also includes the development of additional products, the X-PLO₂R CX™ and the X-PLO₂R DX™ portable oxygen concentrators. The X-PLO₂R CX is expected to produce theequivalent of 4 litres pulse dose oxygen and 750ml continuous flow oxygen. The X-PLO₂R DX is being designed to
produce the equivalent of 6-litres pulse dose oxygen and 2-litres of continuous flow oxygen.

On 2 March 2021 Belluscura received 510(k) clearance from the US Food &Drug Administration (“FDA”) for the XPLO₂R. The Directors do not anticipate requiring additional FDA 510(k) clearances to launch the X-PLO₂R CX and the X-PLO₂R DX portable oxygen concentrators, as it expects to be able to self certify under “substantially equivalent” protocols of the FDA.

Belluscura plans to launch the X-PLO₂R shortly and the X-PLO₂R CX and X-PLO₂R DX within the next 12 months. The Company has a manufacturing agreement to produce the products in the USA. Following a soft launch, the Company plans to appoint distributors in the US to give US-wide coverage; this is expected to occur in the second half of 2021and into 2022. Belluscura will commence International Regulatory clearances during 2021 and 2022 before expanding distribution globally. Following launch in the US, the Company intends, in due course, to pursue commercialisation in the UK, EU, Japan, South Asia, Australia, South America and Latin America.

Belluscura has an experienced executive management team with significant expertise in the medical devices
industry and UK public companies.

The Market
The global respiratory care devices market is estimated to be $23.4 billion in 2021 and expected to reach $28.6 billion by 2024, growing over $1.7 billion per year. (Source: Research&Markets.com – Global Respiratory Care Devices market)

Supplemental Oxygen Therapy Market
Within the respiratory care devices market, the supplemental oxygen therapy devices market was forecast in 2018 to grow by 6 per cent. per year from $3.2 billion in 2021 to $4.2 billion by 2026.

The impact of the COVID-19 pandemic has led to an increase in this growth forecast to 11 per cent. per annum. The market is now forecast to reach $5.7 billion by 2026, an increase of 66 per cent. over the next 5 years. The World Health Organisation (“WHO”) announced on 24 June 2020 that it would be purchasing 184,000 oxygen concentrators, valued at over $100 million, to address oxygen shortages in 120 countries. (Source: Reuters, 24 June 2020 https://www.reuters.com/article/us-health-coronavirus-who-milestone/who-warns-of-oxygen-shortage-ascovid-casesset-to-top-10-million-idUSKBN23V2FG)

As of February 2021, the WHO and partners have distributed over 30,000 concentrators and 40,000 pulse oximeters and patient monitors, reaching 121 countries, including 37 countries that are classified as “fragile”.

Respiratory Diseases
The principal respiratory disease that requires management through the prescription of supplemental oxygen is Chronic Obstructive Pulmonary Disease (“COPD”). In addition, other respiratory diseases where symptoms are alleviated through supplemental oxygen include Coronavirus, Pulmonary Fibrosis and Cystic Fibrosis.

Chronic Obstructive Pulmonary Disease (“COPD”)

COPD is the name for a group of lung conditions that cause breathing difficulties. These conditions include Emphysema, Chronic Bronchitis and Asthma. COPD typically affects middle-aged or older adults who smoke. The World Health Organisation estimates that 328 million people globally have COPD, of whom 65 million have moderate (Stage 2) or Severe (Stage 3) symptoms.

Although originally more common in men, due to increased smoking among women the disease now affects men and women almost equally. COPD also affects non-smokers, though smoking is the cause of 90 per cent. of COPD cases.

Symptoms of COPD comprise breathlessness, a persistent chesty cough, frequent chest infections and persistent wheezing. COPD is progressive and incurable, and by 2030 it is forecast that it will be the third leading cause of death worldwide.

In the early stages of COPD, the progression of the disease can be slowed by inhalers, tablets and pulmonary rehabilitation. As symptoms become more severe, oxygen enrichment products are used to prevent the level of oxygen in the blood falling to a dangerously low level.

COVID-19
The use of oxygen concentrators is a cornerstone treatment for COVID-19, with the WHO indicating that it intends to purchase over 100,000 units to distribute globally. The NHS is recommending oxygen for COVID-19 patients that are breathless and have blood oxygen saturations less than 94 per cent.

Although most people recover from COVID-19 after a short period, for some people, the symptoms can last for considerably longer. According to the NHS, long Covid symptoms include shortness of breath which may require the use of oxygen concentration treatment.

Other Respiratory Diseases
Although COPD is the primary disease for which oxygen enrichment products are used, they are also used to alleviate the symptoms of Pulmonary Fibrosis, Cystic Fibrosis and other respiratory disorders. Currently, it is estimated that 1.5 million adults in the US and 3.5 million adults in Europe use supplemental oxygen for these respiratory disorders

Belluscura Intends to Float on AIM

LONDON, U.K. AND PLANO, TX, U.S. (7 May 2021).  Belluscura plc, a leading medical device developer focused on lightweight and portable oxygen enrichment technology, announces its intention to seek admission of the entire issued and to be issued ordinary share capital of the Company to the AIM market of the London Stock Exchange (“Admission“).

 

Belluscura’s first product, the X-PLORTM, is a lightweight FDA cleared portable oxygen concentrator (“POC”) designed to replace larger, metal oxygen tanks and heavier portable oxygen concentrator devices. The X-PLOR weighs less than 1.5kg (3.25lbs) and the Directors believe it is the world’s first modular portable oxygen concentrator and that it will generate more oxygen by weight than any other FDA cleared POC in its class. The X-PLO2R can deliver up to 95% pure oxygen to patients 24 hours a day, 7 days a week to help improve the quality of life for millions of people worldwide who suffer from chronic lung diseases, such as Chronic Obstructive Pulmonary Disease (COPD) and respiratory distress caused by COVID-19. The X-PLOR will be launched shortly and additional products within the range will be launched within the next 12 months.

 

Belluscura either owns or exclusively licenses a total of 26 patents and applications relating to oxygen enrichment devices and treatments.

 

The Company is seeking to raise £15 million via a conditional placing of shares (“Placing”) to support the commercial roll-out of the X-PLOR and to progress Belluscura’s oxygen enrichment product portfolio. Following completion of the Placing and Admission to AIM, Belluscura is expected to be valued in the region of £50-55 million.

 

Disclaimer:  This press release is for informational purposes only. Nothing in this press release should be construed as, and may not be used in connection with, an offer to sell, or a solicitation of an offer to buy or hold, an interest in any security or investment in Belluscura plc.

pulmonary rehabilitation

Understanding Pulmonary Rehabilitation

Patients with chronic respiratory conditions such as Asthma, Chronic Obstructive Pulmonary Disease (COPD) or Interstitial Lung Disease (ILD) often have difficulty with their activities of daily living due to shortness of breath. If you have been newly diagnosed with a chronic respiratory condition or suffer from other conditions such as pulmonary hypertension, cystic fibrosis, or have upcoming lung surgery​​​ your health care provider may have suggested Pulmonary Rehabilitation (PR). Like other respiratory conditions, COVID-19 can cause respiratory complications and lasting lung damage. Some people may also develop “long COVID,” which occurs when COVID-19 symptoms linger for weeks or months after acquiring the initial infection. Some people refer to this group as “long haulers.”

What is Pulmonary Rehabilitation (PR)?

Pulmonary Rehabilitation (PR) is a comprehensive rehabilitation program designed specifically for patients with lung disease that has been shown to improve quality of life and relieve shortness of breath. PR is a two-step program that includes education and exercise to help you learn more about your lungs and your disease.

Your rehab team will often include:
  • Doctor
  • Nurse
  • Respiratory therapist
  • Physical therapist
  • Exercise Specialist
  • Dietitian

Overall, you will learn how to manage your breathing problems, increase your energy, and decrease your breathlessness. Typically, a PR program will be offered in a group setting, allowing you the opportunity to meet others suffering from similar conditions. A community environment allows you to speak with others with similar lung problems, get useful tips, and discuss topics that arise when dealing with a chronic condition.

What is the role of PR in the Treatment of COVID-19?

Some people who recover from COVID-19 may need pulmonary rehabilitation to help them resume normal activities after staying in the hospital, or following periods of prolonged isolation. Pulmonary rehabilitation can help those with decreased strength begin to move more, gradually building up their stamina. PR for those recovering from COVID-19 can help:

  • Restore function to the muscles
  • Reduce the likelihood of mental health conditions that may occur as a result of limited mobility
  • Enable people to return to their normal lives

Step ONE: Education

PR programs help patients to improve their exercise capacity which helps them get back to daily life. The education portion of the program will help you gain a better understanding on how to best manage your breathing problems so that your breathing is not in charge of you. You will also learn things such as how to pace your breathing with your activities, take your medications, and what questions to ask your healthcare provider.

Step TWO: Exercise

Step TWO is the exercise component. PR provides education on breathing techniques to help you cope with the symptom of breathlessness The exercise program is led by the PR staff; they will monitor you as you exercise to ensure your safety. The exercises are designed for your specific needs and will start at a level that you can handle. The amount of time you exercise will be increased in time and the level of difficulty will change based on your ability. As your muscles get stronger, you will be able to exercise longer, be less tired, and have less shortness of breath.

Takeaway

What you learn during PR should be used throughout life to avoid hospitalizations, complications, and other issues. Most importantly, it provides a support system by allowing patients to meet other people with the same experience. Pulmonary Rehabilitation forms an integral part of the comprehensive care of patients with respiratory conditions. Always consult with your doctor before starting a new exercise routine. People recovering from COVID-19 should also seek help if their symptoms are severe or suddenly worsen.

 

Sources:

National Institues of Health

American Lung Association

Understanding A COPD Diagnosis: Key Facts

If you or someone you know has recently been diagnosed with COPD, you may be wondering what exactly that means. COPD stands for Chronic Obstructive Respiratory Disease. COPD is composed of different respiratory diseases that cause troubled breathing.

The term COPD can be used to describe a singular respiratory disorder, or more than one. COPD encompasses chronic bronchitis, emphysema, asthma, and some forms of bronchiectasis, as well as any combination of the four. According to the American Lung Association, over 16 million Americans are diagnosed with COPD as of October 2020, but millions more suffer from it without being diagnosed.

The group of diseases in which COPD refers to cause airflow obstruction and trouble with breathing. COPD is chronic, meaning it is long-lasting and constantly present. Each individual case of COPD is different, and some cases are more severe than others. The most common cases of COPD include symptoms of both chronic bronchitis and emphysema.

COPD Explained

What is Happening in Your Body?

Your particular case of COPD will determine what is happening within your body. Cases that include chronic bronchitis will cause swelling and increased mucus production in the lung airways, or bronchial tubes. This causes breathing to become more difficult since your airways are inflamed and narrowed with mucus blocking them. Cases including emphysema cause destruction of the air sacs, or alveoli. The air sacs are responsible for oxygen exchange within the lungs, and they lose their elasticity by becoming destroyed. This causes breathing difficulty since the loss of elasticity leads to air being trapped inside the air sacs, making it harder to get oxygen in and carbon dioxide out.

Symptoms of COPD

Some of the most common symptoms include:

  • Increased shortness of breath
  • Frequent coughing (with or without mucus)
  • Wheezing
  • Tightness in the chest

Remember, not all cases of COPD will have the same symptoms. Other symptoms include frequent respiratory infections, lack of energy and unintended weight loss.

What Causes COPD?

COPD is mainly caused by inhaling lung irritants, and smoking is the #1 cause. People, however, do not realize that other potential lung irritants that can also cause COPD include exposure to air pollution, fumes, chemicals, secondhand smoke and dust particles. Oftentimes, inhaling these irritants can be work-related. Working in construction, mining or welding are examples of occupations that increase the risk of obtaining COPD due to increased exposure to lung irritants. A rare genetic factor called alpha-1 antitrypsin deficiency is also known to cause COPD and is passed from parents to their children.

Comorbid conditions seem to be more common in people with COPD than in people with other medical problems. These conditions may include:

  • High blood pressure
  • High cholesterol
  • Heart disease
  • Diabetes
  • Osteoporosis
  • Depression
  • Arthritis
  • Sleep Apnea
  • Cancer
  • Other medical problems

One reason for these additional problems may relate to the lung inflammation that occurs in people with COPD.

What is a Flare-Up?

A COPD flare-up, or exacerbation, is when your symptoms are considerably worse than usual. Some can be treated at home, but more severe flare-ups can require a visit to the hospital. Flare-ups are triggered by further lung inflammation. This can be from exposure to smoke, pollution or allergens as well as contracting the flu or pneumonia. Symptoms to look out for include:

  • Shortness of breath without physical activity
  • Increased mucus
  • Excessive coughing or wheezing
  • Lower blood  oxygen saturation level than normal

Those symptoms can usually be treated at home with antibiotics or inhalers, but the following list of symptoms require professional help.

  • Increased heart rate
  • Being unable to catch your breath
  • Lips or fingernails turn blue or gray
  • Treatments are not working

Does COPD Have a Cure?

COPD is a progressive disease, which means that it gets worse over time. Unfortunately, there is no cure, but luckily many treatment options are available to improve the quality of life. Bronchodilator and steroid medications are available through inhalers to relax the lungs, as well as oral anti-inflammatory medications. Oxygen therapy is also a popular treatment option to help patients achieve healthy blood oxygen levels, which is difficult to maintain when you have COPD. Oxygen therapy allows you to still be active and live a normal life while getting the oxygen into your body that you need, especially with the availability of portable oxygen concentrators. Pulmonary rehabilitation is another option for those with COPD. It helps patients adjust to and get educated about their conditions. Pulmonary rehabilitation programs often provide support and exercise training as well as breathing techniques that are personalized based on specific patient needs.

Living with COPD

Activities of daily living, such as completing chores or bathing, can be harder to accomplish due to shortness of breath. You may have to take constant breaks to catch your breath. Activities will take your energy to perform, so you will get physically exhausted more easily. Living with COPD means slowing down in order to control your breathing and to prevent tiring yourself too quickly. Living with COPD has its challenges, but modifying some activities of daily living can improve your quality of life and help you better manage your disease.

Takeaway

Although COPD is a life-long condition, you can still live a fulfilling life with the help of treatment options, although you may have to slow your pace. COPD takes a toll on your body, so taking care of yourself, monitoring your symptoms and following your doctor’s orders are top priorities.

Sources

https://www.cdc.gov/copd/features/copd-symptoms-diagnosis-treatment.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Ffeatures%2Fcopd-awareness-month%2Findex.html

https://www.copdfoundation.org/What-is-COPD/Understanding-COPD/What-is-COPD.aspx

https://www.hse.gov.uk/copd/causes.htm

https://www.lung.org/lung-health-diseases/lung-disease-lookup/copd/learn-about-copd#:~:text=With%20COPD%2C%20the%20airways%20in,the%20waste%20gas%20carbon%20dioxide.

https://medlineplus.gov/copd.html

https://www.nhlbi.nih.gov/health-topics/copd

https://www.nps.org.au/consumers/chronic-obstructive-pulmonary-disease-copd-explained

COPD Awareness: Understanding the Diagnosis and Stages

Awareness

Being told you have chronic obstructive pulmonary disease (COPD) can be overwhelming. COPD is a progressive disease that obstructs the airflow, making it difficult to breathe and get enough oxygen into your lungs. According to the Chest Foundation, COPD is the third leading cause of death in the US and impacts roughly 24 million Americans.

COPD is made up of two diseases; emphysema accounts for 33 percent, and chronic bronchitis accounts for the remaining 64 percent of diagnosed cases. Emphysema occurs due to the damage that happens to the air sacs in the lungs. These air sacs overfill with air and lose their elasticity which makes it hard to exhale the excess air. In chronic bronchitis, the airways become swollen and inflamed and produce large amounts of mucus. The increased production of mucus obstructs the airways, narrows them, and makes it hard to breathe.

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has classified four stages in which your healthcare provider will determine what stage of COPD you are in. This will help them determine the best treatment plan for you.

Symptoms

The first part of diagnosing your condition will consist of assessing symptoms. It will be important to provide your healthcare provider with the symptoms you have been having that have led you to seek medical attention. Common COPD symptoms include:

  • Shortness of breath
  • Chronic cough
  • New or increased wheezing
  • Coughing up phlegm or and increase in phlegm

Risk Factors

It will be important for your healthcare provider to know if you have had or are currently exposed to any risk factors. Risk factors could include things such as:

  • Genetic factors
  • Abnormalities from birth
  • Tobacco smoke
  • Smoke from cooking/heating fuels
  • Dust
  • Vapor
  • Fumes or other inhaled chemicals

Spirometry

Spirometry will play a large role in your COPD diagnosis. Once you have sought medical care for COPD related symptoms and you have discussed your risk factors, the next step will be for your healthcare provider to order spirometry.

Spirometry is a common breathing test used to see how well your lungs are working by taking a few test measurements while you breathe into a machine. Spirometry will measure the air you breathe in, the air you breathe out, and how quickly you breathe out.

One of the initial spirometry tests that will be performed is called the Forced Vital Capacity (FVC) measurement or the amount of forced air that you can exhale and inhale into the machine. An equally important measurement is the calculation based on the Forced Expiratory Volume in One Second (FEV1). This is the amount of air you can breathe out of the lungs in the first one second of forced expiration.

Your FEV1 is based on factors including your age, sex, height, and ethnicity.  Your healthcare provider will compare your results to a healthy individual and any deviations in measurements are what will lead to a sign of what might be causing your problems.

You will be given a breathing treatment with medication to help open your lungs such as a bronchodilator before you start the test. This is to ensure your lungs are performing at their best.

After your test is completed, your healthcare provider will review the measurements and see which of the four GOLD stages of COPD you fall into based on your results. This testing will serve as a follow-up assessment to determine what other therapies can work for you and to monitor you as the disease progresses.

Four Stages of GOLD

Your spirometry results, particularly your FEV1, will fall into one of the four GOLD classifications of severity which is how your COPD stage will be determined.

GOLD 1
  • Mild Stage, Stage I COPD
  • FEV1  greater than/or equal to 80% of predicted test results compared to a healthy individual
  • In this stage, you will likely experience very mild symptoms
GOLD 2
  • Moderate Stage, Stage II COPD
  • FEV1 between 50 – 79% of predicted test results compared to a healthy individual
  • Symptoms include shortness of breath with activity, cough, and sputum production
GOLD 3
  • Severe Stage, Stage III COPD
  • FEV1  between 30 – 49% of predicted test results compared to a healthy individual
  • In this stage, you may experience shortness of breath, fatigue, and a lower tolerance to physical as well as more frequent COPD exacerbations
GOLD 4
  • Very Severe, Stage III COPD sometimes referred to as End-Stage COPD
  • FEV1 less than 30 % of predicted test results compared to a healthy individual
  • In this stage, you may find that your quality of life is significantly decreased, and you may experience severe and life-threatening exacerbations

Takeaway

COPD is a chronic disease that cannot be cured and as time goes on, the disease progresses. Certain treatments and lifestyle changes can help you manage your symptoms and improve your quality of life. It is important to seek out a healthcare provider who will work with you to improve your breathing.

Sources:

https://foundation.chestnet.org/lung-health-a-z/chronic-obstructive-pulmonary-disease-copd/

https://www.who.int/respiratory/copd/burden/en/

https://goldcopd.org/

What Exactly is Respiratory Therapy?

Respiratory therapy involves caring for patients with chronic breathing problems and lung issues. Factors that cause respiratory problems such as lung cancer, pneumonia, and chronic obstructive pulmonary disease (COPD) are often treated by respiratory therapy interventions. The American Thoracic Society states that the most common diseases needing respiratory therapy include severe asthma, COPD, interstitial or fibrotic lung diseases, pneumonia, lung cancer, lung infections, and bronchiolitis.

Respiratory therapy can also help improve the breathing of premature babies. According to the March of Dimes, 1 in 10 babies born in the U.S. is born prematurely. Many of these premature babies will need assistance breathing well into the first months of life, and some will require respiratory therapy even after they leave the intensive care unit and go home.

Who performs Respiratory Therapy?

A respiratory therapist (RT) specializes in treating patients who require respiratory therapy. They work as part of a team to help diagnose lung and breathing problems and help people improve their respiratory health and day-to-day lung function. RTs’ must have a broad knowledge of how the body works, specifically the lungs, and are part of a medical team that diagnoses and treats patients.

Where do Respiratory Therapist Work?

They work in a variety of settings. They commonly work in hospital settings, including the emergency room, the intensive care unit, and the newborn or pediatric intensive care unit. Respiratory Therapists work with patients of all ages, ranging from premature infants with underdeveloped lungs to elderly patients with advanced heart and lung issues.

Outside of the hospital setting, respiratory therapists also work in pulmonary rehabilitation clinics and manage pulmonary rehabilitation centers. With the evolving pandemic and the rise in patients recovering from the Coronavirus, they may find themselves working in specialized clinics to treat Covid-19 ‘long haulers’. An RT can also work in doctors’ offices, sleep disorder clinics, and long-term care facilities. Careers in teaching, patient education, and roles within the medical devices industry are also new areas where respiratory therapists work.

What duties do Respiratory Therapist Perform?

Along with having extensive knowledge of the cardiopulmonary system, respiratory therapists must be experts in the machines and devices used to administer respiratory care treatments. This encompasses a variety of responsibilities.

Some responsibilities of respiratory therapists include:
  • Managing life support mechanical ventilation systems
  • Administering aerosol breathing treatments
  • Monitoring equipment related to cardiopulmonary therapy
  • Analyzing blood samples to determine levels of oxygen and other gases
  • Evaluating patients for the need for supplemental oxygen

Takeaway

During the last week of October, Respiratory Therapists are celebrated and acknowledged for their dedication to patient care, promoting respiratory health, and being a vital part of the healthcare community.

Seven Steps to Help You Quit Smoking Cigarettes

Smoking is not only a physical addiction, but also a psychological habit. The temporary high that smokers get from tobacco is extremely addictive.

Smoking severely damages your lungs, specifically your alveoli which are tiny sacs found within the lungs. Smoking is the #1 cause of chronic obstructive pulmonary disease (COPD). According to American Lung Association, over 16.4 million people are diagnosed with COPD, yet millions more have COPD without being aware of it. Smokers also have a greater chance of getting cancer, especially in the lungs.

 

Based on information collected from the US Department of Health and Human Services, cigarette smoking is responsible for over 480,000 fatalities in the United States every year. Over 41,000 of these deaths are caused by exposure to secondhand smoke. To put these statistics in perspective, that is 1 in 5 deaths yearly, or 1,300 deaths per day. According to the New England Journal of Medicine, smokers’ lifespans are typically 10 years shorter than nonsmokers. Below are helpful steps to quit smoking.

Step 1: Realize Why You’re Quitting

This reason is usually health related, and quitting smoking will help you live a healthier and longer life. Another reason might be stopping for your loved ones. Living to see your kids or grandchildren grow up is a great motivator to extend your lifespan by quitting smoking. Whatever your reason may be, quitting will give you more time to do the things you love, and will eliminate the anxiety that comes with wondering when you will get to smoke next. You will look better, smell better, and most importantly feel better after quitting.

Step 2: Tell Others

Sharing that you are planning to quit smoking with your loved ones will give you the encouragement and support you need to stop. They will be able to hold you accountable for you dedication to quitting and can be constant reminders of your reason to quit.

Step 3: Get Rid of Cigarettes and Paraphernalia

Dispose of all cigarettes, ashtrays, lighters, or anything that reminds you of smoking. Not having easy access to cigarettes would cost you a trip to the store to buy another pack, and will remind you of your reason for quitting.

Step 4: Consider Alternatives

Nicotine replacement therapy (NRT) is a safe and efficient way to help smokers with nicotine withdrawal. NRT gives you the nicotine that your body is craving in a form other than a cigarette. Cigarettes contain thousands of chemicals when inhaled, including toxic ones found in rat poison and nail polish remover. Although nicotine is an addictive chemical, just taking in nicotine is much safer than smoking cigarettes. The more cigarettes you smoked per day, the higher dose of nicotine you will need starting out.

There are many options when it comes to NRT, and one of the most common is a nicotine patch. There are also other options such as gum, inhalers, nasal spray and lozenges. Some NRT is available over-the-counter, but others you need a prescription for. The goal of NRT is to gradually decrease your dose until you can get off nicotine altogether.

Other types of NRT can be prescribed in pill form as well. These do not contain any nicotine, but they work by cutting cravings and block nicotine receptors in your brain. Talk to your doctor to determine which quitting aid is best for you.

Joining a support group can be very helpful to connect with others that are struggling with the same problems. Support groups can either be online or in person.

Nicotine addiction rehabilitation centers are also available if you feel that you will not be able to quit on your own. These rehab centers offer full-time help along with other people who are going through the same thing as you. There are multiple options available, such as outpatient and residential programs.

Step 5: Keep Busy

You may be irritable, anxious and experience headaches for a few days after quitting suddenly, so keep this in mind if you are around others. Use this time to grow as a person by trying new things, picking up new hobbies and filling your time with activities. This will keep your mind occupied on things other than the need to smoke. Below is a list of ideas to keep yourself entertained.

  • Cook or bake
  • Shoot photography
  • Birdwatch
  • Exercise
  • Call a friend or family member
  • Adopt a pet
  • Try a new food or restaurant
  • Read a book, write or paint
  • Garden
  • Take a class to learn something new

Remember that half of quitting smoking is the psychological aspect.

Step 6: Know and Avoid Your Triggers

Realize what triggers you to smoke a cigarette. Triggers can range from smelling cigarette smoke to finishing a meal, but everyone has different triggers. Avoid the triggers when you can, but it’s a given that not all will be avoidable. For example, if your routine was to wake up and smoke with a morning cup of coffee, go to a coffee shop instead of making your own. This way you won’t be tempted because you can’t smoke inside.

What To Do if You’re Triggered

If you’re thinking about getting more cigarettes, go to a public indoor place such as the mall or a museum where smoking is prohibited instead. This will shift your focus off cigarettes for the time being.

If it’s the feel of the cigarette in your mouth that you are craving, have some gum or mints on hand to fight this urge and keep your mouth busy. Having a glass of water around at all times can be beneficial to drink since your body was used to the motion of moving your hand to your mouth and back.

Step 7: Reap the Benefits

By not smoking anymore, you are saving money which you can use to treat yourself for your hard work. You are also improving your quality of life by having more energy to perform your daily acts of living.

Quitting now will prevent any more damage from being done to your body. Even if you have been smoking for 40 years, you will be able to gain a great portion of your health back.

The American Cancer Society suggests that not smoking for just 12 hours will return your carbon monoxide levels to normal. Around 3 months after, circulation improves, and you will have better lung function. Anytime between 1 and 9 months after quitting, your shortness of breath will decrease along with your coughing. After a year, you will cut your risk of heart disease in half. The longer you go without smoking, the more benefits will come, such as lowering your risk of cancers and diseases.

We wish you the best of luck on your journey to quitting. It may not be easy, but quitting smoking is a great accomplishment and something to be extremely proud of. You are doing this to set yourself up for a healthier lifestyle, and taking this initiative shows how strong of a person you are.

 

Sources:

https://www.addictionsandrecovery.org/quit-smoking/how-to-quit-smoking-plan.htm

https://www.lung.org/lung-health-diseases/lung-disease-lookup/copd/learn-about-copd#:~:text=COPD%20is%20the%20third%20leading,disease%20without%20even%20knowing%20it.

https://www.cancer.org/healthy/stay-away-from-tobacco/benefits-of-quitting-smoking-over-time.html

https://www.ncbi.nlm.nih.gov/books/NBK179276/pdf/Bookshelf_NBK179276.pdf

https://www.nejm.org/doi/full/10.1056/NEJMsa1211128

https://www.rehabs.com/getting-help-for-nicotine-addiction/

 

 

Risk Factors of COPD Among Women

Historically, men have been perceived to have a higher prevalence of chronic obstructive pulmonary disease (COPD) as compared to women, however, studies now show that more women are diagnosed with COPD and their mortality rates are higher. There is evidence of susceptibility among women of the risk factors associated with COPD.

The World Health Organization (WHO) in conjunction with the Global Burden of Disease (GBD), reports a prevalence of 251 million cases of COPD as of 2016. In 2015, it was estimated that 3.17 million deaths, accounting for 5% of global deaths, were caused by COPD. This is something that WHO had not predicted to occur until the year 2030.

As we know, COPD is a progressive respiratory condition that causes various limitations for breathing.

  • Pathophysiological changes involve inflammation in the lungs, narrowing of the airways, and damage to the lung parenchyma
  • The most common risk factors associated with the development of COPD include smoking, exposure to secondhand smoke, air pollution as well as occupational dust and fumes that are inhaled
  • WHO estimates that 25% of deaths attributed to COPD involve low- and middle-income countries and correlate to the increased exposure of household air pollution
  • Women who are exposed to high levels of indoor smoke and are twice as likely to develop COPD as compared to women that use cleaner fuels and technologies

While the diagnosis and treatment of men or women with COPD are the same, the risk factors are not consistent among both sexes. The associated risk factors among women that will be discussed include smoking status, associated comorbidities, occupational exposure, as well as anatomical and biological differences.

Smoking Status

As we know, tobacco smoke is the main cause of COPD in the United States and smoking is the leading cause of preventable death. According to information available from the Centers for Disease Control (CDC) and the U.S. Department of Health and Human Services (HHS) cigarette smoke causes about one of every five deaths annually, or 1,300 deaths every day. Cigarette smoking is responsible for more than 480,000 deaths per year in the United States, of which 201,773 deaths are among women.

The use of tobacco among women has steadily increased over the years, with a dramatic increase in use since the 1950s. During this time, it was more socially acceptable for women to smoke, and the tobacco industry targeted women in their marketing campaigns by promoting sex appeal, independence, and style. Decades later, tobacco companies continued their strategies by marketing cigarettes with slogans that included phrases such as “It’s a woman thing” or “You’ve come a long way, baby.” Some companies even suggesting that reaching for a cigarette was better than reaching for food and over-indulging, aligning with their campaigns that smoking made you more appealing and stylish. The effects of advertising are attributed to the rise in smoking among women in that era and their shift in use explains why consumption levels remain higher in places such as France, as compared to other countries.

Associated Comorbidities

COPD is typically associated with accompanying comorbidities and includes more organ systems than just our lungs. A recent publication in the respiratory care journal shares data researchers gathered regarding comorbidities among COPD patients and their associated healthcare use. The study included a total of 70,274 COPD subjects, women made up 58.2% of the total COPD subjects. Fifteen comorbidities were identified and the most prevalent diagnosed were hypertension accounting for 47.6%, high cholesterol at 29%, and allergies accounting for 34.2%. Women were found to have at least one or more comorbidities, 51.2% of the subjects studied, and had three times as many diagnosed comorbidities than their male counterparts.

In a 2016 review, Barnes discusses sex differences in COPD and notes that women with severe COPD have a higher risk of hospitalization and death from respiratory failure and associated comorbidities. For those women that have developed COPD due to smoking, their risk of dying from coronary heart disease as compared to other middle-aged nonsmokers’ women is five times higher.

Often, comorbidities in COPD patients go undiagnosed and therefore lead to failure in treatment for their needs. More standardized protocols should be developed by organizations with a goal to provide useful management of patients with COPD and comorbidities so that those healthcare providers caring for these patients provide the right care.

Occupational Exposure

Occupational and biomass exposure is another common risk factor for COPD. Workplace exposures can include things such as dust, fumes, gases, and secondhand smoke. Presently, some three billion people use biomass or solid fuel as energy sources to heat and light their homes, and to cook. In developing countries, women often are exposed to these risks as they spend most of their time in the home and do most of the cooking leaving them disproportionately exposed to larger amounts of biomass irritants.

It has been studied that a lower a person’s socioeconomic status, the higher their risk of poor health. This statistic includes women and children who live in severely impoverished countries and have the greatest exposure to air pollutants. In a 2006 WHO review on energy and health, women who cook with solid fuels have an equivalence of smoking two packs of cigarettes a day. To put it in perspective, a 1-year old girl can accumulate a two-pack year smoking history without ever having been exposed to tobacco smoke.

Women now work in similar jobs as do men, taking on careers in factories and chemical plants, working as farmers, mechanic shops, and in the hospitality industry. All these job fields along with others risk their health through exposure to harmful toxins that can in time lead to the development of COPD.

Anatomical and Biological Differences

Recent studies have also discussed the anatomical differences among men and women and how that is factored into the development of COPD. Various authors have compared lung sizes via different radiological tests and proven that men’s lungs are bigger. According to Aryal et al.,  women are more susceptible to developing COPD due to the size difference of their airways. Their airways are relatively smaller than those of males in comparison to their respective lung volumes.  Therefore, the level of tobacco smoke may be increasingly concentrated per unit of small airway surface. However, no difference in size has been observed in the number of alveoli per unit area, the number of alveoli per unit area volume, individual lung units, and alveolar dimensions. Collectively, more studies should investigate the specific differences in lung size as it relates to tobacco particle disposition and inhaled irritants.

Tobacco smoke contains more than 4,000 chemicals, the smoke inhaled into the lungs is then absorbed and metabolized throughout the body. The process involves a multistep approach but what is important to note about it is that cytochromes p450 (CYP) are what differentiates COPD between men and women. CYP is important in the clearance and breakdown of various compounds, irritants from inhaled tobacco being one of them. In fact. According to a 2016 publication by Hardin, female smokers have increased lung expression of CYP enzymes compared with male smokers. This evidence explains why estrogen levels in women have also been linked to the development of COPD. Estrogen may regulate CYP expression, specifically the estrogen receptor Era, which is more prevalent in women. This information collectively suggests female hormones may hasten the metabolism of tobacco smoke, via the CYP pathways, and accelerate the metabolism of nicotine.

Closing Thoughts

While the number of COPD-related deaths has fallen over the years, the number of diagnosed cases is rising. In the UK, COPD cases continue to rise as the population ages. The long-term effects of smoking are also likely to increase the present burden of COPD on healthcare systems. This presents challenges for both patients and the healthcare systems, not just in the U.S. and UK, but worldwide. It is imperative that we understand the underlying differences between men and women as it relates to COPD.  We should continue to work towards improving the diagnosis, treatments, and monitoring of COPD in women. Reducing the stigma surrounding COPD, raising awareness about various risk factors, and tailoring smoking cessation programs to women can help flatten the curve of this incurable disease.

 

Resources:

Aryal, S., Diaz-Guzman, E., & Mannino, D. M. (2014). Influence of sex on chronic obstructive pulmonary disease risk and treatment outcomes. International journal of chronic obstructive pulmonary disease, 9, 1145–1154. https://doi.org/10.2147/COPD.S54476

CDC – Data and Statistics – Chronic Obstructive Pulmonary Disease (COPD). (2018, June 05). Retrieved September 22, 2020, from https://www.cdc.gov/copd/data.html

Barnes PJ. Sex Differences in Chronic Obstructive Pulmonary Disease Mechanisms. Am J Respir Crit Care Med. 2016 Apr 15;193(8):813-4. DOI: 10.1164/rccm.201512-2379ED. PMID: 27082528.

Han, MeiLan. (2020). Chronic Obstructive Pulmonary Disease in Women: A Biologically Focused Review with a Systematic Search Strategy. International Journal of Chronic Obstructive Pulmonary Disease. Volume 15. 711-721. 10.2147/COPD.S237228.

Hardin M, Foreman M, Dransfield MT, et al. Sex-specific features of emphysema among current and former smokers with COPD. Eur Respir J. 2016;47(1):104-112.

Quaderi, S. A., & Hurst, J. R. (2018). The unmet global burden of COPD. Global health, epidemiology, and genomics, 3, e4. https://doi.org/10.1017/gheg.2018.1

Soriano JB, Maier WC, Egger P, et al. Recent trends in physician-diagnosed COPD in women and men in the UKThorax 2000;55:789-794.

U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress. A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. Accessed September 22, 2020.

World Health Organization (WHO). Chronic obstructive pulmonary disease (COPD). http://www.who.int/respiratory/copd/en/. Accessed September 20, 2020

Balanced Diet & Nutritional Tips for Lung Health

If you suffer from chronic obstructive pulmonary disease (COPD) or other respiratory health conditions, you may notice that eating certain foods may affect your breathing. Consuming a balanced diet with the right mix of nutrients can make breathing easier. Below are some general nutritional tips on foods that can help you.

How Does My Diet Relate to My Breathing?

Metabolism is the body’s process of changing food to fuel. Oxygen and food are the raw materials of the process, and energy and carbon dioxide are the finished products.

When our bodies metabolize simple carbohydrates, such as a slice of cake, we use more energy and therefore use up more oxygen. That process can leave us short of breath. Eating a diet with fewer simple carbohydrates and more healthy fats can help you breathe easier.

Nutritional Tips

The American Lung Association is a great resource for lung health & disease management. Some of their recommended guidelines for a balanced diet include:

  • Eat Complex Carbohydrates– such as whole-grain bread and pasta, vegetables, and beans
  • Limit Simple Carbohydrates– such as candy, cake, and soft drinks
  • Limit Foods that cause Bloating– foods such as legumes, cause gas and bloating making breathing difficult
  • Increase your Fiber– aim to eat 20-30 grams of fiber from foods such as nuts, seeds, or oatmeal
  • Eat High Protein Foods– such as grass-fed meats, eggs, milk, and fish such as salmon
  • Consume Healthy Fats– avocados, coconut and coconut oil, olives and olive oil, and cheese are great choices
  • Limit Saturated Fat- foods cooked in lard, vegetable oils, or fried foods should be avoided
  • Consider a Multivitamin– adding calcium and vitamin D could benefit COPD patients who take steroids
  • Limit Your Sodium– foods with too much sodium may cause swelling and increased blood pressure
  • Stay Hydrated– remember to drink 6-8 glasses (8 fl oz each) of water throughout your day and limit caffeine
  • Eat Smaller Meals– this helps the muscle under your lungs move freely and lets your lungs expand easily

Weigh In

Weighing yourself on a regular basis can help you and your health care provider keep track of how your diet is going. Various health complications could result from being underweight or overweight. When your body is well-nourished, it is better equipped to handle infections and respond to treatments.

The Takeaway

It is important to monitor your diet to ensure you are getting the right mixture of nutrients for your overall health, especially if you suffer from COPD. Keep in mind that the ideal diet will vary depending on a person’s weight and lifestyle and each person’s needs are different. Always talk to your health care provider or a registered dietitian nutritionist to help you get started with a balanced diet.

Pulse Oximetry and its Importance in COVID-19

Patients with conditions such as chronic obstructive pulmonary disease (COPD), pulmonary fibrosis, and various cardiac conditions have utilized pulse oximeters as tools in monitoring their supplemental oxygen use. Pulse oximeters have become essential diagnostic tools because of ease of use, portability, and applicability in a wide range of clinical settings. In the face of the current pandemic, pulse oximeters have gained popularity with patients and physicians alike. Could early pulse oximetry monitoring be utilized in COVID-19?

Globally as of today,  09/23/2020, there are now approximately 31,375,325 confirmed cases of COVID-19 according to the World Health Organization (WHO). Since the outbreak, there have been roughly 749,069 cases in Texas with a significant spike in cases just days ago on 09/21 of 9,853. That is the most significant jump in new daily cases since mid-July when cases climbed to 14,916 on 07/17/2020.  While the number of daily new cases is trending down, we should remain cautious and continue to wear masks, social distance, and avoid large gatherings when possible.

When oxygen levels are low, the organs in our body receive less oxygen which can negatively impact their bodily function. Knowing baseline oxygen saturation levels at rest and with activity can help trend changes among various health conditions. In the presence of COVID-19, monitoring pulse oximetry levels can help monitor oxygenation and warn of impending or silent hypoxemia. While only a few independent studies have assessed the performance of pocket oximeters and smartphone-based systems, future studies could be performed to determine their accuracy.

Common Questions regarding Pulse Oximeters:

What is a Pulse Oximeter?

A pulse oximeter is a small, battery-powered device that is used to measure how much oxygen your blood is carrying. The blood oxygen level measured with an oximeter is called your oxygen saturation level (SpO2) and is displayed as a percentage. The device works by sending two wavelengths of light into the finger through the nail bed and measures what is absorbed by the blood. It can also calculate your pulse and that is displayed as beats per minute (bpm).

How are Pulse Oximeters used?

A pulse oximeter comes as a small unit with a built-in finger/toe clip. All you must do is place your finger inside the pulse oximeter. The pulse oximeter delivers a calculated value and will display it once the reading stabilizes. It is normal for the value to fluctuate so do not worry if you see it changing constantly. Remember to keep working batteries in your oximeter to limit interruptions in your monitoring.

What is a Normal Oxygen Saturation Level?

The American Thoracic Society (ATS) recommends you ask your health care provider what oxygen saturation level they want you to maintain. ATS suggests most people need an oxygen saturation level of at least 89% to keep their cells healthy. COPD patients are advised to maintain a pulse oximetry level between 88-92%. Normal oxygen saturation levels run between 95% and 100%. Medical professionals should be consulted if a patient with suspected or confirmed COVID-19 has SpO2 ≤90%. Having a pulse oximeter will allow you to monitor your blood oxygen level, know if you are within your recommended range, and whether you need to increase your supplemental oxygen level.

How Accurate is a Pulse Oximeter?

The oxygen level from a pulse oximeter is reasonably accurate. Most oximeters give a reading 2% over or 2% under what your saturation would be if obtained by arterial blood. A pulse oximeter may also be less accurate with very low oxygen saturation levels (below 80%).

Factors affecting accuracy to read include:

  • Dark-colored nail polish
  • Cold fingers or poor circulation
  • Tremor or movement
  • Too much pressure on the probe
  • Low blood pressure

Closing Thoughts

For patients and health professionals alike, it will be imperative to be vigilant in the use of new technology advances, such as the way consumer tech companies are marketing health capabilities and promoting pulse oximetry monitoring among their devices. What they can do and what they can reliably do may in fact be two separate things. The use of these devices could potentially threaten and jeopardize a person’s health if the user relies on its accuracy to dictate when they seek medical care. Recently, Brian Clark, a pulmonologist and professor at the Yale University School of Medicine was featured in an article in the Washington Post speaking on the topic of emerging tech companies diving into the medical space. He commented, “I agree with you that it is a dangerous trend for technology companies to release medical devices that don’t meet FDA standards and claim that they are not medical devices”. Dr. Clark also adds, “But the more concerning and potentially dangerous scenario is when the devices provide false reassurance and people don’t seek health care when they really need it”.

Patients suffering from respiratory health conditions will continue to use pulse oximetry monitoring devices for the unforeseeable future. Hand-held pulse oximeters have become a common assessment tool and according to various studies, have been useful as diagnostic tools for the assessment of COPD. They can be used during both stable phase and exacerbations, as well as confirming the need for oxygen therapy.

Worldwide, people are looking to health monitors for any clue that they may have COVID-19, the illness caused by the novel coronavirus. For regular supplemental oxygen users that notice oxygen levels trending low, it will be important to speak with your healthcare provider or respiratory therapist as to when to increase or decrease your oxygen level based on pulse oximetry readings. Regardless of preexisting conditions, monitoring yourself for COVID-19, or recovering from recent hospital admission, its important to seek immediate medical attention if you notice significant changes in your oxygen levels. If you are caring for a patient with COVID-19 and their SpO2 ≤90%, refer to their primary care provider for further evaluation and possible treatment.

Sources:
  1. Adler JN, Hughes LA, Vivilecchia R, Camargo CA Jr.Effect of skin pigmentation on pulse oximetry accuracy in the emergency department. Acad Emerg Med1998596570
  2. Fowler, G. (2020). Washington Post [Editorial]. Https://www.washingtonpost.com/technology/2020/09/23/apple-watch-oximeter/. Retrieved September 23, 2020, from https://www.washingtonpost.com/technology/2020/09/23/apple-watch-oximeter/
  3. Luks AM, Swenson ER. Pulse Oximetry for Monitoring Patients with COVID-19 at Home. Potential Pitfalls and Practical Guidance. Ann Am Thorac Soc. 2020 Sep;17(9):1040-1046. DOI: 10.1513/AnnalsATS.202005-418FR. PMID: 32521167; PMCID: PMC7462317.
  4. Lipnick, Michael S. MD*; Feiner, John R. MD*; Au, Paul BS*; Bernstein, Michael BS†; Bickler, Philip E. MD, Ph.D.* The Accuracy of 6 Inexpensive Pulse Oximeters Not Cleared by the Food and Drug Administration: The Possible Global Public Health Implications, Anesthesia & Analgesia: August 2016 – Volume 123 – Issue 2 – p 338-345 DOI: 10.1213/ANE.0000000000001300
  5. WHO Coronavirus Disease (COVID-19) Dashboard. (n.d.). Retrieved September 23, 2020, from https://covid19.who.int/