World Health Organization · 1st edition, 2026 · 235 pages
Practical operational guidance for biomedical engineers and technicians on installation, maintenance, and safe use of oxygen systems and respiratory care devices.
- Issuer
- World Health Organization
- Edition
- 1st edition, 2026
- Audience
- Biomedical engineers and technicians, health facility managers, clinicians, maintenance personnel, electricians, plumbers, mechanics working with respiratory care equipment
- Evidence
- Expert consensus based on manufacturer specifications, international standards (ISO, IEC, NFPA, HTM), and operational experience during COVID-19 response
- Reviewed
- 17 Oct 2026 · GMJ
What this guideline says
GMJ summary
This comprehensive 235-page manual addresses the critical gaps in medical oxygen system management exposed by the COVID-19 pandemic across the WHO South-East Asia Region. It provides standardised technical guidance for biomedical engineers, technicians, and health facility managers on the entire oxygen ecosystem—from production and storage through distribution to patient delivery—along with patient monitoring, diagnostic equipment, fire safety, and biomedical waste management.
The manual comprises ten detailed operating guides covering: oxygen production equipment (PSA plants, oxygen concentrators), oxygen storage (cylinders, liquid oxygen tanks), medical gas pipeline systems and manifolds, ventilators (invasive and non-invasive including CPAP, BiPAP, HFNC), consumable delivery devices (nasal cannulae, masks), regulation and conditioning devices (flowmeters, humidifiers, pressure regulators), patient monitoring (pulse oximeters, multiparameter monitors), diagnostic equipment (ABG analysers, ECG, ultrasound, X-ray), fire safety measures, and biomedical waste management. Each guide includes installation procedures, preventive and corrective maintenance protocols, troubleshooting, safety considerations, and links to technical specifications.
Developed through consultative processes with biomedical experts and aligned with WHA76.3 (2023) on increasing access to medical oxygen, the manual emphasises that a resilient oxygen ecosystem requires not only equipment availability but also strong systems, trained personnel, appropriate infrastructure, effective governance, and sustainable maintenance mechanisms. It serves as both a practical reference and a template for Member States to develop national operational manuals.
Key points
For clinicians — doses and thresholds as stated in the guideline
- PSA oxygen generation plants produce 93% (±3%) pure oxygen using zeolite molecular sieves and require power consumption of approximately 1.22 kWh ±5% per m³ of total oxygen flow with three-phase power supply of 380–400V at 50 Hz
- Bedside oxygen concentrators deliver 0.5–20 LPM flow (depending on model) and produce oxygen with purity >82% (typically 93% ±3%), consuming 300–600W for a 10 LPM unit, requiring 100–240V AC ±10% / 50–60 Hz ±10%
- High-pressure oxygen cylinders require hydrostatic testing every 5–10 years by competent third parties and must undergo weight loss testing (>5% indicates failure) and corrosion inspection
- Medical gas pipeline systems must maintain gas working pressure between 300–600 kPa (3–6 bar or 43.5–87 psi) at all terminal units from closest to farthest point from source
- Nasal cannulae deliver oxygen concentrations of 24% at 1 L/min up to 44% at 6 L/min; flow rates above 5 LPM require humidification to prevent dryness of nasal passages
- Pulse oximeters must have ±1% accuracy sensors and be calibrated at least annually; oxygen concentrators require daily purity checks with oxygen analysers showing >90% concentration (low oxygen alarm activates below 90%)
- Invasive ventilators for ICU must provide FiO₂ 21–100%, tidal volume 20–1500 mL, inspiratory pressure 0–40 cmH₂O, I:E ratio including inverse ratio capability, respiratory rate 10–60 breaths/min minimum, and PEEP 0–20 cmH₂O minimum
- Biomedical workshops must maintain inventory of device-specific spare parts, conduct preventive maintenance according to manufacturer schedules, and ensure 24/7 on-call qualified technician availability for oxygen systems supporting SARI patients and critical care services
Comparison of oxygen production sources: PSA plants vs bedside oxygen concentrators
Table extracted from the guideline
| Characteristic | PSA oxygen generation plant | Bedside oxygen concentrators |
|---|---|---|
| Description | Onsite oxygen-generating system using PSA technology, supplies oxygen via central pipeline or refilled cylinders | Self-contained, electrically powered device concentrating oxygen from ambient air using PSA technology |
| Distribution mechanism | Central or subcentral MGPS or through refilled cylinders via manifolds | Direct to patient with tubing or through flowmeter stand |
| Oxygen purity | 93% (±3%) | 93% (±3%), >82% minimum |
| Electricity requirement | 1.22 kWh ±5% per m³ total flow; 380–400V three-phase at 50 Hz continuous power | 300–600W for 10 LPM unit; 100–240V AC ±10% / 50–60 Hz ±10% |
| Maintenance requirement | Significant maintenance by highly trained technicians/engineers; SLA or maintenance contract recommended | Moderate maintenance by trained technicians; can be in-house |
| Advantages | Cost-effective for large facilities; continuous supply with continuous power | Continuous supply at low running cost; output can be split among multiple patients |
| Considerations | High capital investment; high maintenance cost; high electricity consumption; requires adequate infrastructure; backup cylinder supply needed | Low pressure output, not suitable for CPAP or ventilators; requires uninterrupted power; backup cylinder supply needed |
| Human resource | Operator(s) onsite 24/7; qualified technician(s) on call 24/7; manager of operations for large operations | Dedicated technical staff may not be necessary 24/7, but on-call technician allows quick support; functional replacement units for easy swap |
Source: World Health Organization, Regional manual with operating guides on respiratory care equipment and devices. Reproduced in summary form.
From the guideline
Verbatim
“Medical oxygen is an essential medicine with no substitute. It is a critical component of quality health-care delivery, indispensable for the management of respiratory illnesses, emergency care, surgery, critical care, maternal and child health services, and pandemic preparedness and response.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As someone who has worked with WHO on health system strengthening across Eastern Europe, I recognise this manual addresses a critical gap exposed during COVID-19: we rapidly deployed oxygen equipment across Georgia and the region but lacked standardised maintenance protocols and trained biomedical personnel. The manual's most valuable contribution for Georgian clinicians and hospital administrators is the detailed preventive maintenance schedules and troubleshooting algorithms—these will extend equipment lifespan and prevent treatment interruptions that we witnessed too often during the pandemic. I would particularly stress to our biomedical engineers the daily oxygen purity monitoring requirement (alarm at <90%) and the 5–10 year hydrostatic testing cycle for cylinders, as these are often neglected. The realistic implementation caveat for Georgia is the shortage of qualified biomedical engineers: we must invest in training programmes and establish the regional biomedical workshop structure the manual outlines, rather than expecting individual hospitals to maintain complex PSA plants without adequate technical support and spare parts inventory.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 17 Oct 2026
Applicability
Georgia and the South Caucasus
This manual is directly relevant for Georgia and the South Caucasus region, where oxygen infrastructure expanded rapidly during COVID-19 but sustainable maintenance systems remain underdeveloped. Georgia’s health system, moving toward universal health coverage since 2013, requires standardised protocols for the PSA oxygen plants, concentrators, and medical gas pipeline systems installed in recent years. The shortage of qualified biomedical engineers and technicians—a challenge across Eastern Europe—makes the manual’s step-by-step maintenance protocols and training frameworks particularly valuable. National programmes should adapt these operating guides to local regulatory requirements (including pressure vessel certification standards), establish biomedical workshops at regional levels as outlined, and develop Armenian, Azerbaijani, and Georgian language versions. The infrastructure requirements (three-phase power supply, backup generators, ventilation) and electricity consumption estimates (1.22 kWh per m³ for PSA plants) will help health facilities in the region with limited or unstable power supplies plan appropriate backup systems and calculate operational costs for sustainable oxygen therapy programmes.
Questions this guideline answers
Quick answers
What oxygen purity level requires alarm activation in PSA plants and concentrators?
A low oxygen concentration alarm must activate if oxygen purity falls below 90%. PSA plants and concentrators should produce oxygen with 93% (±3%) purity. Daily purity checks using oxygen analysers with ±1% accuracy sensors are mandatory, with readings recorded in maintenance logs.
How often must high-pressure oxygen cylinders undergo hydrostatic testing?
High-pressure gas cylinders require hydrostatic (pressure) testing by a competent third party or authorized inspection agency every 5–10 years. Between formal testing, users must conduct frequent visual inspections and leakage checks. Weight loss testing showing >5% loss indicates cylinder failure. Only cylinders passing strict QA verification for medical application should be used.
What electrical requirements are needed for a PSA oxygen generation plant?
PSA plants require three-phase power supply of 380V–400V at 50 Hz with continuous, reliable electrical source. Power consumption is approximately 1.22 kWh ±5% per m³ of total oxygen flow. Voltage stabilization is imperative to avoid interruption. Backup power source like diesel generator is recommended for areas with frequent or serious power outages.
When is humidification required during oxygen therapy?
Humidification is required when oxygen flow rate exceeds 5 litres per minute (LPM) to prevent dryness of nasal passageways, mouth, and throat. Bubble humidifiers (non-heated) work best at water temperature of at least 30°C. Heated humidifiers, working best at 37°C, are used for CPAP, HFNC, and ventilator therapy. Humidifiers must be kept upright, downstream of oxygen source, and as close to patient as practical (not on floor).
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- Issuer
- World Health Organization
- Type
- Manual
- Edition
- 1st edition, 2026
- Status
- Current
- Published
- 2026-08-17
- Languages
- English
- Scope
- Regional (WHO South-East Asia) but globally applicable
- Audience
- Biomedical engineers and technicians, health facility managers, clinicians, maintenance personnel, electricians, plumbers, mechanics working with respiratory care equipment
- Pages
- 235
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 9789292800055
- Evidence
- Expert consensus based on manufacturer specifications, international standards (ISO, IEC, NFPA, HTM), and operational experience during COVID-19 response
- Record history
- Created 17 Oct 2026 · updated 17 Oct 2026 · next check Apr 2027
World Health Organization, Regional Office for South-East Asia. Regional manual with operating guides on respiratory care equipment and devices. New Delhi: WHO Regional Office for South-East Asia; 2026. 235 p. Licence: CC BY-NC-SA 3.0 IGO.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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