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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. FREO 2 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 FREO 2 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., Competing Interests: Competing interests: BS, RR, DP are directors of FREO2 Foundation Australia., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

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., Competing Interests: During the period of the trial described in this manuscript, authors KR and JB were employees of FREO2 Foundation Australia Ltd, a not-for-profit company aiming to reduce health inequalities around provision of medical grade oxygen in low-resource environments. Authors DP, BS and RR are directors and co-founders of FREO2 Foundation Australia Ltd. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

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., (Copyright © 2017 by Daedalus Enterprises.)

The World Health Organization recommends oxygen therapy for children with severe pneumonia, but this essential medicine is unavailable in many health centres in limited-resource settings. To address this need, an appropriate means of oxygen provision will need to be low-cost and robust, require little maintenance and not compete for fuel with other vital functions, and be environmentally sustainable. This report presents the preliminary results of the Fully Renewable Energy Oxygen (FREO2) system, confirming the viability of a novel means of producing medical grade oxygen without any electricity. The approach relies on exploiting the reduction in pressure of water flowing through a raised siphon to create a source of vacuum. This is used to power a customised vacuum-pressure-swing-adsorption system and produce medical grade oxygen. The FREO2 system has been designed to meet the criteria for successful oxygen delivery in small health facilities. It is ideally suited for deployment in tropical or mountainous regions with proximity to flowing water. Importantly, the oxygen generating capacity of FREO2 rises with the increased demand commonly observed during the rainy season in such climates., (© The Author(s) 2015.)