indications, effects and distribution in Scandinavian mas Ringbæk, Hjerte-lungemed. afd. Hvidovre, Københ
Home Oxygen Therapy: indications, effects and distribution in Scandinavian
Thomas Ringbæk, Hjerte-lungemed. afd. Hvidovre, København
Overview Types of home oxygen therapies (terminology) Evidence: a) COT
b) STOT (unstable condition)c) SBOT (short burst of oxygen)d) NOT (nocturnal oxygen)e) ambulatory & portable oxygen
How do we do in practice?Home Oxygen Therapy in various countries:
a) practice/organisation b) qualityc) prevalence/incidence
d) survival
The Terminology of Home Oxygen Therapy
The Terminology of Home Oxygen Therapy
COT in COPD: effect on survivalPaO2 <7.3 kPa;7.3-8.0: EVF>55% or cor pulmonale)
Post-PaO2 >8.6 kPa; Stabile and optimal treated; Non-smokers
MRC NOTTN 87 203Age 58 66Men% 76 80FEV1% 30 30PO2, 6.8 6.8 kPaPCO2 7.2 6.9 kPaHtc.% 52 47Smoking 45% ?Flow 2 1-3+1Hours 13.5 17.7/12Mobile - +/-
Effects of COT
ventilatory work hemodynamic PAP Htc.: 4-8% FEV1: unchanged
PO2? kidney function (oedema) dyspnoea physical capacity
tiered sleep cognitive performance QoL survival: 2 4 år hospitalisation: 25%
COT in non-COPD
Lung fibrosis: 62 patients. No effect on survival.Unpublished data.
Crockett AJ et al. Domiciliary oxygen for interstitial lung disease. Cochrane Database Syst Rev 2001; 3:CD002883
RCT on moderate hypoxaemic COPD patients 1987-92 in Poland1987-92 in Poland 135 COPD patients with P135 COPD patients with PaaOO22 7.4-8.7 kPa. 7.4-8.7 kPa. Post-PO2 >8.7 kPa (mean 9.9 kPa)Post-PO2 >8.7 kPa (mean 9.9 kPa) >17 hrs/day vs. no oxygen (used 13½ hrs)>17 hrs/day vs. no oxygen (used 13½ hrs) Only concentratorOnly concentrator Not assessed: QoLNot assessed: QoL
Daily activity/exerciseDaily activity/exerciseHospitalisationHospitalisation
RCT on moderate hypoxaemic COPD patients (planned study) 3.200 COPD pts. in USA3.200 COPD pts. in USA
Usual careUsual care Sat.OSat.O22 89-93%: 89-93%:
LTOT+ portable oxygenLTOT+ portable oxygen
Outcomes: QoLOutcomes: QoLDaily activity/exerciseDaily activity/exerciseSurvivalSurvival
Oxygen devices
Portable Oxygen devices
Concentrator Cylinders Liquid ”on-demand” valves
Aims of portable and ambulatory oxygen
Portable Oxygen (hypoxaemic at rest) hrs on oxygen
daily activity
Ambulatory Oxygen (normoxaemic at rest)
Desaturate and/or dyspnoea during exercise
exercise tolerance/daily activity
Portable oxygen in 159 COPD pts on COTFrance 1984-6; presc. >15 hrs/day; 12 MWD>200 m
Flow: 1.7 L/min at rest and 2.2 L/min during exercise. Randomised.
Gr.A=75Gr.A=75 Gr.B=84Gr.B=84 CConc.onc. Conc+small cyl.*(51)Conc+small cyl.*(51) Liquid(33)Liquid(33)
12MWD –O12MWD –O22 407 m407 m 423423
12MWD+O12MWD+O22 485 m485 m 478478
Hrs/day:Hrs/day: 14 hrs14 hrs 17 hrs 17 hrs (B1 = B2) <0,01 (B1 = B2) <0,01
Outdoor with OOutdoor with O22: : 55%55% 67%67%
Activity outdoor: Activity outdoor: equalequal
25% did not use portable oxygen, and 15% only indoor. 25% did not use portable oxygen, and 15% only indoor. Too heavy according to the patient: Cyl.: 50%, Liquid: 33%Too heavy according to the patient: Cyl.: 50%, Liquid: 33%
*) 2½ L cyl. + stroller (used by 10% of the pts) Vergeret J. Eur Respir J 1989
Effect and usage of portable oxygen in COPD pts on COT
COT: 3-12 months
Excluded pts. who were not expected to live > 1 year.
Conc.: 3 mdr. Conc.+O2: 3 mdr. Conc.-O2:3 mdr.
Lacasse Y, ERJ 2005
Effects and use of portable (3½ kg) oxygen in 24 COPD pts on LTOT. 3 x 3 months
•No effect on QoL and 6 MWD
Lacasse Y, ERJ 2005
Portable oxygen in 930 COPD pts on COTFrance before 1996; Presc. 16 hrs/day; COT >3 months
Portable oxygen to 30% of 893 ptt. with a concentrator. Only used by 52% in a 3 months period Only used outdoor by 4% –
especially those with liquid oxygen
Pepin JL et al. Chest 1996
The Terminology of Home Oxygen Therapy
STOT (oxygen at home while unstable)
Re-evaluation: 1 month later: normalised in 30%1 and 70%2
2-3 months later: 30-50% normalised1,3
PO2<6.7 kPa: only 1 of 23 normalised1
Despite LTOT: 17% died <2 months4
No RCT
1) Levi-Valensi et al. Am Rev Respir Dis 19862) Andersson et al. Respir Med 20023) NOTT study4) Eaton et al. Respir Med 2001
The Terminology of Home Oxygen Therapy
SBOT (palliation of attacks of dyspnoea)
Very few studies1,2
Only mentioned superficially in BTS, ATS, GOLD COPD: 6-12 wks: 4 studies (PO2 8.5-10 kPa):
2 showed a small effect compared to air. Cancer:
+hypoxaemia at rest: 5 L O2/min > air.
- hypoxaemia at rest: 4 L O2/min= 4 L air/min
1) Booth S et al.Respir Med 20042) Booth S et al. Am J Respir Crit Care Med 1996
The Terminology of Home Oxygen Therapy
Scenaries with hypoxaemia
% SAT.O2
95 90 85
nat Flyvning anstrengelse/anfald
7 timer 3-8 timer 0,5-2 timer
The Terminology of Home Oxygen Therapy
Ambulatory oxygen to pts with desat. and/or dyspnoea. Prevalence in COPD
10% desaturate ≥4% 10% desaturate ≥4% 5.926 COPD pts with FEV5.926 COPD pts with FEV11 1.5-2 L (1) 1.5-2 L (1)
32% desaturate ≥4% and 32% desaturate ≥4% and 88% 88% 81 COPD pts with FEV81 COPD pts with FEV11 =1,29 (2) =1,29 (2)
1. Hadeli KO et al. Chest 2001;120;88-92 1. Hadeli KO et al. Chest 2001;120;88-92
2. Knower MT et al. 2. Knower MT et al. Arch Intern Med 2001;161:732-6Arch Intern Med 2001;161:732-6
The clinical relevance of desaturation during exercise?
Desat. is poorly assoc. tol 6-MWD (and dyspnoea)Desat. is poorly assoc. tol 6-MWD (and dyspnoea)
1. Mak VH et al. Thorax 1993;48(1):33-81. Mak VH et al. Thorax 1993;48(1):33-82. Baldwin DR et al. Respir Med 1995;89(9):599-6012. Baldwin DR et al. Respir Med 1995;89(9):599-601
Pulmonal hypertension, hospitalisation, and mortality?Pulmonal hypertension, hospitalisation, and mortality?
Acute effect of ambul.oxygen
Borg dyspnoea score 0.5-1.0
Physical tolerance 5-20%
+
Weight of device
Risk of stumbling over the tube
Ashamed
-
• No effect of oxygen pre- or post-exerciseKillen JWW, Thorax
2000Lewis CA, ERJ 2003McKeon JL, Thorax
1988Stevenson NJ, Thorax.
2004
Effect of ambul. oxygenCombination with rehabilitation
No effect Garrod R, Thorax 2000 Emtner M, AJRCCM 2003 Rooyackers JM, ERJ 1997 Wadell K, J Rehabil Med 2001
Puhan MA Respir Res 2004
International criteria for COT
PaO2 <7.3 kPa (Sat. 88%) (7.3-8.0: EVF>55% or cor pulmonale)
Post-PaO2 >8.6 kPa Stabile and optimal treated Non-smokers Used >15 hours daily Follow-up after 3 months and then every Follow-up after 3 months and then every
6 months. 6 months.
Follow-up in different countries
Country Adherence rate
Guidelines
Denmark1 60% 3 wks apart then every ½yr
UK2 61% The same
Norway ? 3 wks then every 3 months
Sweden3 39% 2 wks then every 6 months
1) Ringbaek et al. Respir Med 2006
2) Walshaw MJ et al. BMJ 1988
3) Utsättningsförsök hos KOL-pts startet ved forsämring
Sat.O2 92%: stop
Sat.O2: 89-91: a-puncture
Sat.O2 88: continous
Home visits by a respiratory nurse?
Country Available?
Norway Yes
Denmark Most places with pulm. physicians
Sweden Recommended
UK Recommended and available many places
Smoking and COT
Effect? Probably 15-24 hrs/day? Not possible for heavy
smokers Safe? Not everybody Ethical aspects? Seretide to smokers?
Effect of oxygen and CO on 12-minute walking distance
Calverley PMA, BMJ 1981
580
600
620
640
660
680
700
720
740
760
Air Oxygen Air+CO Oxygen+CO
12-MWD
meter p<0.01 p<0.01 p<0.01
15 COPD; FEV1=0.56 L; PO2: 5.2-7.7 kPa
Tobacco and COTin different countries
Country Prev. Guidelines
Denmark 21% Consider if PO2<6.7 kPa and max. 3 cig./day
Sweden 1.1% No
The Netherlands 26% No
Australia 14% No
UK 26% No
Norway ? No
Adhere to the hypoxaemic criteriaPPaaOO22 <7.3 kPa (Sat. 88%) <7.3 kPa (Sat. 88%)
(7.3-8.0: EVF>55% or cor pulmonale)(7.3-8.0: EVF>55% or cor pulmonale)
Country Adherence rate
Denmark 60-70%
France 55-80%
UK 60%
Norway1 2002
2004
2005
44% of 25 pts
66% of 32 pts
35% of 48%
Sweden (2006) 81%
1) Glittreklinikken; PO2 <7.3 kPa
Use/prescribed oxygen 16-24 hours daily
Country Adherence rate
Denmark 60/82%
UK 60%
Norway
Sweden (2006) ?/97%
Prevalence of HOT in various countries (per 100.000)
0102030405060708090
100
1987 1993 2006
DK
SE
F
N
Oxygen devices in different countries and economy
Country Concentrator Liquid Mobile unite
Denmark 72 11 58
Sweden 69%
Norway 60% 40%
UK <10 <50%
Appr. 10.000 Nkr. yearly per patient
Survival rates of new COPD patients on COT from Denmark compared to patients from other countries
0
10
20
30
40
50
60
70
80
90
100
0 3 6 9 12 15 18 21 24 27 30 33 36 39
Months
Cu
mu
lativ
e s
urv
iva
l pro
po
rtio
n (
%)
%)
Denmark (n=5659)
Sweden (n=403)
Belgium (n=270)
France (n=252)
Australia (n=505)
NOTT, COT (n=101)
Japan (n=4552)
Conclusions
COT improves survival in hypoxaemic patients
Most patients started after hospitalisation Only about 50% are followed up Portable oxygen is still too heavy In general, poor survival
Thank you for your attention