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Unpublished data.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

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

Assoc. with increased mortalityAssoc. with increased 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

Sweden 39% 2 wks then every 6 months

1) Ringbaek et al. Respir Med 2006

2) Walshaw MJ et al. BMJ 1988

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?

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)

010203040506070

8090

100

1987 1993 2006 2010

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. 12.000 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

Test

1. PO2=6.8 kPa at rest; ex-smoker. Start home oxygen therapy?

2. Portable oxygen to mobile hypoxaemic patients: - increase activity?

increase hours on oxygen?

3. Ambulatory oxygen improves effect of pulmonary rehabilitation?