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Home Oxygen Therapy: indications, effects and distribution in Scandinavian
Thomas Ringbæk, Hjerte-lungemed. afd. Hvidovre, København
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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
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The Terminology of Home Oxygen Therapy
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The Terminology of Home Oxygen Therapy
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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 - +/-
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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%
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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Unpublished data.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
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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
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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
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Oxygen devices
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Portable Oxygen devices
Concentrator Cylinders Liquid ”on-demand” valves
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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
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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
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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
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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
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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
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The Terminology of Home Oxygen Therapy
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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
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The Terminology of Home Oxygen Therapy
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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
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The Terminology of Home Oxygen Therapy
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Scenaries with hypoxaemia
% SAT.O2
95 90 85
nat Flyvning anstrengelse/anfald
7 timer 3-8 timer 0,5-2 timer
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The Terminology of Home Oxygen Therapy
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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
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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?
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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
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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
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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.
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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
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Home visits by a respiratory nurse?
Country Available?
Norway Yes
Denmark Most places with pulm. physicians
Sweden Recommended
UK Recommended and available many places
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Smoking and COT
Effect? Probably 15-24 hrs/day? Not possible for heavy
smokers Safe? Not everybody Ethical aspects? Seretide to smokers?
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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
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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
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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
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Use/prescribed oxygen 16-24 hours daily
Country Adherence rate
Denmark 60/82%
UK 60%
Norway
Sweden (2006) ?/97%
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Prevalence of HOT in various countries (per 100.000)
0102030405060708090
100
1987 1993 2006
DK
SE
F
N
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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
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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)
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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