Oxygen for breathlessness in patients with chronic obstructive pulmonary disease who do not qualify for home oxygen therapy

Palliative home oxygen: practical framework for clinicians

The British Thoracic Society 2015 guidelines on home oxygen use in adults have been pivotal in guiding clinicians on the use of long-term oxygen therapy in improving survival outcomes for patients. However, guidance for use of home oxygen in the palliative care setting has not been as robust owing to the lack of evidence-based studies. Therefore, this narrative review aims to provide a clinical framework on the use of palliative home oxygen therapy by considering its prognostic and symptomatic benefits as well as offering pragmatic advice for palliative home oxygen in end-of-life care.

Smoking and home oxygen therapy: a review and consensus statement from a multidisciplinary Swedish taskforce

BACKGROUND

Home oxygen therapy (HOT) improves survival in patients with hypoxaemic chronic respiratory disease. Most patients evaluated for HOT are former or active smokers. Oxygen accelerates combustion and smoking may increase the risk of burn injuries and fire hazards; therefore, it is considered a contraindication for HOT in many countries. However, there is variability in the practices and policies regarding this matter. This multidisciplinary Swedish taskforce aimed to review the potential benefits and risks of smoking in relation to HOT, including medical, practical, legal and ethical considerations.

METHODS

The taskforce of the Swedish Respiratory Society comprises 15 members across respiratory medicine, nursing, medical law and ethics. HOT effectiveness and adverse risks related to smoking, as well as practical, legal and ethical considerations, were reviewed, resulting in five general questions and four PICO (population-intervention-comparator-outcome) questions. The strength of each recommendation was rated according to the GRADE (grading of recommendation assessment, development and evaluation) methodology.

RESULTS

General questions about the practical, legal and ethical aspects of HOT were discussed and summarised in the document. The PICO questions resulted in recommendations about assessment, management and follow-up of smoking when considering HOT, if HOT should be offered to people that meet the eligibility criteria but who continue to smoke, if a specific length of time of smoking cessation should be considered before assessing eligibility for HOT, and identification of areas for further research.

CONCLUSIONS

Multiple factors need to be considered in the benefit/risk evaluation of HOT in active smokers. A systematic approach is suggested to guide healthcare professionals in evaluating HOT in relation to smoking.

Bacterial contamination on clinical surfaces and oxygen device accessories in the emergency unit of a tertiary health facility in Ghana

BACKGROUND

Nosocomial infections have gradually become an emerging threat to the healthcare system over the past decades and have been attributed to poor decontamination of hospital articles and weak antibacterial stewardship policies. This study sought to investigate the effect of disinfection on the prevalence and resistance profile of bacterial contaminants on oxygen device accessories, and clinical surfaces at the emergency unit of a tertiary health facility in Ghana.

METHODS

The study employed a cross-sectional study design to evaluate the occurrence of bacteria on surfaces in a tertiary hospital. Luminal swabs of the oxygen device accessories and swabs from clinical surfaces used by healthcare providers were collected for isolation and identification of bacteria. The identified bacteria isolates were then tested for their susceptibility to antibacterial agents. Data from this study were analyzed using Excel (Microsoft Office Suite), and GraphPad Prism 8 software programs.

RESULTS

A quarter of the total 44 bacterial isolates obtained from both post-disinfected and pre-disinfected surfaces were Gram-positive, with the remaining isolates being Gram-negative. Pseudomonas aeruginosa was the most frequent bacteria species isolated (41%) followed by Citrobacter sp. (21%). P. aeruginosa, S. aureus, and S. pneumoniae were found to be highly resistant to Chloramphenicol (36%), and Sulfamethoxazole (100%); whereas Ciprofloxacin (91%) was the most effective antibacterial drug used.

CONCLUSION

The almost equal prevalence of multidrug-resistant bacteria from both post-disinfected and pre-disinfected surfaces of inanimate objects, and oxygen device accessories connote an ineffective disinfection process which may influence resistance in bacterial contaminants. This requires the overhaul of disinfection protocol and training of hospital staff, and rational use of antibacterial agents at the hospital to mitigating the burden of nosocomial infections.

Oxygen Therapy in COPD

Long-term oxygen therapy (LTOT) is a mainstay treatment for patients with severe resting hypoxemia secondary to chronic respiratory conditions including COPD. The evidence for LTOT is based on two trials that are now several decades old but have been insufficiently revisited. Therefore, many questions remain about precisely which patients experience the most benefit from LTOT, as well as how to define that benefit. Most studies have examined LTOT's effect on longevity rather than its impact on quality of life. In addition, many challenges exist in training both clinicians and patients on best practices for LTOT and associated equipment. Reimbursement policies have reduced the kinds of equipment available to the LTOT patient community, presenting additional challenges. This paper will review the current evidence for LTOT in COPD, the challenges involved with providing optimal therapy, and potential avenues of modernizing this essential intervention.

Current Management Options for Dyspnea in Cancer Patients

OPINION STATEMENT

Dyspnea is one of the most frequent and distressing symptoms in patients with advanced cancer. As dyspnea deteriorates patients' quality of life markedly and tends to worsen as the disease progresses, comprehensive assessment and timely treatment of the underlying etiologies are essential. International guidelines recommend various non-pharmacological and pharmacological management options. However, there is a scarcity of confirmatory clinical trials on cancer dyspnea, and the overall level of evidence is weak. Recently, observational and survey studies indicated a wide range of practice patterns of palliative care specialists, providing important insight into the real-world management of dyspnea. In this paper, we summarize current management options for dyspnea in cancer patients, highlight major controversies in the literature, and propose future research directions toward quality care for patients with dyspnea and their families.

Automated Oxygen Administration Alleviates Dyspnea in Patients Admitted with Acute Exacerbation of COPD: A Randomized Controlled Trial

Objective

Devices for Automated Oxygen Administration (AOA) have been developed to optimize the therapeutic benefit of oxygen supplementation. We aimed to investigate the effect of AOA on multidimensional aspects of dyspnea and as-needed consumption of opioids and benzodiazepines, as opposed to conventional oxygen therapy, in hospitalized patients with Acute Exacerbation of COPD (AECOPD).

Method and Patients

A multicenter randomized controlled trial across five respiratory wards in the Capital Region of Denmark. Patients admitted with AECOPD (n=157) were allocated 1:1 to either AOA (O2matic Ltd), a closed loop device automatically delivering oxygen according to the patient's peripheral oxygen saturation (SpO₂), or conventional nurse-administered oxygen therapy. Oxygen flows and SpO₂ levels were measured by the O2matic device in both groups, while dyspnea, anxiety, depression, and COPD symptoms were accessed by Patient Reported Outcomes.

Results

Of the 157 randomized patients, 127 had complete data for the intervention. The AOA reduced patients' perception of overall unpleasantness significantly on the Multidimensional Dyspnea Profile (MDP) with a difference in medians of -3 (p=0.003) between the intervention group (n=64) and the control group (n=63). The AOA also provided a significant between group difference in all single items within the sensory domain of the MDP (all p-values≤0.05) as well as in the Visual Analogue Scale - Dyspnea (VAS-D) within the past three days (p=0.013). All between group differences exceeded the Minimal Clinical Important Difference of the MDP and VAS-D, respectively. AOA did not seem to have an impact on the emotional response domain of the MDP, the COPD Assessment Test, the Hospital Anxiety and Depression Scale, or use of as-needed opioids and/or benzodiazepines (all p-values>0.05).

Conclusion

AOA reduces both breathing discomfort and physical perception of dyspnea in patients admitted with AECOPD but did not seem to impact the emotional status or other COPD symptoms.

Evidence-based management approaches for patients with severe chronic obstructive pulmonary disease (COPD): A practice review

BACKGROUND

Patients with chronic obstructive pulmonary disease (COPD) face limited treatment options and inadequate access to palliative care.

AIM

To provide a pragmatic overview of clinical guidelines and produce evidence-based recommendations for severe COPD. Interventions for which there is inconsistent evidence to support their use and areas requiring further research were identified.

DESIGN

Practice review of guidelines supported by scoping review methodology to examine the evidence reporting the use of guideline-recommended interventions.

DATA SOURCES

An electronic search was undertaken in MEDLINE, EMBASE, PsycINFO, CINAHL and The Cochrane Database of Systematic Reviews, complemented by web searching for guidelines and publications providing primary evidence (July 2021). Guidelines published within the last 5 years and evidence in the last 10 years were included.

RESULTS

Severe COPD should be managed using a multidisciplinary approach with a holistic assessment. For stable patients, long-acting beta-agonist/long-acting muscarinic antagonist and pulmonary rehabilitation are recommended. Low dose opioids, self-management, handheld fan and nutritional support may provide small benefits, whereas routine corticosteroids should be avoided. For COPD exacerbations, systematic corticosteroids, non-invasive ventilation and exacerbation action plans are recommended. Short-acting inhaled beta-agonists and antibiotics may be considered but pulmonary rehabilitation should be avoided during hospitalisation. Long term oxygen therapy is only recommended for patients with chronic severe hypoxaemia. Short-acting anticholinergic inhalers, nebulised opioids, oral theophylline or telehealth are not recommended.

CONCLUSIONS

Recommended interventions by guidelines are not always supported by high-quality evidence. Further research is required on efficacy and safety of inhaled corticosteroids, antidepressants, benzodiazepines, mucolytics, relaxation and breathing exercises.

Behaviour change and physical activity interventions for physical activity engagement in community dwelling adults with chronic obstructive pulmonary disease: protocol for a systematic review

Background: Chronic obstructive pulmonary disease (COPD) is a complex respiratory disease and the third leading cause of death worldwide. Pulmonary rehabilitation is recognised as the gold standard of care in the management of COPD, however engagement with pulmonary rehabilitation is low and maintenance of a physically active lifestyle in community dwelling adults with COPD is poor. Supporting positive behaviour change in people with COPD could help to increase their engagement with physical activity. This systematic review will examine behaviour change and physical activity interventions delivered to community dwelling adults with COPD with the aim of increasing physical activity engagement. Interventions will be mapped against Michie’s theoretical domains framework (TDF) to inform clinical practice and health policy.

Methods: The following databases will be searched from inception until December 2021: Web of Science, CENTRAL, MEDLINE (via EBSCO), EMBASE, APA PsychINFO, CINAHL (via EBSCO), AMED, PROSPERO, Cochrane Airways Trials Register. Reference lists of the relevant studies and grey literature will be searched using Grey Literature Report, Open Grey and Google Scholar search engines. Relevant studies will be systematically reviewed and subject to quality appraisal to determine the impact of behaviour change and physical activity interventions on outcomes of community-dwelling adults with COPD. Interventions will be mapped to Michie’s TDF and a narrative synthesis with respect to nature, effectiveness on target population and setting/environment will be provided. Findings will be reported in relation to the generalisability of the primary results and research question, and will include secondary findings on quality of life, self-reported participation in physical activity, exercise capacity, adverse events and intervention adherence. The review will be presented according to the PRISMA guidelines 2020.

Conclusions: This systematic review is necessary to explain the impact of behaviour change and physical activity interventions on outcomes of community dwelling people with COPD.

PROSPERO registration: CRD42021264965 (29.06.2021)

Behaviour change and physical activity interventions for physical activity engagement in community dwelling adults with chronic obstructive pulmonary disease: protocol for a systematic review

Background: Chronic obstructive pulmonary disease (COPD) is a complex respiratory disease and the third leading cause of death worldwide. Pulmonary rehabilitation is recognised as the gold standard of care in the management of COPD, however engagement with pulmonary rehabilitation is low and maintenance of a physically active lifestyle in community dwelling adults with COPD is poor. Supporting positive behaviour change in people with COPD could help to increase their engagement with physical activity. This systematic review will examine behaviour change and physical activity interventions delivered to community dwelling adults with COPD with the aim of increasing physical activity engagement. Interventions will be mapped against Michie’s theoretical domains framework (TDF) to inform clinical practice and health policy. Methods: The following databases will be searched from inception until December 2021: Web of Science, CENTRAL, MEDLINE (via EBSCO), EMBASE, APA PsychINFO, CINAHL (via EBSCO), AMED, PROSPERO, Cochrane Airways Trials Register. Reference lists of the relevant studies and grey literature will be searched using Grey Literature Report, Open Grey and Google Scholar search engines. Relevant studies will be systematically reviewed and subject to quality appraisal to determine the impact of behaviour change and physical activity interventions on outcomes of community-dwelling adults with COPD. Interventions will be mapped to Michie’s TDF and a narrative synthesis with respect to nature, effectiveness on target population and setting/environment will be provided. Findings will be reported in relation to the generalisability of the primary results and research question, and will include secondary findings on quality of life, self-reported participation in physical activity, exercise capacity, adverse events and intervention adherence. The review will be presented according to the PRISMA guidelines 2020. Conclusions: This systematic review is necessary to explain the impact of behaviour change and physical activity interventions on outcomes of community dwelling people with COPD. PROSPERO registration: CRD42021264965 (29.06.2021)

Nursing Research on Patients with Chronic Obstructive Pulmonary Disease and Respiratory Failure Based on Big Data

This work organically integrates a systematic and individualized nursing plan with big data technology and applies it to the care of patients with chronic obstructive pulmonary disease (COPD) and respiratory failure (RF) and explores the continuous care model based on modern big data technologies to improve COPD and RF. It aims to relieve the symptoms of COPD and RF, reduce the number of acute episodes of COPD and RF and the number of hospitalizations, and improve the quality of life of patients. One hundred COPD and RF patients hospitalized in the respiratory medicine department of a tertiary hospital were selected and were categorized into control and experimental group. The nursing mode of the patients in the control group was the original telephone follow-up in the department, and the contents of the follow-up were determined according to the questions of the patients on the telephone at that time. Based on the original nursing in the department, the experimental group adopted individualized continual nursing plans based on the Internet and big data techniques for patients to conduct a pulmonary rehabilitation-related functional assessment, functional exercise guidance, and health guidance. Experimental results show that, compared with traditional continuous care, individualized continuous care combined with big data techniques can improve the lung function of patients with stable COPD and RF, reduce the number of acute COPD and RF attacks and the number of readmissions, and improve self-management ability and quality of life. The method can be applied and implemented in continuous nursing care.

Exercise Capacity, Ventilatory Response, and Gas Exchange in COPD Patients With Mild to Severe Obstruction Residing at High Altitude

Background

Exercise intolerance, desaturation, and dyspnea are common features in patients with chronic obstructive pulmonary disease (COPD). At altitude, the barometric pressure (BP) decreases, and therefore the inspired oxygen pressure and the partial pressure of arterial oxygen (PaO₂) also decrease in healthy subjects and even more in patients with COPD. Most of the studies evaluating ventilation and arterial blood gas (ABG) during exercise in COPD patients have been conducted at sea level and in small populations of people ascending to high altitudes. Our objective was to compare exercise capacity, gas exchange, ventilatory alterations, and symptoms in COPD patients at the altitude of Bogotá (2,640 m), of all degrees of severity.

Methods

Measurement during a cardiopulmonary exercise test of oxygen consumption (VO₂), minute ventilation (VE), tidal volume (VT), heart rate (HR), ventilatory equivalents of CO₂ (VE/VCO₂), inspiratory capacity (IC), end-tidal carbon dioxide tension (PETCO₂), and ABG. For the comparison of the variables between the control subjects and the patients according to the GOLD stages, the non-parametric Kruskal–Wallis test or the one-way analysis of variance test was used.

Results

Eighty-one controls and 525 patients with COPD aged 67.5 ± 9.1 years were included. Compared with controls, COPD patients had lower VO₂ and VE (p < 0.001) and higher VE/VCO₂ (p = 0.001), A-aPO₂, and V_D/V_T (p < 0.001). In COPD patients, PaO₂ and saturation decreased, and delta IC (p = 0.004) and VT/IC increased (p = 0.002). These alterations were also seen in mild COPD and progressed with increasing severity of the obstruction.

Conclusion

The main findings of this study in COPD patients residing at high altitude were a progressive decrease in exercise capacity, increased dyspnea, dynamic hyperinflation, restrictive mechanical constraints, and gas exchange abnormalities during exercise, across GOLD stages 1–4. In patients with mild COPD, there were also lower exercise capacity and gas exchange alterations, with significant differences from controls. Compared with studies at sea level, because of the lower inspired oxygen pressure and the compensatory increase in ventilation, hypoxemia at rest and during exercise was more severe; PaCO₂ and PETCO₂ were lower; and VE/VO₂ was higher.

The effectiveness of supplemental oxygen during exercise training in patients with chronic obstructive pulmonary disease who show severe exercise-induced desaturation: a protocol for a meta-regression analysis and systematic review

BACKGROUND

Supplemental oxygen during exercise training is used to increase the training effect of an exercise program in patients with chronic obstructive pulmonary disease (COPD) who show exercise-induced desaturation. Exercise-induced desaturation is not clearly defined in the guidelines; however, it is generally defined in clinical studies as a decrease in SpO2 of more than 4% from rest or a decrease to less than 88% during exercise. Although some meta-analyses examined the effectiveness of supplemental oxygen during exercise training, these studies concluded that it does not further improve exercise tolerance compared to exercise training alone. However, supplemental oxygen during exercise training may be effective in improving exercise tolerance in COPD patients with severe exercise-induced desaturation. Therefore, this study will be performed to elucidate the effectiveness of supplemental oxygen during exercise training and the relationship between its effectiveness and severity of exercise-induced desaturation at baseline.

METHODS

We will first assess the effectiveness of supplemental oxygen during exercise training in COPD. The main outcome is the change in exercise tolerance before and after the intervention, indicated by the 6-min walking distance, the walking distance, or the walking time in incremental shuttle walking test, and analyzed as the standardized mean difference (SMD). The quality and risk of bias in individual studies will be assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system and risk-of-bias tool (RoB ver.2). If statistical heterogeneity in terms of the effectiveness of exercise tolerance is shown, we will conduct meta-regression analyses to examine the association between the effectiveness of exercise training with supplemental oxygen and severity of exercise-induced desaturation at baseline.

DISCUSSION

One strength of this study is that it is a systematic review with meta-regression analysis to elucidate the effectiveness of supplemental oxygen during exercise training in patients with COPD who show severe exercise-induced desaturation. Furthermore, we will assess the severity of exercise-induced desaturation for which exercise training with supplemental oxygen is effective, the influence of acute effects at baseline, and the effect of supplemental oxygen on adverse events.

SYSTEMATIC REVIEW REGISTRATION

Registration number, UMIN000039960.

High-Flow Nasal Cannula Therapy for Exertional Dyspnea in Patients with Cancer: A Pilot Randomized Clinical Trial

BACKGROUND

Exertional dyspnea is common in patients with cancer and limits their function. The impact of high-flow nasal cannula on exertional dyspnea in nonhypoxemic patients is unclear. In this double-blind, parallel-group, randomized trial, we assessed the effect of flow rate (high vs. low) and gas (oxygen vs. air) on exertional dyspnea in nonhypoxemic patients with cancer.

PATIENTS AND METHODS

Patients with cancer with oxygen saturation >90% at rest and exertion completed incremental and constant work (80% maximal) cycle ergometry while breathing low-flow air at 2 L/minute. They were then randomized to receive high-flow oxygen, high-flow air, low-flow oxygen, or low-flow air while performing symptom-limited endurance cycle ergometry at 80% maximal. The primary outcome was modified 0-10 Borg dyspnea intensity scale at isotime. Secondary outcomes included dyspnea unpleasantness, exercise time, and adverse events.

RESULTS

Seventy-four patients were enrolled, and 44 completed the study (mean age 63; 41% female). Compared with low-flow air at baseline, dyspnea intensity was significantly lower at isotime with high-flow oxygen (mean change, -1.1; 95% confidence interval [CI], -2.1, -0.12) and low-flow oxygen (-1.83; 95% CI, -2.7, -0.9), but not high-flow air (-0.2; 95% CI, -0.97, 0.6) or low-flow air (-0.5; 95% CI, -1.3, 0.4). Compared with low-flow air, high-flow oxygen also resulted in significantly longer exercise time (difference + 2.5 minutes, p = .009), but not low-flow oxygen (+0.39 minutes, p = .65) or high-flow air (+0.63 minutes, p = .48). The interventions were well tolerated without significant adverse effects.

CONCLUSION

Our preliminary findings support that high-flow oxygen improved both exertional dyspnea and exercise duration in nonhypoxemic patients with cancer. (ClinicalTrials.gov ID: NCT02357134).

IMPLICATIONS FOR PRACTICE

In this four-arm, double-blind, randomized clinical trial examining the role of high-flow nasal cannula on exertional dyspnea in patients with cancer without hypoxemia, high-flow oxygen, but not high-flow air, resulted in significantly lower dyspnea scores and longer exercise time. High-flow oxygen delivered by high-flow nasal cannula devices may improve clinically relevant outcomes even in patients without hypoxemia.

Unanswered questions and future direction in the management of terminal breathlessness in patients with cancer

Breathlessness is among the most common and deteriorating symptoms in patients with advanced cancer, which may worsen towards the end of life. Breathlessness in patients with estimated life expectancy of weeks to days has unique clinical features: it tends to worsen rapidly over days to hours as death approaches often despite current symptom control measures. Breathlessness in patients during the last weeks to days of life can be called ‘terminal breathlessness’. While evidence has accumulated for the management of breathlessness in patients with cancer who are not dying, such evidence may not be fully applied to terminal breathlessness. Only a few studies have investigated the best practice of terminal breathlessness in patients with cancer. In this paper, we summarise the current evidence for the management of terminal breathlessness, and propose future directions of clinical research.

Is Structured Exercise Performed with Supplemental Oxygen a Promising Method of Personalized Medicine in the Therapy of Chronic Diseases?

Aim: This systematic review aimed to explore the literature to identify in which types of chronic diseases exercise with supplemental oxygen has previously been utilized and whether this type of personalized therapy leads to superior effects in physical fitness and well-being. Methods: Databases (PubMed/MEDLINE, CINHAL, EMBASE, Web of knowledge and Cochrane Library) were searched in accordance with PRISMA. Eligibility criteria included adult patients diagnosed with any type of chronic diseases engaging in supervised exercise training with supplemental oxygen compared to normoxia. A random-effects model was used to pool effect sizes by standardized mean differences (SMD). Results: Out of the identified 4038 studies, 12 articles were eligible. Eleven studies were conducted in chronic obstructive pulmonary disease (COPD), while one study included coronary artery disease (CAD) patients. No statistical differences were observed for markers of physical fitness and patient-reported outcomes on well-being between the two training conditions (SMD −0.10; 95% CI −0.27, 0.08; p = 0.26). Conclusions: We found that chronic exercise with supplemental oxygen has mainly been utilized for COPD patients. Moreover, no superior long-term adaptations on physical fitness, functional capacity or patient-reported well-being were found, questioning the role of this method as a personalized medicine approach. Prospero registration: CRD42018104649.

COVID-19: guidance on palliative care from a European Respiratory Society international task force

BACKGROUND

Many people are dying from coronavirus disease 2019 (COVID-19), but consensus guidance on palliative care in COVID-19 is lacking. This new life-threatening disease has put healthcare systems under pressure, with the increased need of palliative care provided to many patients by clinicians who have limited prior experience in this field. Therefore, we aimed to make consensus recommendations for palliative care for patients with COVID-19 using the Convergence of Opinion on Recommendations and Evidence (CORE) process.

METHODS

We invited 90 international experts to complete an online survey including stating their agreement, or not, with 14 potential recommendations. At least 70% agreement on directionality was needed to provide consensus recommendations. If consensus was not achieved on the first round, a second round was conducted.

RESULTS

68 (75.6%) experts responded in the first round. Most participants were experts in palliative care, respiratory medicine or critical care medicine. In the first round, consensus was achieved on 13 recommendations based upon indirect evidence and clinical experience. In the second round, 58 (85.3%) out of 68 of the first-round experts responded, resulting in consensus for the 14th recommendation.

CONCLUSION

This multi-national task force provides consensus recommendations for palliative care for patients with COVID-19 concerning: advance care planning; (pharmacological) palliative treatment of breathlessness; clinician-patient communication; remote clinician-family communication; palliative care involvement in patients with serious COVID-19; spiritual care; psychosocial care; and bereavement care. Future studies are needed to generate empirical evidence for these recommendations.

Short Term Home Oxygen Therapy for COVID-19 patients: The COVID-HOT algorithm

Innovative solutions are required to effectively address the unprecedented surge of demand on our healthcare systems created by the COVID-19 pandemic. Home treatment and monitoring of patients who are asymptomatic or mildly symptomatic can be readily implemented to ameliorate the health system burden while maintaining safety and effectiveness of care. Such endeavor requires careful triage and coordination, telemedicine and technology support, workforce and education, as well as robust infrastructure. In the understandable paucity of evidence-based, protocolized approaches toward HOT for COVID-19 patients, our group has created the current document based on the cumulative experience of members of the Joint ACAIM-WACEM COVID-19 Clinical Management Taskforce. Utilizing available evidence-based resources and extensive front-line experience, the authors have suggested a pragmatic pathway for providing safe and effective home oxygen therapy in the community setting.

Dyspnea in COPD: New Mechanistic Insights and Management Implications

Dyspnea is the most common symptom experienced by patients with chronic obstructive pulmonary disease (COPD). To avoid exertional dyspnea, many patients adopt a sedentary lifestyle which predictably leads to extensive skeletal muscle deconditioning, social isolation, and its negative psychological sequalae. This "dyspnea spiral" is well documented and it is no surprise that alleviation of this distressing symptom has become a key objective highlighted across COPD guidelines. In reality, this important goal is often difficult to achieve, and successful symptom management awaits a clearer understanding of the underlying mechanisms of dyspnea and how these can be therapeutically manipulated for the patients' benefit. Current theoretical constructs of the origins of activity-related dyspnea generally endorse the classical demand-capacity imbalance theory. Thus, it is believed that disruption of the normally harmonious relationship between inspiratory neural drive (IND) to breathe and the simultaneous dynamic response of the respiratory system fundamentally shapes the expression of respiratory discomfort in COPD. Sadly, the symptom of dyspnea cannot be eliminated in patients with advanced COPD with relatively fixed pathophysiological impairment. However, there is evidence that effective symptom palliation is possible for many. Interventions that reduce IND, without compromising alveolar ventilation (VA), or that improve respiratory mechanics and muscle function, or that address the affective dimension, achieve measurable benefits. A common final pathway of dyspnea relief and improved exercise tolerance across the range of therapeutic interventions (bronchodilators, exercise training, ambulatory oxygen, inspiratory muscle training, and opiate medications) is reduced neuromechanical dissociation of the respiratory system. These interventions, singly and in combination, partially restore more harmonious matching of excessive IND to ventilatory output achieved. In this review we propose, on the basis of a thorough review of the recent literature, that effective dyspnea amelioration requires combined interventions and a structured multidisciplinary approach, carefully tailored to meet the specific needs of the individual.

Patient registries for home oxygen research and evaluation

Randomized clinical trials are the preferred study design to address key research questions about the benefits or harms of interventions. However, randomized trials of oxygen therapy are difficult to conduct and have limitations. The purpose of this article is to offer our view on the potential use of patient registries in the field of home oxygen in COPD as an alternative to randomized trials by referring to the Swedish experience with a national registry for respiratory failure. Patient registries use observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure. As opposed to administrative databases, patient registries serve one or more predetermined scientific, clinical, or policy purposes. By systematically and prospectively compiling relevant data, patient registries may describe the natural history of a disease, determine effectiveness and cost-effectiveness, assess safety or harm, and measure quality of care. Registry-based randomized trials (ie, randomized trials within a clinical registry) combine the advantages of a prospective randomized trial with the strengths of a large-scale all-comers clinical registry. Challenges and issues in the design and implementation of patient registries include the representativeness of participants, data collection, quality assurance, ownership, and governance. Notwithstanding their limitations, patient registries represent valuable tools in the conduct of research in the area of home oxygen therapy.

Holistic services for people with advanced disease and chronic or refractory breathlessness: a mixed-methods evidence synthesis

Background

Breathlessness is a common and distressing symptom of many advanced diseases, affecting around 2 million people in the UK. Breathlessness increases with disease progression and often becomes chronic or refractory. Breathlessness-triggered services that integrate holistic assessment and specialist palliative care input as part of a multiprofessional approach have been developed for this group, offering tailored interventions to support self-management and reduce distress.

Objectives

The aim was to synthesise evidence on holistic breathlessness services for people with advanced disease and chronic or refractory breathlessness. The objectives were to describe the structure, organisation and delivery of services, determine clinical effectiveness, cost-effectiveness and acceptability, identify predictors of treatment response, and elicit stakeholders’ evidence-based priorities for clinical practice, policy and research.

Design

The mixed-methods evidence synthesis comprised three components: (1) a systematic review to determine the clinical effectiveness, cost-effectiveness and acceptability of holistic breathlessness services; (2) a secondary analysis of pooled individual data from three trials to determine predictors of clinical response; and (3) a transparent expert consultation (TEC), comprising a stakeholder workshop and an online consensus survey, to identify stakeholders’ priorities.

Results

Thirty-seven papers reporting on 18 holistic breathlessness services were included in the systematic review. Most studies enrolled people with thoracic cancer, were delivered over 4–6 weeks, and included breathing training, relaxation techniques and psychological support. Meta-analysis demonstrated significant reductions in the Numeric Rating Scale (NRS) distress due to breathlessness, significant reductions in the Hospital Anxiety and Depressions Scale (HADS) depression scores, and non-significant reductions in the Chronic Respiratory Disease Questionnaire (CRQ) mastery and HADS anxiety, favouring the intervention. Recipients valued education, self-management interventions, and expertise of the staff in breathlessness and person-centred care. Evidence for cost-effectiveness was limited and inconclusive. The responder analysis (n = 259) revealed baseline CRQ mastery and NRS distress to be strong predictors of the response to breathlessness services assessed by these same measures, and no significant influence from baseline breathlessness intensity, patient diagnosis, lung function, health status, anxiety or depression. The TEC elicited 34 priorities from stakeholders. Seven priorities received high agreement and consensus, reflecting stakeholders’ (n = 74) views that services should be person-centred and multiprofessional, share their breathlessness management skills with others, and recognise the roles and support needs of informal carers.

Limitations

The evidence synthesis draws predominantly from UK services and may not be generalisable to other settings. Some meta-analyses were restricted by reporting biases and statistical heterogeneity.

Conclusions

Despite heterogeneity in composition and delivery, holistic breathlessness services are highly valued by recipients and can lead to significant improvements in the distress caused by breathlessness and depression. Outcomes of improved mastery and reduced distress caused by breathlessness are not influenced by patient diagnosis, lung function or health status. Stakeholders highlighted the need for improved access to person-centred, multiprofessional breathlessness services and support for informal carers.

Future work

Our research suggests that key therapeutic components of holistic breathlessness services be considered in clinical practice and models of delivery and educational strategies to address stakeholders’ priorities tested.

Study registration

This study is registered as PROSPERO CRD42017057508.

Funding

The National Institute for Health Research (NIHR) Health Services and Delivery programme. Matthew Maddocks, Wei Gao and Irene J Higginson are supported by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London; Matthew Maddocks is supported by a NIHR Career Development Fellowship (CDF-2017-009), William D-C Man is supported by the NIHR CLAHRC Northwest London and Irene J Higginson holds a NIHR Emeritus Senior Investigator Award.

REgistry-based randomized controlled trial of treatment and Duration and mortality in long-term OXygen therapy (REDOX) study protocol

OBJECTIVE

Long-term oxygen therapy (LTOT) during 15 h/day or more prolongs survival in patients with chronic obstructive pulmonary disease (COPD) and severe hypoxemia. No randomized controlled trial has evaluated the net effects (benefits or harms) from LTOT 24 h/day compared with 15 h/day or the effect in conditions other than COPD. We describe a multicenter, national, phase IV, non-superiority, registry-based, randomized controlled trial (R-RCT) of LTOT prescribed 24 h/day compared with 15 h/day. The primary endpoint is all-cause-mortality at 1 year. Secondary endpoints include cause-specific mortality, hospitalizations, health-related quality of life, symptoms, and outcomes in interstitial lung disease.

METHODS/DESIGN

Patients qualifying for LTOT are randomized to LTOT 24 h/day versus 15 h/day during 12 months using the Swedish Register for Respiratory Failure (Swedevox). Planned sample size in this pragmatic study is 2126 randomized patients. Clinical follow-up and concurrent treatments are according to routine clinical practice. Mortality, hospitalizations, and incident diseases are assessed using national Swedish registries with expected complete follow-up. Patient-reported outcomes are assessed using postal questionnaire at 3 and 12 months.

DISCUSSION

The R-RCT approach combines the advantages of a prospective randomized trial and large clinical national registries for enrollment, allocation, and data collection, with the aim of improving the evidence-based use of LTOT.

TRIAL REGISTRATION

Clinical Trial registered with www.clinicaltrials.gov , Title: REgistry-based Treatment Duration and Mortality in Long-term OXygen Therapy (REDOX); ID: NCT03441204.

Exercise response to oxygen supplementation is not associated with survival in hypoxemic patients with obstructive lung disease

Purpose

Hypoxemia is associated with more severe lung disease and worse outcomes. In some patients with chronic obstructive lung diseases who desaturate on exertion, supplemental oxygen improves exercise capacity. The clinical significance of this exercise response to oxygen supplementation is not known.

Patients and methods

We identified chronic obstructive lung disease patients at our center who underwent a 6-minute walking test (6MWT) for ambulatory oxygen assessment and who desaturated breathing air and therefore had an additional walk test on supplemental oxygen, between August 2006 and June 2016. Responders were defined as walking ≥26 m further with oxygen. Survival was determined up to February 1, 2017. We compared survival in oxygen responders and nonresponders in patients with obstructive lung diseases.

Results

One hundred and seventy-four patients were included in the study, median age 70 years. Seventy-seven (44.3%) of the patients were oxygen responders. Borg dyspnea score improved by 1.4 (±1.4) units (P<0.0005) on oxygen. Median survival was 66 months with death occurring in 84 (48.2%) patients. Kaplan–Meier analysis revealed no survival difference between both responders and nonresponders (P=0.571). Cox regression analysis showed that more 6MWT desaturation, lower 6-minute walking distance on room air, male gender, lower hemoglobin, and body mass index were associated with higher mortality risk.

Conclusion

Acute exercise response to supplemental oxygen is not associated with long-term survival in patients with obstructive lung disease. This supports the use of ambulatory oxygen treatment for symptomatic purposes only.

Long-term effects of oxygen-enriched high-flow nasal cannula treatment in COPD patients with chronic hypoxemic respiratory failure

BACKGROUND

This study investigated the long-term effects of humidified high-flow nasal cannula (HFNC) in COPD patients with chronic hypoxemic respiratory failure treated with long-term oxygen therapy (LTOT).

PATIENTS AND METHODS

A total of 200 patients were randomized into usual care ± HFNC. At inclusion, acute exacerbation of COPD (AECOPD) and hospital admissions 1 year before inclusion, modified Medical Research Council (mMRC) score, St George's Respiratory Questionnaire (SGRQ), forced expiratory volume in 1 second (FEV1), 6-minute walk test (6MWT) and arterial carbon dioxide (PaCO2) were recorded. Patients completed phone interviews at 1, 3 and 9 months assessing mMRC score and AECOPD since the last contact. At on-site visits (6 and 12 months), mMRC, number of AECOPD since last contact and SGRQ were registered and FEV1, FEV1%, PaCO2 and, at 12 months, 6MWT were reassessed. Hospital admissions during the study period were obtained from hospital records. Hours of the use of HFNC were retrieved from the high-flow device.

RESULTS

The average daily use of HFNC was 6 hours/day. The HFNC group had a lower AECOPD rate (3.12 versus 4.95/patient/year, p<0.001). Modeled hospital admission rates were 0.79 versus 1.39/patient/year for 12- versus 1-month use of HFNC, respectively (p<0.001). The HFNC group had improved mMRC scores from 3 months onward (p<0.001) and improved SGRQ at 6 and 12 months (p=0.002, p=0.033) and PaCO2 (p=0.005) and 6MWT (p=0.005) at 12 months. There was no difference in all-cause mortality.

CONCLUSION

HFNC treatment reduced AECOPD, hospital admissions and symptoms in COPD patients with hypoxic failure.

Highs and lows of hyperoxia: physiological, performance, and clinical aspects

Molecular oxygen (O₂) is a vital element in human survival and plays a major role in a diverse range of biological and physiological processes. Although normobaric hyperoxia can increase arterial oxygen content ([Formula: see text]), it also causes vasoconstriction and hence reduces O₂ delivery in various vascular beds, including the heart, skeletal muscle, and brain. Thus, a seemingly paradoxical situation exists in which the administration of oxygen may place tissues at increased risk of hypoxic stress. Nevertheless, with various degrees of effectiveness, and not without consequences, supplemental oxygen is used clinically in an attempt to correct tissue hypoxia (e.g., brain ischemia, traumatic brain injury, carbon monoxide poisoning, etc.) and chronic hypoxemia (e.g., severe COPD, etc.) and to help with wound healing, necrosis, or reperfusion injuries (e.g., compromised grafts). Hyperoxia has also been used liberally by athletes in a belief that it offers performance-enhancing benefits; such benefits also extend to hypoxemic patients both at rest and during rehabilitation. This review aims to provide a comprehensive overview of the effects of hyperoxia in humans from the "bench to bedside." The first section will focus on the basic physiological principles of partial pressure of arterial O₂, [Formula: see text], and barometric pressure and how these changes lead to variation in regional O₂ delivery. This review provides an overview of the evidence for and against the use of hyperoxia as an aid to enhance physical performance. The final section addresses pathophysiological concepts, clinical studies, and implications for therapy. The potential of O₂ toxicity and future research directions are also considered.

Updates in palliative care - recent advancements in the pharmacological management of symptoms

Symptom management is an important part of both palliative care and end-of-life care. This article will examine the recent research evidence about drugs commonly used for symptom management in adult patients receiving palliative care. In particular, the management of symptoms where recent palliative care-based evidence has changed recommended practice will be reviewed. This includes: breathlessness, delirium, nausea and vomiting in bowel obstruction, opioid-induced constipation and upper respiratory tract secretions. For each symptom, a review of recent pharmacological evidence has been undertaken, with emphasis on potential important changes to physicians' practice.

Which patients with moderate hypoxemia benefit from long-term oxygen therapy? Ways forward

Long-term oxygen therapy (LTOT) improves prognosis in patients with COPD and chronic severe hypoxemia. The efficacy in moderate hypoxemia (tension of arterial oxygen; on air, 7.4−8.0 kPa) was questioned by a recent large trial. We reviewed the evidence to date (five randomized trials; 1,191 participants, all with COPD). Based on the current evidence, the survival time may be improved in patients with moderate hypoxemia with secondary polycythemia or right-sided heart failure, but not in the absence of these signs. Clinically, LTOT is not indicated in moderate hypoxemia except in the few patients with polycythemia or signs of right-sided heart failure, which may reflect more chronic and severe hypoxemia.

The Breathing, Thinking, Functioning clinical model: a proposal to facilitate evidence-based breathlessness management in chronic respiratory disease

Refractory breathlessness is a highly prevalent and distressing symptom in advanced chronic respiratory disease. Its intensity is not reliably predicted by the severity of lung pathology, with unhelpful emotions and behaviours inadvertently exacerbating and perpetuating the problem. Improved symptom management is possible if clinicians choose appropriate non-pharmacological approaches, but these require engagement and commitment from both patients and clinicians. The Breathing Thinking Functioning clinical model is a proposal, developed from current evidence, that has the potential to facilitate effective symptom control, by providing a rationale and focus for treatment.