COPD Patients' Experience of Long-Term Domestic Oxygen-Enriched Nasal High Flow Treatment: A Qualitative Study

Thoracic Society of Australia and New Zealand clinical practice guideline on adult home oxygen therapy

This Thoracic Society of Australia and New Zealand Guideline on the provision of home oxygen therapy in adults updates a previous Guideline from 2015. The Guideline is based upon a systematic review and meta-analysis of literature to September 2022 and the strength of recommendations is based on GRADE methodology. Long-term oxygen therapy (LTOT) is recommended for its mortality benefit for patients with COPD and other chronic respiratory diseases who have consistent evidence of significant hypoxaemia at rest (PaO2 ≤ 55 mm Hg or PaO2 ≤59 mm Hg in the presence of hypoxaemic sequalae) while in a stable state. Evidence does not support the use of LTOT for patients with COPD who have moderate hypoxaemia or isolated nocturnal hypoxaemia. In the absence of hypoxaemia, there is no evidence that oxygen provides greater palliation of breathlessness than air. Evidence does not support the use of supplemental oxygen therapy during pulmonary rehabilitation in those with COPD and exertional desaturation but normal resting arterial blood gases. Both positive and negative effects of LTOT have been described, including on quality of life. Education about how and when to use oxygen therapy in order to maximize its benefits, including the use of different delivery devices, expectations and limitations of therapy and information about hazards and risks associated with its use are key when embarking upon this treatment.

Effectiveness, Adherence and Safety of Home High Flow Nasal Cannula in Chronic Respiratory Disease and Respiratory Insufficiency: A Systematic Review

INTRODUCTION

The effectiveness of home high flow nasal cannula (HFNC) for the treatment of chronic respiratory failure in patients with chronic respiratory diseases (CRDs) has not been summarized. We aimed to conduct a systematic review of the effectiveness, adherence, and safety of HFNC in the long-term treatment of patients with chronic respiratory diseases and respiratory failure.

METHODS

A systematic review was conducted. PubMed, Web of science, and SCOPUS were search up to August 2023. Long-term HFNC studies (≥4 weeks) reporting dyspnea; exacerbations, hospitalizations; peripheral oxygen saturation (SpO2), comfort; patient experience, health-related quality of life or partial pressure of carbon dioxide (paCO2) were included.

RESULTS

Thirteen articles (701 patients) based on 10 studies were selected: randomized control trials (n=3), randomized crossover trials (n=2), crossover (n=3) and retrospective (n=2) studies. COPD (n=6), bronchiectasis (n=2), COPD/bronchiectasis (n=1) and ILD (n=1) were the underlined CRDs. HFNC reduced exacerbations when compared to usual care/home respiratory therapies (n=6). Quality of life outcomes were also in favor of HFNC in patients with COPD and bronchiectasis (n=6). HFNC had significant effects on hospitalizations, paCO2, and lung function. Adherence ranged from 5.2 to 8.6h/day (n=5). Three studies reported no events, 3 non-serious events and 2 no differences compared with other home respiratory therapies.

CONCLUSIONS

HFNC seems more effective than usual care or other home respiratory therapies in reducing exacerbations and improving quality of life in patients with COPD and bronchiectasis, while presenting good adherence and being safe. Its apparently superior effectiveness needs to be better studied in future real-world pragmatic trials.

Home-based respiratory support

This review provides an overview of home-based respiratory support modalities for patients with chronic lung diseases. It discusses the increasing use of long-term high-flow nasal cannula (LT-HFNC) and long-term non-invasive ventilation (LT-NIV) and their potential to enhance patient quality of life. This review addresses various types of respiratory failure and their respective treatments, emphasising the significance of monitoring and telemedicine in home care. This comprehensive review underscores the clinical relevance of these interventions in the management of chronic lung diseases.

Effects of long-term oxygen therapy on the mental state of patients with chronic obstructive pulmonary disease: A systematic review

OBJECTIVES

This systematic review aimed to examine the effects of long-term oxygen therapy on the mental state of patients with chronic obstructive pulmonary disease.

METHODS

Web of Science, Medline, CINAHL, EMBASE, ProQuest, and Cochrane Library were selected to search for relevant studies. We followed the Cochrane Handbook for Systematic Reviews of Interventions, adopted the Cochrane risk-of-bias tool and Risk Of Bias In Non-randomized Studies of Interventions tool, and synthesized the outcomes narratively with Grading of Recommendations, Assessment, Development and Evaluations evidence profile.

RESULTS

Six studies were included. Moderate quality of evidence supported no effects of long-term oxygen therapy on the mental state in patients with severe resting hypoxemia and moderate resting hypoxemia (or exertional desaturation) at follow-up of 6 to 12 months; however, adverse effects on mental state among patients with moderate resting or exertional desaturation were reported at the follow-up of 36 to 48 months.

DISCUSSION

Nurses should focus on the mental state of patients treated with long-term oxygen therapy, especially those who use it for a prolonged time. Due to ethical constraints in this study, a quasi-experimental study with faithful consideration of internal validity can be commenced in the future.

A Real-Life Study of Combined Treatment with Long-Term Non-Invasive Ventilation and High Flow Nasal Cannula in Patients with End-Stage Chronic Obstructive Lung Disease

Patients with end-stage chronic obstructive pulmonary disease (COPD) often develop persistent hypoxic or hypercapnic respiratory failure, or a combination of both. Ventilatory support, in terms of a long-term high-flow nasal cannula (LT-HFNC) and long-term non-invasive ventilation (LT-NIV), may be indicated. Often, clinicians choose either one or the other. This paper explores combined treatment with LT-HFNC and LT-NIV in a real-life setting. In total, 33 patients with COPD and persistent respiratory failure were included in this study. Of those, 17 were initiated on LT-HFNC and used it for 595 (374) days and 16 were initiated on LT-NIV and used it for 558 (479) days. On average, patients used respiratory support continuously for 908 (586) days. Baseline characteristics were comparable, apart from PaCO₂ at first ventilatory support initiation (LT-HFNC/LT-NIV 7.1 (1.1) kPa/8.8 (0.9) kPa respectively (p = 0.002)). Both groups experienced a reduction in hospitalizations in the first twelve months after treatment initiation, compared to the twelve months before (LT-HFNC p = 0.022 and LT-NIV p = 0.014). In total, 25% of LT-NIV patients stopped treatment after HFNC initiation due to intolerance and 59% stopped LT-HFNC treatment 126 (36) days after LT-NIV initiation as monotherapy was sufficient. In 44% of these patients, LT-HFNC was re-initiated at the end of life. At the time of analysis, 70% of patients had died. In the last three months of life, patients stopped using LT-NIV, whereas 91% used LT-HFNC. In conclusion, the combined use of LT-NIV and LT-HFNC reduced hospitalizations in patients with COPD and persistent respiratory failure. The study indicates that LT-HFNC is well tolerated, and better tolerated than LT-NIV at the very end stages of COPD.

Nocturnal nasal high-flow oxygen therapy in elderly patients with concomitant chronic obstructive pulmonary disease and obstructive sleep apnea

PURPOSE

The coexistence of obstructive sleep apnea (OSA) and chronic obstructive pulmonary disease (COPD) is known as "overlap syndrome" (OS). Patients with OS are usually older than patients with OSA alone, suffer from more profound oxygen desaturation during the obstructive events often accompanied by sustained nocturnal hypoventilation. Although oxygen-enriched positive airway pressure (PAP) is the treatment of choice in these patients, this therapy is often poorly tolerated particularly by the elderly. The aim of this study was to assess the usefulness of nocturnal oxygen therapy via nasal high flow (NHF-OT) as a possible alternative to PAP in patients with OS.

METHODS

Patients > 65 years old with OS and nocturnal respiratory failure (time spent below SaO2 90% (T90) > 30%) had cardio-respiratory monitoring performed at baseline, during NHF-OT, or during conventional oxygen therapy (COT).

RESULTS

A total of 40 patients were enrolled in the study. NHF-OT significantly reduced the apnea-hypopnea index (AHI) in all patients compared to baseline and COT. The mean basal AHI was 25.4 ± 8.6. During COT and NHF-OT, the AHI was 19.4 ± 7 and 5.4 ± 4.6, respectively (P < 0.001) and 19 patients reached an AHI < 5 during NHF-OT. The mean nocturnal SaO2% was 86.2 ± 2.6 at baseline and at equivalent FiO2 it significantly increased to 91.8 ± 2.4 during COT and to 93.9 ± 2.5 during NHF-OT (P < 0.001). The T90% was 48.7 ± 20.1 at baseline, 16.8 ± 11.7 during COT, and 8.8 ± 8.0 during NHF-OT (P < 0.001).

CONCLUSIONS

In elderly patients with OS, nocturnal treatment with NHF-OT significantly reduces obstructive episodes and improves oxygenation. As the treatment is generally well tolerated compared to PAP, NHF-OT may be a possible alternative therapy in this subgroup of patients.

Cost-Effectiveness of Humidified High-Flow Therapy (HHFT) for COPD Patients on Long-Term Oxygen Therapy

Purpose

Chronic obstructive pulmonary disease (COPD) is the third leading cause of mortality, and is associated with significant respiratory impairment, decreased quality of life, and high health care costs. Recent evidence indicates significant clinical benefit results from adding humidified high-flow therapy (HHFT) to standard long-term oxygen therapy (LTOT) as a home-based therapy in persons with severe COPD. The objective was to evaluate the cost-effectiveness of adding HHFT to standard treatment of COPD patients using LTOT with US healthcare cost estimates.

Patients and Methods

A Markov state-transition model was developed using data from a prospective clinical trial of adding HHFT to standard therapy for persons with severe COPD using LTOT. The analysis was conducted from the US health care system perspective using a 5-year time horizon and 3% discount rate. QALYs and downstream healthcare costs were modeled. One-way and probabilistic sensitivity analyses were used to examine the impact of input parameters on the incremental net monetary benefit (NMB).

Results

Incremental QALYs accrued were 0.058 (2.047 vs 1.989 QALYs for HHFT and standard therapy groups respectively). Incremental total costs were -$3939 ($47,516 vs $51,455 for HHFT and standard therapy groups respectively). Thus, HHFT was the dominant treatment in the analysis, resulting on both better health and lower total costs. Varying utility and cost inputs individually never resulted in NMB approaching 0. Probabilistic analyses indicate that HHFT is cost-effective in 84% of simulations.

Conclusion

Our results indicate that the reductions in acute exacerbations of COPD (AECOPDs) that result from adding HHFT for persons with COPD on LTOT will produce both health benefit (QALYs) and cost savings. Cost savings occur because the HHFT device costs are more than offset by reductions in costly COPD exacerbations. Health care systems and payors can benefit from wider implementation of HHFT with existing treatments.

The Danish respiratory society guideline for long-term high flow nasal cannula treatment, with or without supplementary oxygen

Introduction

Long-term High Flow Nasal Cannula (LT-HFNC), defined as High Flow Nasal Cannula treatment provided to patients with chronic pulmonary conditions during stable phases, has emerged as a home treatment in different categories of patients with chronic lung diseases in recent years.

Methods

This paper summarizes the physiological effects of LT-HFNC and evaluates the clinical knowledge to date about treatment in patients with chronic obstructive lung disease, interstitial lung disease and bronchiectasis. The guideline is translated and summarized in this paper and presented unabridged as an appendix to the paper.

Results

The paper describes the working process behind the Danish Respiratory Society's National guideline for treatment of stable disease, which has been written to support clinicians in both evidence-based decision making and practical issues concerning the treatment.

High flow nasal cannula therapy in the pediatric home setting

BACKGROUND

High-flow nasal cannula (HFNC) therapy may be better tolerated than traditional noninvasive ventilation (NIV) and is rapidly gaining acceptance in pediatric acute care. In Israel, HFNC is approved for domestic use. We aim to describe its indications, efficacy, parental satisfaction, and safety.

METHODS

Retrospective study of children treated with home HFNC therapy in three pediatric centers. Data included demographic parameters, indication of use, weight and days of hospitalization before and after initiation. Safety, tolerability, and parental satisfaction were assessed via standardized telephone questionnaire.

RESULTS

Median (interquartile range [IQR]) age of initiating home HFNC in 75 children was 8.3 (2.2, 29.6) months. Indications were obstructive sleep apnea (33; 44%), airway malacia (19; 25%), chronic lung disease (15; 20%), neuromuscular disease (4; 5%), and postextubation support (4; 5%). Weight standard deviation score rose from -2.3 pre-HFNC to -1.7 at 6.7 months post-HFNC initiation, p < 0.001. Hospital admission days during the 2 months pre- versus post-HFNC initiation were 22 (5.5, 60) and 5 (0, 14.7) respectively, p < 0.008. Median (IQR) parental satisfaction score was 5/5 (4, 5). Fifty of 60 (83%) respondents would recommend home HFNC to other families in a similar situation. There were no serious adverse events.

CONCLUSION

In our population, domestic HFNC appeared safe and well tolerated for a variety of indications. Its introduction was associated with improved weight gain, fewer hospitalization days and high parental satisfaction. Further work is required to characterize groups of children most likely to benefit from HFNC, as opposed to traditional modes of NIV.

IPF Respiratory Symptoms Management - Current Evidence

Idiopathic pulmonary fibrosis (IPF) is a progressive, chronic disease of the lungs which is characterized by heavy symptom burden, especially in the last year of life. Despite recently established anti-fibrotic treatment IPF prognosis is one of the worst among interstitial lung diseases. In this review available evidence regarding pharmacological and non-pharmacological management of the main IPF symptoms, dyspnea and cough, is presented.

Experiences in elderly people with chronic obstructive pulmonary disease in relation to the use of long-term home oxygen therapy: a qualitative study about feelings attributed to therapy

Background

Elderly people are more likely to suffer severe chronic obstructive pulmonary disease (COPD) and require long-term home oxygen therapy (LTOT) as part of their treatment. LTOT has advantages such as improvement in symptoms, but there are also disadvantages such as physical barriers, psychosocial barriers and emotional challenges. The aim of this study is to understand the experiences of elderly people with COPD using LTOT with respect to their feelings attributed to therapy.

Methods

Qualitative study. Seven semidirected interviews were conducted with patients with a confirmed COPD diagnosis who used LTOT and were treated at an outpatient service. The content analysis technique was applied with the support of WebQDA software 2.0.

Results

Three categories emerged that were associated with the use of LTOT: (1) poor self-image; (2) feelings of sadness and (3) the impact of LTOT on others such as family and friends.

Conclusions

LTOT in elderly people with COPD was associated with a poor self-image, feelings of sadness and impacted on others apart from the patient. When LTOT is prescribed, healthcare practitioners should proactively address these concerns to minimise the negative biopsychosocial experiences caused by LTOT.

The effect of domiciliary high flow nasal cannula treatment on dyspnea and walking distance in patients with interstitial lung disease - A pilot study

INTRODUCTION

Interstitial Lung Diseases (ILD) affect the lung parenchyma and are often complicated by respiratory failure (RF) and impaired physical activity. High Flow Nasal Cannula (HFNC) has proved effective in other disease entities with RF. The aim of this study is to investigate the effect of domiciliary HFNC in ILD on dyspnea and walking distance.

METHODS

A 6 weeks cross-over study with domiciliary HFNC-treatment/6 weeks' observation in ILD-patients requiring ambulatory oxygen therapy or with newly prescribed (within 12 months) long term oxygen therapy. Patients were advised to use HFNC 8 h/day, recommended night-time use. Body phletysmography; 6-min walk test (6MWT) including BORG-score, oxygen saturation (SO2) at start, minimum SO2 and time to recovery after 6MWT; arterial blood gasses; modified Medical Research Council (mMRC)-score; quality of life, by the St George Respiratory Questionnaire (SGRQ) and QoS, by the Richards-Campbell Sleep Questionnaire (RCSQ) were investigated at baseline; six weeks and 12 weeks.

RESULTS

10 patients were included; one later withdrew consent. Patients used HFNC between 8-<1 h/day. There were no differences in lung function; blood gasses; SGRQ or RCSQ over the observational period). Walking distance improved significantly (393-441 m p = 0.049) as did time to recovery (3.4-2-2 min, p = 0.001). When correcting for HFNC use (hours/day) significant improvement was also seen in mMRC-score (p = 0.035) and minimum saturation during 6MWT (p = 0.01).

CONCLUSION

Despite a very heterogenous group and no effect on quality of life and -sleep, the study indicates an improvement in dyspnea and physical ability of HFNC in ILD patients.

Patients' Perspective on Automated Oxygen Administration during Hospitalization for Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Qualitative Study Nested in a Randomized Controlled Trial

Recently, health technology systems offering monitoring of the peripheral oxygen saturation level and automated oxygen administration (AOA) have emerged. AOA has been shown to reduce duration of hypoxemia and the length of hospital stay, but the patients' perspective on AOA has not been investigated. This qualitative study, based on the interpretive description methodology, aimed to explore how patients hospitalized with exacerbation of chronic obstructive pulmonary disease (COPD) experience being treated with AOA. Eighteen patients treated with AOA were included in the study. Data was collected during admission or in the patients' homes using semi-structured interviews focusing on patients' experiences of AOA using the word "robot" as used by patients. The findings revealed two themes "adaptation of behavior to the robot" and "robots can make patients feel safe but not cared for" and six subthemes. Our findings illustrate how patients were willing to compromise their own therapy and thereby safety by avoiding behavior triggering AOA alarms and disturbing their fellow patients and the health care professionals. Adherence, defined as patients' consistency in taking their medications as prescribed, becomes an important point of attention for health professionals when applying individualized robotic therapies such as AOA to patients with COPD. To support patients in the process of managing adherence to therapeutic technology, we propose a person-centered care approach that, through education and communication with the patients, generates an understanding of how they can self-manage AOA and its alarms without activating avoiding behavior that threatens their treatment and recovery.