Long term domiciliary oxygen therapy in chronic obstructive pulmonary disease

Effectiveness and Safety of Supervised Home-Based Physical Training in Patients With COPD on Long-term Home Oxygen Therapy: A Randomized Trial

BACKGROUND

Patients with COPD in advanced stages who need long-term home oxygen therapy (LTHOT) have difficulty participating in outpatient pulmonary rehabilitation (PR) programs. This difficulty is due to the severity of their disease, limitations involving transportation and mobility, high costs, and issues related to patients' safety and individual needs. Unsupervised home-based physical training (PT) is frequently used.

RESEARCH QUESTION

The main objective of this study was to investigate the effectiveness of a supervised home-based PT program on exercise capacity and other outcomes in patients with COPD receiving LTHOT.

STUDY DESIGN AND METHODS

In a randomized clinical trial, patients with COPD who were on LTHOT were allocated into two groups: the supervised physical training (PT) group, consisting of patients who received home-based supervised muscle strength and endurance training in twice-weekly 60-min sessions for 12 weeks; and the unsupervised activity booklet group, consisting of patients who received a booklet advising them to perform exercise twice a week for 12 weeks. All participants were assessed prior to and following the intervention in terms of exercise capacity (6-min step-test and the 1-min sit-to-stand test); dyspnea (Medical Research Council scale); fatigue (Brazilian Portuguese version of the Fatigue Severity Scale); and health status (COPD Assessment Test).

RESULTS

A total of 44 patients were assessed (mean age, 70 ± 8 years; FEV₁, 33 ± 14% predicted) (PT group, n = 22; booklet group, n = 22). Only the PT group patients presented significant improvement in the 6-min step-test (21 ± 9 vs 14 ± 11; P = .001), Medical Research Council scale (3.3 ± 1.0 vs 3.9 ± 0.9; P = .013), Brazilian Portuguese version of the Fatigue Severity Scale (5.0 ± 1.4 vs 5.2 ± 1.3; P = .015), and COPD Assessment Test (21 ± 8 vs 26 ± 6; P = .001). No adverse effects were observed.

INTERPRETATION

Supervised home-based PT was effective and safe in improving exercise capacity, dyspnea, fatigue, and health status in patients with COPD on LTHOT.

CLINICAL TRIAL REGISTRATION

Brazilian Registry of Clinical Trials; No.: RBR-535smn; URL: http://www.ensaiosclinicos.gov.br.

Impact of a hospital-based home-care program on the management of COPD patients receiving long-term oxygen therapy

STUDY OBJECTIVES

To analyze the influence of a hospital-based home-care program (HCP) on the management of patients with COPD receiving long-term oxygen therapy.

DESIGN AND SETTING

Randomized, controlled study in a 1,000-bed university hospital.

INTERVENTION

The HCP applied to patients in the intervention group (HCP group) consisted of a monthly telephone call, home visits every 3 months, and home or hospital visits on a demand basis. Patients in the control group were given conventional medical care.

MEASUREMENTS

Pulmonary function data, gas exchange, use of hospital resources (emergency department visits, admissions, and hospital stay) and the cost of medical assistance were investigated in both groups before and after 1 year of study. Quality of life was analyzed using the chronic respiratory questionnaire in the first 40 consecutive patients included in the study. Survival throughout the study was also assessed.

RESULTS

One hundred twenty-two patients were enrolled in the study, and 94 patients (46 in the HCP group and 48 in the control group) completed the 1-year follow-up period: 83 patients (88%) were men, and mean (+/- SD) age was 68 +/- 8 years. During the follow-up period, there was a highly significant decrease in the mean number of emergency department visits (0.45 +/- 0.83 vs 1.58 +/- 1.96; p = 0.0001) and also a significant decrease in hospital admissions (0.5 +/- 0.86 vs 1.29 +/- 1.7; p = 0.001) and days of hospital stay (7.43 +/- 15.6 vs 18.2 +/- 24.5; p = 0.01) in the HCP group. Patients in the intervention group required a total of 221 home visits (mean per patient, 4.8 +/- 0.8) and 69 hospital visits (mean per patient, 1.5 +/- 1.07). In spite of the cost of the program, cost analysis showed a total saving of 8.1 million pesetas ($46,823) in the HCP group, mainly due to a decrease in the use of hospital resources. There was no difference in pulmonary function, gas exchange, quality of life, and survival between the two groups.

CONCLUSIONS

Hospital-based home care is an effective alternative to hospital admission. It reduces the use of hospital resources and the cost of health care.

Do patients using long-term liquid oxygen differ from those on traditional treatment with oxygen concentrators and/or compressed gas cylinders? A comparison of two national registers

Long-term oxygen therapy (LTOT) in patients with chronic hypoxaemia is an expanding field. Traditional stationary oxygen, with and without portable compressed gas cylinders, and portable liquid oxygen equipment is available today. No official guidelines exist for the prescription of liquid oxygen vs traditional oxygen supply in LTOT, although it is generally though that patients receiving liquid oxygen are younger and less seriously affected. The authors tested this hypothesis by comparing register data from two national Scandinavian registers of patients on LTOT in the same time period; one including all the patients on traditional oxygen treatment alone, e.g. concentrators and compressed gas cylinders (n = 1039), the other including all the patients using portable liquid oxygen alone (n = 117). About 80% of the patients in both groups suffered from chrome obstructive pulmonary disease. Younger patients were found in the liquid oxygen group (P < 0.004), but with clinically slightly worse blood gas derangement (mostly statistically significant). They had higher frequency of previous or present oedema (P < 0.0001), and there were more smokers in this group (P < 0.0001). No significant differences were seen with respect to sex distribution or oxygen delivery systems. Higher oxygen dose and longer daily oxygen treatment (P < 0.0001) were prescribed for the liquid oxygen patients compared with the patients on traditional oxygen with statistically higher oxygen tension during the prescribed treatment. A slight further increase in PaCO2 was seen in both groups during oxygen treatment, of doubtful significance. Compared with patients on traditional oxygen, liquid oxygen thus appears to be prescribed for younger patients, independent of clinical status or blood gas levels.

[Continuous domiciliary oxygen therapy in Zaragoza: a cross-sectional home study]

To assess use of long-term domiciliary oxygen therapy (LDOT) in Saragossa by means of home interviews. We conducted a cross-sectional study of patients undergoing LDOT, interviewing 312 of the 614 patients who used O2 at home in January 1993 (103/100,000 h). Health care workers visited the patients at home and collected all available information related to indications, pattern of use of O2 and complementary tests done. The interviewer also took spirometric readings, SaO2 readings breathing room air and after 30 min breathing O2, and administered a quality of life questionnaire (only to patients with pneumopathies). All patients selected were assessed; 195 (62.5%) suffered from chronic obstructive pulmonary disease (COPD), 33 (10.6%) from asthma, 31 (9.9%) from other pneumopathies, and 53 (17%) from a variety of conditions that were not primarily bronchopulmonary. Thirty-six (11.5%) were active smokers. Only 101 of the 184 patients for whom arterial gasometric readings were available met the criteria for prescribing LDOT. SaO2 without O2 was > or = 92% in 89 (28.5%) patients and > or = 90% in 193 (61.8%). Only 96 (31%) patients reported using O2 more than 15 hours/day and there was a weak inverse relation (p = 0.04) between hours of use and FEV1 in the COPD group. Quality of life for patients with pneumophaties depended entirely on degree of lung function deterioration and was unrelated to use of O2. The rate of use of LDOT Saragossa is one of the highest in Spain. In an estimated 28.5-46% of cases, the indications are inappropriate, mainly due to infrequent use of arterial gas measurement and the prescription of LDOT for patients without COPD. This situation largely explains why patients hardly ever use LDOT on a daily basis.

Review of the prescription of domiciliary long term oxygen therapy in Scotland

BACKGROUND

Since 1989 long term oxygen therapy (LTOT) in Scotland has been prescribable only by respiratory physicians, whereas in England and Wales general practitioners can also prescribe this treatment. The effect of this policy has been audited.

METHOD

Six hundred and thirty patients were prescribed LTOT in Scotland between 1 October 1989 and 30 September 1991, of which 519 case notes were reviewed.

RESULTS

In 79% of patients the diagnosis was chronic obstructive pulmonary disease (COPD), with a near equal male to female ratio. The mean (SD) age was 65 (13) years (range 0.2-90). Sixty percent of patients died during the study period. Compliance with treatment was 14.9 (6.0) hours daily (range 1-24) and in 44% was less than 15 hours daily. Sixty one percent were clinically unstable when assessed and 14% were still smoking. Only 14% of those with COPD fulfilled all of the relative criteria for the prescription of LTOT. Only 56% had a repeated arterial blood gas measurement within 12 months of prescription and 51% of these were taken during a period of clinical instability. Expenditure on oxygen cylinders was six times greater than on oxygen concentrators over this period.

CONCLUSIONS

Compliance with LTOT in Scotland, where prescription is the responsibility of respiratory physicians, is similar to other studies and ranges widely. The greatest problem concerning adherence to the guidelines is assessment during clinical instability. The number of deaths suggest that prescription occurs late in the course of the disease. This study highlights the areas where the prescription of LTOT needs to be improved.

Palliation in chronic respiratory disease

Prognosis in severe chronic obstructive pulmonary disease is poor, and it is increasingly accepted that such patients need good palliative care. This paper reviews the medical management of chronic obstructive pulmonary disease, and also discusses the place of long-term oxygen therapy. A multidisciplinary programme termed 'pulmonary rehabilitation' is being used increasingly, and, although this probably does not improve survival, there is evidence that it increases quality of life. The drug treatment of dyspnoea has been disappointing, but close attention to psychosocial aspects can improve mobility and control. The place of palliation in a number of other chronic lung conditions is also mentioned.