Adverse Effects, Smoking, Alcohol Consumption and Quality of Life During Long-Term Oxygen Therapy: A Nationwide Study

Pulmonary fibrosis: pathogenesis and therapeutic strategies

Pulmonary fibrosis (PF) is a chronic and progressive lung disease characterized by extensive alterations of cellular fate and function and excessive accumulation of extracellular matrix, leading to lung tissue scarring and impaired respiratory function. Although our understanding of its pathogenesis has increased, effective treatments remain scarce, and fibrotic progression is a major cause of mortality. Recent research has identified various etiological factors, including genetic predispositions, environmental exposures, and lifestyle factors, which contribute to the onset and progression of PF. Nonetheless, the precise mechanisms by which these factors interact to drive fibrosis are not yet fully elucidated. This review thoroughly examines the diverse etiological factors, cellular and molecular mechanisms, and key signaling pathways involved in PF, such as TGF-β, WNT/β-catenin, and PI3K/Akt/mTOR. It also discusses current therapeutic strategies, including antifibrotic agents like pirfenidone and nintedanib, and explores emerging treatments targeting fibrosis and cellular senescence. Emphasizing the need for omni-target approaches to overcome the limitations of current therapies, this review integrates recent findings to enhance our understanding of PF and contribute to the development of more effective prevention and management strategies, ultimately improving patient outcomes.

Long-Term Oxygen Therapy for 24 or 15 Hours per Day in Severe Hypoxemia

BACKGROUND

Long-term oxygen supplementation for at least 15 hours per day prolongs survival among patients with severe hypoxemia. On the basis of a nonrandomized comparison, long-term oxygen therapy has been recommended to be used for 24 hours per day, a more burdensome regimen.

METHODS

To test the hypothesis that long-term oxygen therapy used for 24 hours per day does not result in a lower risk of hospitalization or death at 1 year than therapy for 15 hours per day, we conducted a multicenter, registry-based, randomized, controlled trial involving patients who were starting oxygen therapy for chronic, severe hypoxemia at rest. The patients were randomly assigned to receive long-term oxygen therapy for 24 or 15 hours per day. The primary outcome, assessed in a time-to-event analysis, was a composite of hospitalization or death from any cause within 1 year. Secondary outcomes included the individual components of the primary outcome assessed at 3 and 12 months.

RESULTS

Between May 18, 2018, and April 4, 2022, a total of 241 patients were randomly assigned to receive long-term oxygen therapy for 24 hours per day (117 patients) or 15 hours per day (124 patients). No patient was lost to follow-up. At 12 months, the median patient-reported daily duration of oxygen therapy was 24.0 hours (interquartile range, 21.0 to 24.0) in the 24-hour group and 15.0 hours (interquartile range, 15.0 to 16.0) in the 15-hour group. The risk of hospitalization or death within 1 year in the 24-hour group was not lower than that in the 15-hour group (mean rate, 124.7 and 124.5 events per 100 person-years, respectively; hazard ratio, 0.99; 95% confidence interval [CI], 0.72 to 1.36; 90% CI, 0.76 to 1.29; P = 0.007 for nonsuperiority). The groups did not differ substantially in the incidence of hospitalization for any cause, death from any cause, or adverse events.

CONCLUSIONS

Among patients with severe hypoxemia, long-term oxygen therapy used for 24 hours per day did not result in a lower risk of hospitalization or death within 1 year than therapy for 15 hours per day. (Funded by the Crafoord Foundation and others; REDOX ClinicalTrials.gov number, NCT03441204.).

Association of Lifestyle Behaviors with Quality of Life in Patients with COPD: A Cross-Sectional Study in Primary Care

Background/Objectives: The association between healthy lifestyle behaviors and their effect on quality of life among patients with COPD remains unclear. Therefore, the aim of this study was to explore the lifestyle behaviors and their association with the disease-specific quality of life among a primary care population with COPD in Greece. Methods: This cross-sectional study included 236 participants aged 40 years and older from the COCARE COPD study. The healthy lifestyle index (HLI) was created based on smoking, alcohol consumption, BMI, physical activity, and sleep duration, with each factor categorized as either healthy (1) or unhealthy (0). The HLI ranged from 0 (least healthy) to 5 (healthiest). COPD-specific quality of life was assessed using the COPD assessment test (CAT), where higher scores indicate poorer health status. Multiple logistic regression was used to analyze the association between HLI and CAT scores, adjusting for confounders. Results: Half of the participants were non-smokers or former smokers, while 92% reported consuming low levels of alcohol (less than 14 units per week). Additionally, 56% had a BMI below 30, indicating they were not obese. Surprisingly, only 32% engaged in regular exercise, with at least 150 min per week, and only 25% reported getting adequate sleep, ranging from 7 to 9 h per night. Importantly, poorer health status was inversely associated with non/former smoking (OR: 0.543, 95% CI: 0.282-1.049), physical activity (OR: 0.238, 95% CI: 0.122-0.463), and adequate sleep (OR: 0.337, 95% CI: 0.160-0.710). Patients with higher HLI scores were less likely to have poor health status. Conclusions: In conclusion, our findings indicate that a significant proportion of patients with COPD failed to adhere to a minimum of three out of five healthy behaviors. Additionally, a higher number of healthy lifestyle factors defined by a high HLI score were independently associated with a better disease-specific quality of life. This is particularly important for COPD where quality of life is in the epicenter of management. Therefore, healthcare providers could significantly improve the management of COPD and patient outcomes by targeting and improving these lifestyle behaviors with targeted and holistic intervention strategies.

The benefits and drawbacks of home oxygen therapy for COPD: what's next?

INTRODUCTION

Home oxygen therapy is one of the few interventions that can improve survival in patients with chronic obstructive pulmonary disease (COPD) when administered appropriately, although it may cause side effects and be an unnecessary burden for some patients.

AREAS COVERED

This narrative review summarizes the current literature on the assessment of hypoxemia, different types of home oxygen therapy, potential beneficial and adverse effects, and emerging research on home oxygen therapy in COPD. A literature search was performed using MEDLINE and EMBASE up to January 2024, with additional articles being identified through clinical guidelines.

EXPERT OPINION

Hypoxemia is common in patients with more severe COPD. Long-term oxygen therapy is established to prolong survival in patients with chronic severe resting hypoxemia. Conversely, in the absence of chronic severe resting hypoxemia, home oxygen therapy has an unclear or conflicting evidence base, including for palliation of breathlessness, and is generally not recommended. However, beneficial effects in some patients cannot be precluded. Evidence is emerging on the optimal daily duration of oxygen use, the role of high-flow and auto-titrated oxygen therapy, improved informed decision-making, and telemonitoring. Further research is needed to validate novel oxygen delivery systems and monitoring tools and establish long-term effects of ambulatory oxygen therapy in COPD.

European Respiratory Society clinical practice guideline on symptom management for adults with serious respiratory illness

Respiratory symptoms are ubiquitous and impair health-related quality of life in people with respiratory disease. This European Respiratory Society (ERS) task force aimed to provide recommendations for symptomatic treatment in people with serious respiratory illness. The ERS task force comprised 16 members, including representatives of people with serious respiratory illness and informal caregivers. Seven questions were formulated, six in the PICO (Population, Intervention, Comparison, Outcome) format, which were addressed with full systematic reviews and evidence assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation). One question was addressed narratively. An "evidence-to-decision" framework was used to formulate recommendations. To treat symptoms in people with serious respiratory illness, the task force suggests the use of graded exercise therapy (conditional recommendation, low certainty of evidence); and suggests the use of a multicomponent services, handheld fan and breathing techniques (conditional recommendations, very low certainty of evidence). The task force suggests not to use opioids (conditional recommendation, very low certainty of evidence); and suggests either administering or not administering supplemental oxygen therapy (conditional recommendation, low certainty of evidence). The task force suggests that needs assessment tools may be used as part of a comprehensive needs assessment, but do not replace patient-centred care and shared decision making (conditional recommendation, low certainty of evidence). The low certainty of evidence, modest impact of interventions on patient-centred outcomes, and absence of effective strategies to ameliorate cough highlight the need for new approaches to reduce symptoms and enhance wellbeing for individuals who live with serious respiratory illness.

Supplemental oxygen therapy in chronic obstructive pulmonary disease: is less is more? How much is too much?

PURPOSE OF REVIEW

Currently available evidence supporting the use of supplemental oxygen therapy (SOT) in chronic obstructive pulmonary disease (COPD) is complex, and data on the mortality reduction associated with SOT usage in patients with severe daytime resting hypoxemia have not been updated since the development of other treatments.

RECENT FINDINGS

No reduction in mortality was found when SOT was used in patients with moderate resting daytime, isolated nocturnal, or exercise-induced hypoxemia. However, some of these patients obtain other significant benefits during SOT, including increased exercise endurance, and a mortality reduction is possible in these 'responders'. The adverse effects of long-term oxygen therapy also need to be considered, such as reduced mobility and social stigma. Furthermore, conservative SOT could improve outcomes in the setting of COPD exacerbations compared with higher concentration oxygen regimens. Compared with usual fixed-dose SOT, automated oxygen administration devices might reduce dyspnea during exercise and COPD exacerbations.

SUMMARY

Current recommendations for SOT need to be revised to focus on patients who respond best and benefit most from this therapy. A conservative approach to SOT can reduce side effects compared with higher concentration oxygen regimens, and automated oxygen administration devices may help to optimize SOT.

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.

Perception of Long-Term Oxygen Therapy for Chronic Lung Diseases May Affect Poor Adherence in Korea

BACKGROUND

Long-term oxygen therapy (LTOT) improves the survival of patients with hypoxemia due to chronic respiratory diseases. The clinical outcomes of LTOT are strongly associated with patient adherence. To improve the adherence of patients, physicians have focused on the efficacy of LTOT. However, poor adherence may stem from patients' perceptions of LTOT. Herein we evaluated patients' perceptions of LTOT affecting adherence.

METHODS

We conducted a cross-sectional survey study using descriptive, open, and closed-ended questionnaire. Patients using oxygen therapy (OT) or requiring it but avoiding OT responded to the questionnaires at three university hospitals.

RESULTS

Seventy-nine patients responded to the questionnaires. The number of patients using home and portable OT was 69 (93%) and 37 (46.3%), respectively. Patients with good adherence were 22 (30.1%). Among patients with good adherence, 90.9% used oxygen according to physicians' prescriptions whereas only 37.3% of those with poor adherence followed physicians' prescriptions (p<0.01). The reasons for avoiding using home OT were fear of permanent use (50%), unwanted attention (40%), and lack of symptoms (40%). They avoided portable OT because of unwanted attention (39%), heaviness (31.7%), and lack of symptoms (21.6%).

CONCLUSION

Patients on LTOT had the perception of the misunderstanding the effects of OT and of psychosocial barriers to initiate or use LTOT. Considering these findings, health professionals need to provide effective education on the purpose of LTOT to improve patient adherence to OT and provide sufficient support for the management of psychosocial barriers in patients using LTOT.

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.