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					HOME OXYGEN THERAPY and RESPIRATORY ASSESSMENT SERVICES
Wisia Wedzicha
University College London Chair BTS Oxygen Working Group

HOME OXYGEN THERAPY

• Long term Oxygen Therapy • Ambulatory Oxygen Therapy • Short Burst Oxygen Therapy • Emergency Oxygen Therapy • Travel Oxygen

(%)

LTOT SURVIVAL CURVES

100

Cumulative percent survival

90
80

70
60

COT

50
40 30

NOT

MRC O2
MRC controls

20 10 0
10 20 30 40 50 Time (months) 60 70

NOTT : Ann Intern Med 1980, MRC: Lancet 1981

• Increased survival • Prevention of deterioration of pulmonary hypertension • Reduction in secondary polycythaemia • Neuropsychological improvement • Improved sleep quality • Reduction in cardiac arrhythmias • Reduction in exacerbation and
hospitalisation?

BENEFITS OF LONG TERM OXYGEN THERAPY

INDICATIONS FOR LTOT IN COPD

• PaO2 < 7.3 kPa (55 mmHg) on air when stable • Pao2 7.3-8.0 kPa in the presence of •
(Gorecka et al Thorax 1997)

secondary polycythaemia, nocturnal SaO2 <90%, peripheral oedema, pulmonary hypertension Should not be used if PaO2 > 8 kPa

PURPOSE OF ASSESSMENT FOR LONG TERM OXYGEN THERAPY
RCP guidelines 1999

• Confident clinical diagnosis • Check on optimum medical management • Measurement of arterial blood gases • Evaluation of required oxygen flow
rate

• Record SaO2 on air and oxygen • Check oxygen usage - static and • • • •

PATIENT FOLLOW UP - PURPOSE
ambulatory Check correct location of equipment, appropriate nasal cannulae and masks available Provide contact details for oxygen supplier and respiratory nurse/physiotherapist/technician Reinforce non-smoking Education and support

Palliative Care

• • •

Severe disabling breathlessness End stage chronic lung or heart disease Cancer ASSESSMENTS NOT INDICATED FOR THESE CONDITIONS – PATIENTS WILL NEED AN OXYGEN CONCENTRATOR

• Longer term improvement in quality of life • Improvements in daily activities • Improvements in exercise capacity • Reduction in dyspnoea • Enhanced rehabilitation? • Increases hours of use of long term oxygen
therapy

OBJECTIVES OF AMBULATORY OXYGEN THERAPY

RESPONSES TO OXYGEN DURING EXERCISE
6 5
Dyspnea (Borg Scale)
35

O2

F (breaths/min)

RA

RA

30 25 20 15 10

O2

4 3 2 1

*

**
Exercise time (min)

isotime
0 0 2 4 6 8 10

O’Donnell D et al. AJRCCM (2001)

Exercise time (min) *p<0.05, **p<0.01 difference at isotime

PLACEBO EFFECTS OF AMBULATORY OXYGEN
Lock S et al Portable oxygen therapy : assessment and usage Respiratory Medicine 1991;85:407-12

% change 6 min walk

20 18 16 14 12 10 8 6 4 2 0 Baseline Air Cylinder Oxygen cylinder

Mean PaO2 56 mmHg

LIQUID AND GASEOUE OXYGEN FOR PORTABLE DOMICILIARY USE
S Lock et al Thorax 1992; 47: 98-100

Total hours of use
25 20 15

Outdoor use
20

15

10
10 5 0 Cylinders Liquid

5

0 Cylinders Liquid

RCT of AMBULATORY OXYGEN THERAPY
Lacasse et al ERJ 2005

Poor ambulatory oxygen use 7.5 cylinders/3months in oxygen group and 7.4 cylinders in placebo group

Patients went out for about 2 hours/day and 3 times more Often without oxygen

Data from the London COPD Study

8

10

P=0.004
6 0 2 4

0 NONo No

Long Term Oxygen Therapy

Yes

1

HOUSEBOUND PATIENTS in EAST LONDON ON LTOT

• Only 55% of patients able to go

of the home • 23% of patients were over age 75 47% only able to go out of home Used less daily oxygen than older patients

out

• GRADE 1 OXYGEN REQUIREMENTS LTOT patients with low activity

AMBULATORY OXYGEN THERAPYPATIENT GRADING

• GRADE 2 OXYGEN REQUIREMENTS • GRADE 3 OXYGEN REQUIREMENTS patients with exercise desaturation but not on LTOT

Mobile LTOT patients

Ambulatory oxygen equipment available
• Small portable cylinders
 429l, weighs 3.4kg, lasts 3.5 hrs at 2l/min

• ‘Lightweight cylinders’ • Liquid oxygen cylinders
 -240°F, lasts 8hrs at 2l/min  Lasts 10.5 hours at 2 l/min with conserver

• Oxygen conserving devices (3.6kg)

Comparison of continuous v PDOD
(Garrod et al Thorax 1999)

AMBULATORY OXYGEN THERAPYPATIENT ASSESSMENT

• • •

GRADE 1 OXYGEN REQUIREMENTS - Same
flow rate as for static source GRADE 2 OXYGEN REQUIREMENTS - Evaluate

oxygen flow rate to correct Exercise SaO2 above 90% using exercise test eg 6 minute walk GRADE 3 OXYGEN REQUIREMENTS - Exercise
test required, performed on air and oxygen. Require evidence of exercise desaturation and

improvement with oxygen

 Short-term response to an exercise test is an  The assessment should be used as an

PURPOSE OF ASSESSMENT FOR AMBULATORY OXYGEN

imperfect predictor of improved quality of life or continued concordance with oxygen usage.
opportunity to make an initial assessment, set flow rate and introduce patient to the device. after pulmonary rehabilitation.

 The assessment should ideally be performed  The initial assessment should be followed in
grades 2&3 by a review after two months when the true value of ambulatory oxygen can be judged by interview and oxygen usage. Ambulatory oxygen should be withdrawn if unhelpful.

WALKI NG TESTS FOR ASSESSMENTS

• • • •

Trained health care professionals 6 minute or shuttle tests

Practice walks required Ideally perform on same equipment as patient will use

• May need to repeat with higher flow rates • Measure oximetry during walk and on
oxygen

Considerations
• • • • • • Time Space Ease of Test Number of Staff the Test Involves Type of Test Being Used Physical Limitation of Patients

Assessing Usage
• Walking testing does not predict long term usage or QOL • People need time to learn how to use oxygen • Pulmonary rehabilitation may increase exercise capacity

Determining Actual Usage
• At two months – Assess by interview/diary – Oxygen usage (information from contractor) – Increase / decrease hours per day – Withdraw if unhelpful

SHORT BURST OXYGEN THERAPY

• Pre-Oxygenation before exercise • Recovery from exercise • Breathlessness at rest • Palliative care
ASSESSMENT - No specific methodology

Borg score for breathlessness before and after exercise in (A) patients breathing oxygen (open symbols) or air (solid symbols)
Stevenson, N J, Calverley PMA Thorax 2004;59:668-672

With nose clip

With face mask

Copyright ©2004 BMJ Publishing Group Ltd.

SHORT BURST OXYGEN THERAPY who has it at home?

• • • •

Hypoxaemic patients - should be on LTOT Non-hypoxaemic patients - either exercise desaturators or non-desaturators

Palliative use
Heart failure


				
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