Portable oxygen concentrators versus oxygen cylinder during walking in interstitial lung disease: A randomized crossover trial

Health and Economic Impact of Different Long-Term Oxygen Therapeutic Strategies in Patients with Chronic Respiratory Failure: A French Nationwide Health Claims Database (SNDS) Study

INTRODUCTION

Long-term oxygen therapy (LTOT) is reported to improve survival in patients with chronic respiratory failure. We aimed to describe effectiveness, burden, and cost of illness of patients treated with portable oxygen concentrators (POC) compared to other LTOT options.

METHODS

This retrospective comparative analysis included adult patients with chronic respiratory insufficiency and failure (CRF) upon a first delivery of LTOT between 2014 and 2019 and followed until December 2020, based on the French national healthcare database SNDS. Patients using POC, alone or in combination, were compared with patients using stationary concentrators alone (aSC), or compressed tanks (CTC) or liquid oxygen (LO2), matched on the basis of age, gender, comorbidities, and stationary concentrator use.

RESULTS

Among 244,719 LTOT patients (mean age 75 ± 12, 48% women) included, 38% used aSC, 46% mobile oxygen in the form of LO2 (38%) and POC (18%), whereas 9% used CTC. The risk of death over the 72-month follow-up was estimated to be 13%, 15%, and 12% lower for patients in the POC group compared to aSC, CTC, and LO2, respectively. In the POC group yearly mean total costs per patient were 5% higher and 4% lower compared to aSC and CTC groups, respectively, and comparable in the LO2 group. The incremental cost-effectiveness ratio (ICER) of POC was €8895, €6288, and €13,152 per year of life gained compared to aSC, CTC, and LO2, respectively.

CONCLUSION

Within the POC group, we detected an association between higher mobility (POCs autonomy higher than 5 h), improved survival, lower costs, and ICER - €6 238, compared to lower mobility POCs users.

Effects of walking with a portable oxygen concentrator on muscle oxygenation while performing normal or pursed-lip breathing in patients with interstitial lung disease: a randomized crossover trial

BACKGROUND

In patients with interstitial lung disease (ILD), decreased oxygen saturation (SpO2) reduces physical performance and causes exertional dyspnea. Portable oxygen concentrator (POC) and pursed-lip breathing (PLB) have the potential to improve these parameters in ILD patients.

OBJECTIVE

To evaluate the effects of PLB while using a POC during walking in ILD patients.

DESIGN

Prospective, randomized crossover trial.

METHODS

We compared two breathing techniques. Participants not trained in PLB received a familiarization session before the first 6-min walking test (6MWT). During the first visit, patients performed the 6MWT under natural breathing (NB1) without oxygen (O₂); during the second visit, they performed the 6MWT twice, once each with PLB (PLB1) and natural breathing (NB2) under O₂ supplementation, to compare the effectiveness of NB and PLB.

RESULTS

Twenty participants were recruited; half had exercise-induced desaturation (EID) and half normal SpO₂. In the normoxemia group (NG), the difference in the 6-min walking distance (6MWD) between NB1 and PLB1 was 28.8 ± 24.0 m, indicating reduced exercise capacity in PLB1. There were no significant differences in the quadriceps tissue saturation index (TSI), SpO₂, and 6MWD between the PLB1 and NB2 in any patient or subgroup. All participants showed a significant increase in the SpO₂ at rest, nadir SpO₂, and mean SpO₂ during the 6MWT with PLB and NB2 using a POC than with NB1. TSI showed a significant improvement at the beginning of 6MWT in ILD patients with EID in the PLB and NB2 condition.

CONCLUSION

Acute exposure to PLB did not improve symptoms, muscle oxygenation, or SpO₂; however, it decreased the walking distance in the normoxemia group. POC improved leg muscle oxygenation in ILD patients with EID. The use of PLB and POC should be prescribed according to disease characteristics and severity.

Ambulatory oxygen for treatment of exertional hypoxaemia in pulmonary fibrosis (PFOX trial): a randomised controlled trial

INTRODUCTION

Interstitial lung diseases are characterised by scarring of lung tissue that leads to reduced transfer of oxygen into the blood, decreased exercise capacity and premature death. Ambulatory oxygen therapy may be used to treat exertional oxyhaemoglobin desaturation, but there is little evidence to support its efficacy and there is wide variation in clinical practice. This study aims to compare the clinical efficacy and cost-effectiveness of ambulatory oxygen versus ambulatory air in people with fibrotic interstitial lung disease and exertional desaturation.

METHODS AND ANALYSIS

A randomised, controlled trial with blinding of participants, clinicians and researchers will be conducted at trial sites in Australia and Sweden. Eligible participants will be randomised 1:1 into two groups. Intervention participants will receive ambulatory oxygen therapy using a portable oxygen concentrator (POC) during daily activities and control participants will use an identical POC modified to deliver air. Outcomes will be assessed at baseline, 3 months and 6 months. The primary outcome is change in physical activity measured by number of steps per day using a physical activity monitor (StepWatch). Secondary outcomes are functional capacity (6-minute walk distance), health-related quality of life (St George Respiratory Questionnaire, EQ-5D-5L and King's Brief Interstitial Lung Disease Questionnaire), breathlessness (Dyspnoea-12), fatigue (Fatigue Severity Scale), anxiety and depression (Hospital Anxiety and Depression Scale), physical activity level (GENEActive), oxygen saturation in daily life, POC usage, and plasma markers of skeletal muscle metabolism, systematic inflammation and oxidative stress. A cost-effectiveness evaluation will also be undertaken.

ETHICS AND DISSEMINATION

Ethical approval has been granted in Australia by Alfred Hospital Human Research Ethics Committee (HREC/18/Alfred/42) with governance approval at all Australian sites, and in Sweden (Lund Dnr: 2019-02963). The results will be published in peer-reviewed scientific journals, presented at conferences and disseminated to consumers in publications for lay audiences.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03737409).

[Guideline for Long-Term Oxygen Therapy - S2k-Guideline Published by the German Respiratory Society]

Long-term oxygen therapy is of great importance both for reducing mortality and for improving performance in patients with chronic lung diseases. The prerequisites for Long-term oxygen therapy are adequate diagnostics and clearly defined indication. A causal distinction into chronic hypoxaemic and hypercapnic respiratory failure is reasonable, from which the differential indication for non-invasive ventilation results.The revised guideline covers the diagnostics and indication of chronic lung and heart diseases, the role of oxygen in terminal illness and gives a detailed description of available oxygen devices. The guideline is intended to help avoid undersupply, oversupply and false prescriptions. Furthermore, the chapter "Postacute Oxygen Therapy" discusses the procedure, relevant in everyday life, but not yet clearly defined, for prescribing oxygen therapy for the home at the end of an inpatient stay. Another important point, the correct prescription of mobile oxygen systems, is also presented in the guideline. This document is a revised version of the guideline for longterm oxygen therapy and replaces the version of 2008.

Home Oxygen Therapy for Adults with Chronic Lung Disease. An Official American Thoracic Society Clinical Practice Guideline

Background: Evidence-based guidelines are needed for effective delivery of home oxygen therapy to appropriate patients with chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD).Methods: The multidisciplinary panel created six research questions using a modified Delphi approach. A systematic review of the literature was completed, and the Grading of Recommendations Assessment, Development and Evaluation approach was used to formulate clinical recommendations.Recommendations: The panel found varying quality and availability of evidence and made the following judgments: 1) strong recommendations for long-term oxygen use in patients with COPD (moderate-quality evidence) or ILD (low-quality evidence) with severe chronic resting hypoxemia, 2) a conditional recommendation against long-term oxygen use in patients with COPD with moderate chronic resting hypoxemia, 3) conditional recommendations for ambulatory oxygen use in patients with COPD (moderate-quality evidence) or ILD (low-quality evidence) with severe exertional hypoxemia, 4) a conditional recommendation for ambulatory liquid-oxygen use in patients who are mobile outside the home and require >3 L/min of continuous-flow oxygen during exertion (very-low-quality evidence), and 5) a recommendation that patients and their caregivers receive education on oxygen equipment and safety (best-practice statement).Conclusions: These guidelines provide the basis for evidence-based use of home oxygen therapy in adults with COPD or ILD but also highlight the need for additional research to guide clinical practice.

Oxygen for interstitial lung diseases

PURPOSE OF REVIEW

Supplemental oxygen therapy is prescribed for management of hypoxaemia in patients with interstitial lung disease (ILD). This review summarizes current evidence and implications of the use of supplemental oxygen therapy at home and during exercise training in ILD.

RECENT FINDINGS

Despite the significance of hypoxaemia in patients with ILD, there is a lack of high-quality evidence to guide the use of oxygen therapy in this population. Recent studies suggest that ambulatory oxygen may improve symptoms and health-related quality of life in patients with ILD. Long-term oxygen therapy for resting hypoxaemia in ILD is recommended by international guidelines. Supplemental oxygen during exercise may augment training effects, whereas therapeutic effects of nocturnal oxygen therapy are yet to be evaluated in patients with ILD. Nevertheless, it is important to consider the potential burden imposed by oxygen therapy on patients' daily activities of living.

SUMMARY

Ambulatory oxygen may be considered in ILD patients with exertional hypoxaemia, with long-term oxygen therapy being a standard care for resting hypoxaemia. Trials are currently underway to clarify therapeutic potentials of supplemental oxygen for exertional hypoxaemia and during exercise training in ILD patients, with additional research needed for the evaluation of nocturnal oxygen therapy.

Optimizing Home Oxygen Therapy. An Official American Thoracic Society Workshop Report

More than 1.5 million adults in the United States use supplemental oxygen for a variety of respiratory disorders to improve their quality of life and prolong survival. This document describes recommendations from a multidisciplinary workshop convened at the ATS International Conference in 2017 with the goal of optimizing home oxygen therapy for adults. Ideal supplemental oxygen therapy is patient-specific, provided by a qualified clinician, includes an individualized prescription and therapeutic education program, and offers oxygen systems that are safe, promote mobility, and treat hypoxemia. Recently, patients and clinicians report a growing number of problems with home oxygen in the United States. Oxygen users experience significant functional, mechanical, and financial problems and a lack of education related to their oxygen equipment-problems that impact their quality of life. Health care providers report a lack of readily accessible resources needed to prescribe oxygen systems correctly and efficiently. Patients with certain lung diseases are affected more than others because of physically unmanageable or inadequate portable systems. Analysis is needed to quantify the unintended impact that the Centers for Medicare and Medicaid Services Competitive Bidding Program has had on patients receiving supplemental oxygen from durable medical equipment providers. Studies using effectiveness and implementation research designs are needed to develop and evaluate new models for patient education, identify effective ways for stakeholders to interface, determine the economic benefit of having respiratory therapists perform in-home education and follow-up testing, and collaborate with technology companies to improve portable oxygen devices. Generation of additional evidence of the benefit of supplemental oxygen across the spectrum of advanced lung diseases and the development of clinical practice guidelines should both be prioritized.

Oxygen therapy in COPD and interstitial lung disease: navigating the knowns and unknowns

Domiciliary oxygen therapy is often prescribed for patients with hypoxaemia due to advanced lung disease, most commonly chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD). Long-term oxygen therapy (LTOT) trials conducted in patients with COPD in the 1980s remain the basis for clinical decisions and guideline recommendations regarding LTOT for patients with non-COPD conditions as there is a lack of high-quality evidence concerning its use in the non-COPD population. There is also a lack of evidence for the use of ambulatory and nocturnal oxygen therapy in patients with isolated exertional and nocturnal hypoxaemia. These deficiencies pose significant challenges in patient care, with consequent discrepancies in guideline recommendations and clinical approaches. In recent years, new studies have been and are currently being conducted to fill the gaps in our understanding and use of domiciliary oxygen therapy for other indications, including ILD. This article provides a comparison of the epidemiology and significance of hypoxaemia in patients with COPD and ILD, with an up-to-date review of current evidence regarding the role of different types of domiciliary oxygen therapy in these conditions.

Despite the significance of hypoxaemia in patients with chronic lung diseases, an up-to-date review shows current evidence for clinical use of domiciliary oxygen therapy remains limitedhttp://bit.ly/33aW31n

Clinician Strategies to Improve the Care of Patients Using Supplemental Oxygen

This article reviews four key clinician strategies to improve the care of adult patients receiving supplemental oxygen in the outpatient setting in the United States. The current barriers to adequate oxygen services are substantial and complex and include decreased reimbursement to durable medical equipment (DME) companies; a substantially lower number of available DME suppliers; difficult communication with DME suppliers; rigid patient testing, prescription, and documentation requirements; and unclear patient benefit and adherence. Recent data documenting frequent and varied problems reflect the significant impact of supplemental oxygen therapy on patients and caregivers. Areas where clinicians can improve patient oxygen experiences are highlighted in this review and include understanding Centers for Medicare and Medicaid Services oxygen prescription requirements, matching oxygen equipment to patient needs, providing essential patient education, and understanding mechanisms for patients and clinicians to report unresolved oxygen problems.

Pulmonary rehabilitation, physical activity, respiratory failure and palliative respiratory care

The CIRO Academy in Horn (the Netherlands) organised a 2-day meeting to present and discuss the studies published in 2017 pertaining to key priority areas of respiratory and critical care medicine. This review summarises studies focussing on pulmonary rehabilitation and exercise training, physical activity, chronic respiratory failure and palliative respiratory care published in 2017.

Home oxygen therapy: re-thinking the role of devices

INTRODUCTION

A range of devices are available for delivering and monitoring home oxygen therapy (HOT). Guidelines do not give indications for the choice of the delivery device but recommend the use of an ambulatory system in subjects on HOT whilst walking. Areas covered: We provide a clinical overview of HOT and review traditional and newer delivery and monitoring devices for HOT. Despite relevant technology advancements, clinicians, faced with many challenges when they prescribe oxygen therapy, often remain familiar to traditional devices and continuous flow delivery of oxygen. Some self-filling delivery-less devices could increase the users' level of independence with ecological advantage and, perhaps, reduced cost. Some newer portable oxygen concentrators are being available, but more work is needed to understand their performances in different diseases and clinical settings. Pulse oximetry has gained large diffusion worldwide and some models permit long-term monitoring. Some closed-loop portable monitoring devices are also able to adjust oxygen flow automatically in accordance with the different needs of everyday life. This might help to improve adherence and the practice of proper oxygen titration that has often been omitted because difficult to perform and time-consuming. Expert commentary: The prescribing physicians should know the characteristics of newer devices and use technological advancements to improve the practice of HOT.