Oxygen therapy use in older adults with chronic obstructive pulmonary disease

Pulmonary Diseases in Older Patients: Understanding and Addressing the Challenges

As the global population ages, pulmonary diseases among older people have emerged as a significant and growing public health concern. The increasing incidence of these conditions has led to higher rates of morbidity and mortality among older adults. This perspective study offers a thorough overview of the prevalent pulmonary diseases affecting the elderly demographic. It delves into the challenges encountered during the diagnosis and management of these conditions in older individuals, considering factors such as comorbidities, functional limitations, and medication complexities. Furthermore, innovative strategies and personalized interventions such as precision medicine, advanced therapies, telemedicine solutions, and patient-centered support systems aimed at enhancing the care provided to older individuals grappling with pulmonary disorders are thoroughly explored. By addressing the unique needs and complexities of this vulnerable population, healthcare systems can strive towards improving outcomes and enhancing the quality of life for elderly individuals affected by pulmonary diseases.

Influence of ethnicity on adherence to nonsurgical interventions for COPD: a scoping review

Objective

Poor therapeutic adherence and the contributing factors have been extensively researched in several chronic diseases, including COPD. However, the influence of ethnicity on adherence to nonsurgical treatment interventions for COPD (e.g. smoking cessation and pulmonary rehabilitation) is not well understood. This scoping review was performed to better understand variations in adherence among people from minority ethnic communities diagnosed with COPD.

Method

This scoping review was designed based on the refined frameworks of Arksey and O'Malley, developed by JBI (Joanna Briggs Institute). Systematic searches were performed across three databases: CINHAL (EBSCO), MEDLINE (Ovid) and Embase (Ovid).

Results

Out of 3654 identified records, 37 studies were deemed eligible for inclusion; these were conducted in various countries and involved populations of diverse ethnic groups diagnosed with COPD. The included studies considered provision and/or adherence to medication (n=8, 21.6%), smoking cessation (n=11, 29.7%), influenza vaccinations (n=7, 18.9%), pulmonary rehabilitation (n=11, 29.7%) and oxygen therapy (n=2, 5.4%). Outcomes varied widely between studies within a single intervention (e.g. initiation, adherence and completion of pulmonary rehabilitation programme). However, most of the included studies suggested the presence of inequalities linked to ethnicity across interventions.

Conclusion

This review indicated the presence of poor adherence to nonsurgical interventions among people from minority ethnic backgrounds living with COPD. However, due to the heterogeneity in population groups considered and compared within the individual studies, it is challenging to identify and understand the key inequalities influencing adherence to nonsurgical interventions. Further research is needed to better explore this.

Asthma and Chronic Obstructive Pulmonary Disease

In the United States, asthma and chronic obstructive pulmonary disease (COPD) disproportionately affect African Americans, Puerto Ricans, and other minority groups. Compared with non-Hispanic whites, minorities have been marginalized and more frequently exposed to environmental risk factors such as tobacco smoke and outdoor and indoor pollutants. Such divergent environmental exposures, alone or interacting with heredity, lead to disparities in the prevalence, morbidity, and mortality of asthma and COPD, which are worsened by lack of access to health care. In this article, we review the burden and risk factors for racial or ethnic disparities in asthma and COPD and discuss future directions in this field.

A narrative review of research advances in hypoxic pulmonary hypertension

Background and Objective

Hypoxic pulmonary hypertension (HPH) is a pathological syndrome characterized by pulmonary vasoconstriction and pulmonary vascular remodeling caused by hypoxia, which eventually leads to right heart failure or death. There are 2 stages of onset of HPH: hypoxic pulmonary vasoconstriction (HPV) and hypoxic pulmonary vascular remodeling (HPVR). It is an important pathophysiological link in the pathogenesis of chronic obstructive pulmonary disease (COPD) and chronic mountain sickness (CMS), and its severity is closely related to the course and prognosis of COPD and CMS. However, there is a lack of systematic review on the diagnosis, pathogenesis and treatment of HPH. The objective of this paper is to review the diagnosis, pathogenesis, treatment of HPH.

Methods

In this paper, the method of literature review is adopted to obtain the information about HPH. Based on the literature, comprehensive and systematic review is made. The diagnosis, pathogenesis, treatment of HPH are summarized.

Key Content and Findings

Right heart catheterization is the gold standard for diagnosing HPH. Hypoxia-inducible factor, oxidative stress, metal metabolism, ion channel, inflammatory cytokines, cell apoptosis and vascular factors are the main pathogenesis of HPH. The treatment of HPH includes long-term oxygen therapy, statins, prostaglandins, phosphodiesterase inhibitor and ET receptor antagonists.

Conclusions

Although great progress has been made in the pathophysiology and molecular biology of HPH, it is still unclear which factors play a leading role in the pathogenesis of HPH, and no breakthrough has been made in the treatment of HPH. It is believed that the specific mechanism will be revealed as the research continues, and earlier diagnosis and the development of more effective targeted drugs will be the focus of future research.

Reassessment of Home Oxygen Prescription after Hospitalization for Chronic Obstructive Pulmonary Disease. A Potential Target for Deimplementation

Rationale: Hypoxemia associated with acute exacerbations of chronic obstructive pulmonary disease (COPD) often resolves with time. Current guidelines recommend that patients recently discharged with supplemental home oxygen after hospitalization should not have renewal of the prescription without assessment for hypoxemia. Understanding patterns of home oxygen reassessment is an opportunity to improve quality and value in home oxygen prescribing and may provide future targets for deimplementation.Objectives: We sought to measure the frequency of home oxygen reassessment within 90 days of hospitalization for COPD and determine the potential population eligible for deimplementation.Methods: We performed a cohort study of patients ≥40 years hospitalized for COPD at five Veterans Affairs facilities who were prescribed home oxygen at discharge. Our primary outcome was the frequency of reassessment within 90 days by oxygen saturation (Sp_O2) measurement. Secondary outcomes included the proportion of patients potentially eligible for discontinuation (Sp_O2 > 88%) and patients in whom oxygen was discontinued. Our primary exposures were treatment with long-acting bronchodilators, prior history of COPD exacerbation, smoking status, and pulmonary hypertension. We used a mixed-effects Poisson model to measure the association between patient-level variables and our outcome, clustered by site. We also performed a positive deviant analysis using chart review to uncover system processes associated with high-quality oxygen prescribing.Results: A total of 287 of 659 (43.6%; range 24.8-78.5% by site) patients had complete reassessment within 90 days. None of our patient-level exposures were associated with oxygen reassessment. Nearly half of those with complete reassessment were eligible for discontinuation on the basis of Medicare guidelines (43.2%; n = 124/287). When using the newest evidence available by the Long-Term Oxygen Treatment Trial, most of the cohort did not have resting hypoxemia (84.3%; 393/466) and would be eligible for discontinuation. The highest-performing Veterans Affairs facility had four care processes to support oxygen reassessment and discontinuation, versus zero to one at all other sites.Conclusions: Fewer than half of patients prescribed home oxygen after a COPD exacerbation are reassessed within 90 days. New system processes supporting timely reassessment and discontinuation of unnecessary home oxygen therapy could improve the quality and value of care.

Economic Burden of Chronic Obstructive Pulmonary Disease (COPD): A Systematic Literature Review

Background and Objectives

Chronic obstructive pulmonary disease (COPD) affects over 250 million people globally, carrying a notable economic burden. This systematic literature review aimed to highlight the economic burden associated with moderate-to-very severe COPD and to investigate key drivers of healthcare resource utilization (HRU), direct costs and indirect costs for this patient population.

Materials and Methods

Relevant publications published between January 1, 2006 and November 14, 2016 were captured from the Embase, MEDLINE and MEDLINE In-Process databases. Supplemental searches from relevant 2015-2016 conferences were also performed. Titles and abstracts were reviewed by two independent researchers against pre-defined inclusion and exclusion criteria. Studies were grouped by the type of economic outcome presented (HRU or costs). Where possible, data were also grouped according to COPD severity and/or patient exacerbation history.

Results

In total, 73 primary publications were included in this review: 66 reported HRU, 22 reported direct costs and one reported indirect costs. Most of the studies (94%) reported on data from either Europe or North America. Trends were noted across multiple studies for higher direct costs (including mean costs per patient per year and mean costs per exacerbation) being associated with increasingly severe COPD and/or a history of more frequent or severe exacerbations. Similar trends were noted according to COPD severity and/or exacerbation history for rate of hospitalization and primary care visits. Multivariate analyses were reported by 29 studies and demonstrated the statistical significance of these associations. Several other drivers of increased costs and HRU were highlighted for patients with moderate-to-very severe COPD, including comorbidities, and treatment history.

Conclusion

Moderate-to-very severe COPD represents a considerable economic burden for healthcare providers despite the availability of efficacious treatments and comprehensive guidelines on their use. Further research is warranted to ensure cost-efficient COPD management, to improve treatments and ease budgetary pressures.

End-of-Life Strategies among Patients with Advanced Chronic Obstructive Pulmonary Disease

RATIONALE

The burden of advanced chronic obstructive pulmonary disease (COPD) is high globally; however, little is known about how often end-of-life strategies are used by this population.

OBJECTIVES

To describe trends in the use of end-of-life care strategies by people with advanced COPD in Ontario, Canada.

METHODS

A population-based repeated cross-sectional study examining end-of-life care strategies in individuals with advanced COPD was conducted. Annual proportions of individuals who received formal palliative care, long-term oxygen therapy, or opioids from 2004 to 2014 were determined. Results were age and sex standardized and stratified by age, sex, socioeconomic status, urban/rural residence, and immigrant status. Measurement/Main Results: There were 151,912 persons with advanced COPD in Ontario between 2004 and 2014. Use of formal palliative care services increased 1% per year from 5.3% in 2004 to 14.3% in 2014 (P value for trend < 0.001), whereas use of long-term oxygen therapy increased 1.1% per year from 26.4% in 2004 to 35.3% in 2013 (P value for trend < 0.001). The use of opioids was relatively stable (40.0% in 2004 and 41.8% in 2014; P value for trend = 0.08). Younger individuals were less likely to use formal palliative care services and long-term oxygen therapy. Males were less likely than females to receive long-term oxygen therapy and opioids.

CONCLUSIONS

The proportion of people with advanced COPD using end-of-life strategies, although increasing, remains low. Efforts should focus on increasing access to such strategies and educating patients and providers of their benefits.

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

Patient registries for home oxygen research and evaluation

Randomized clinical trials are the preferred study design to address key research questions about the benefits or harms of interventions. However, randomized trials of oxygen therapy are difficult to conduct and have limitations. The purpose of this article is to offer our view on the potential use of patient registries in the field of home oxygen in COPD as an alternative to randomized trials by referring to the Swedish experience with a national registry for respiratory failure. Patient registries use observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure. As opposed to administrative databases, patient registries serve one or more predetermined scientific, clinical, or policy purposes. By systematically and prospectively compiling relevant data, patient registries may describe the natural history of a disease, determine effectiveness and cost-effectiveness, assess safety or harm, and measure quality of care. Registry-based randomized trials (ie, randomized trials within a clinical registry) combine the advantages of a prospective randomized trial with the strengths of a large-scale all-comers clinical registry. Challenges and issues in the design and implementation of patient registries include the representativeness of participants, data collection, quality assurance, ownership, and governance. Notwithstanding their limitations, patient registries represent valuable tools in the conduct of research in the area of home oxygen therapy.

Characteristics of long-term home oxygen therapy users in the municipality of Curitiba, Brazil

Abstract Introduction: Long-term home oxygen therapy (LTOT) can be successfully used in the treatment and prevention of chronic lung diseases, as it improves quality of life, increases survival, and reduces the lenght of hospital stays. However, to the authors’ knowledge there are no descriptive studies with details of the clinical and social profile of patients using LTOT in the state of Paraná. Objective: To analyze the profile of LTOT users in the state of Paraná. Method: All patients registered in the LTOT program of the Curitiba Municipal Department of Health were recruited to the study. Participants answered a questionnaire with questions about their education level, family income, main diagnosis, comorbidities, hours/day of O2 use, and hospitalizations in the previous year. Results: 386 patients (67 ± 20.4 years; 66% females) were interviewed. Chronic obstructive pulmonary disease (COPD) was the most common disease (58.5%); 60.6% were former smokers and 84.5% did not practice any kind of physical activity; dyspnea was the most common symptom (81.3%) and immobility was the most commonly reported inconvenience (33%); 55.7% used O2 24 hours a day; 53.6% had been hospitalized in the previous year; 33.9% had not completed primary school; 31.4% had an income of one minimum monthly wage or less. Conclusion: LTOT users in Curitiba are primarily elderly women with COPD, with low family income and limited schooling. It is extremely important that health professionals provide educational and preventive measures for this population, to minimize the impact of COPD in the community.

Nonpharmacological therapies for interstitial lung disease

A PURPOSE OF REVIEW

Interstitial lung diseases (ILDs) cause unpredictable degrees of fibrosis and inflammation in the lungs leading to functional decline and varying symptom burden for patients. Some patients may live for years and be responsive to therapy and others disease trajectory may be shorter and similar to patients with lung cancer. This ultimately affects the patient's quality of life as well as their caregiver(s).

B RECENT FINDINGS

Nonpharmacological therapies play an important role in treatment of interstitial lung disease. These include symptom management, pulmonary rehabilitation, oxygen therapy, and palliative care. While ILDs are associated with high morbidity and mortality, different models of care exist globally. New tools help clinicians identify and address palliative care needs in daily practice and specialty nurses and ILD centers can optimize care.

C SUMMARY

This paper provides an overview of nonpharmacological therapies available for patients with interstitial lung disease.

Detection of early-stage changes in people with chronic diseases: A telehome monitoring-based telenursing feasibility study

Chronic diseases, such as chronic obstructive pulmonary disease, amyotrophic lateral sclerosis, and diabetes mellitus, require long-term management, which daily telenurse monitoring can provide. The aim of the present feasibility study was to determine if using a telenursing protocol with home monitoring during a 12 week implementation could also identify early signs of deterioration and factors correlated with participants' change in status, while attaining patient acceptance and satisfaction. The purposive sample of 43 participants provided 4533 combined days of monitoring. Outcome feasibility indicators were the range of triggering protocol alerts (70~100%) and diagnoses with exacerbations (20~29.3%). Highly correlated were participants' activity limitation and palpitations with chronic obstructive pulmonary disease, activity limitation and ineffective sputum clearance with amyotrophic lateral sclerosis, and fatigue with diabetes. Acceptance and adherence were high with daily monitoring, including "feelings of safety," and "understanding own condition". Telenursing with home monitoring indicated a trend to accurately detect early-stage changes. Participant acceptance was acceptable. It would be feasible to conduct a randomized, controlled trial using this model with some modifications.

Long-term effects of oxygen-enriched high-flow nasal cannula treatment in COPD patients with chronic hypoxemic respiratory failure

BACKGROUND

This study investigated the long-term effects of humidified high-flow nasal cannula (HFNC) in COPD patients with chronic hypoxemic respiratory failure treated with long-term oxygen therapy (LTOT).

PATIENTS AND METHODS

A total of 200 patients were randomized into usual care ± HFNC. At inclusion, acute exacerbation of COPD (AECOPD) and hospital admissions 1 year before inclusion, modified Medical Research Council (mMRC) score, St George's Respiratory Questionnaire (SGRQ), forced expiratory volume in 1 second (FEV1), 6-minute walk test (6MWT) and arterial carbon dioxide (PaCO2) were recorded. Patients completed phone interviews at 1, 3 and 9 months assessing mMRC score and AECOPD since the last contact. At on-site visits (6 and 12 months), mMRC, number of AECOPD since last contact and SGRQ were registered and FEV1, FEV1%, PaCO2 and, at 12 months, 6MWT were reassessed. Hospital admissions during the study period were obtained from hospital records. Hours of the use of HFNC were retrieved from the high-flow device.

RESULTS

The average daily use of HFNC was 6 hours/day. The HFNC group had a lower AECOPD rate (3.12 versus 4.95/patient/year, p<0.001). Modeled hospital admission rates were 0.79 versus 1.39/patient/year for 12- versus 1-month use of HFNC, respectively (p<0.001). The HFNC group had improved mMRC scores from 3 months onward (p<0.001) and improved SGRQ at 6 and 12 months (p=0.002, p=0.033) and PaCO2 (p=0.005) and 6MWT (p=0.005) at 12 months. There was no difference in all-cause mortality.

CONCLUSION

HFNC treatment reduced AECOPD, hospital admissions and symptoms in COPD patients with hypoxic failure.

Supplemental oxygen in patients with stable chronic obstructive pulmonary disease: evidence from Nocturnal Oxygen Treatment Trial to Long-term Oxygen Treatment Trial

PURPOSE OF REVIEW

Oxygen therapy was the first treatment shown to prolong life in patients with chronic obstructive pulmonary disease (COPD) and has been joined by lung volume reduction surgery in selected patients with emphysema, smoking cessation, and potentially noninvasive ventilation in chronic hypercapneic respiratory failure. Although there is consensus around the survival-enhancing effect of supplemental oxygen (SupplO2) for patients with chronic severe hypoxemia at rest, the impact of SupplO2 for COPD patients with moderate hypoxemia and exertional desaturation had been less clear.

RECENT FINDINGS

The recently published Long-term Oxygen Treatment Trial (LOTT) showed no benefit of SupplO2 for the composite outcome of survival and all-cause hospitalizations, or for component outcomes, severe COPD exacerbations, or quality of life in COPD patients with moderate resting hypoxemia or room air normoxemia with exercise desaturation.

SUMMARY

Results of the LOTT challenge the practice of prescribing SupplO2 for patients with COPD and moderate resting hypoxemia or isolated exertional desaturation. In the context that LOTT may not have recruited patients for whom SupplO2 conferred subjective benefit, there may be a role for short-term trials of SupplO2 with assessment of subjective benefit in such patients.

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.

Pulmonary Rehabilitation Utilization in Older Adults With Chronic Obstructive Pulmonary Disease, 2003 to 2012

PURPOSE

To assess the trends in pulmonary rehabilitation (PR) utilization and factors associated with its use in older adults with chronic obstructive pulmonary disease (COPD).

METHODS

We examined data for Medicare beneficiaries with COPD who received PR from January 1, 2003, to December 31, 2012. Persons with COPD were identified by (1) ≥2 outpatient visits >30 days apart within 1 year with an encounter diagnosis of COPD or (2) an acute care hospitalization with COPD as the primary diagnosis or a primary diagnosis of acute respiratory failure with a secondary discharge diagnosis of COPD. PR utilization was the study outcome identified by health care common procedure coding system codes G0237, G0238, G0239, and G0424 (after year 2010) or current procedural terminology codes (97001, 97003, 97110, 97116, 97124, 97139, 97150, 97530, 97535, and 97537) in a calendar year.

RESULTS

Patients with COPD who received PR increased from 2.6% in 2003 to 3.7% in 2012 (P = .001). In a multivariable analysis, factors associated with receipt of PR were younger age, non-Hispanic white race, high socioeconomic status, multiple comorbidities (OR = 1.20; 95% CI = 1.13-1.27), and evaluation by a pulmonary physician (OR = 2.23; 95% CI = 2.13-2.33). Increased use of PR was attributed to prior users rather than new users of PR.

CONCLUSIONS

Utilization of PR during the study period increased only 1.1% in these Medicare beneficiaries with COPD and remained low.

DNA damage and repair capacity in lymphocyte of chronic obstructive pulmonary diseases patients during physical exercise with oxygen supplementation

BACKGROUND

We hypothesized that the use of oxygen supplementation during aerobic exercise induces less DNA damage than exercise alone. The aim of this study is to assess the level of DNA damage induced by physical exercise with and without oxygen supplementation in chronic obstructive pulmonary diseases (COPD) patients.

METHODS

Peripheral blood was collected before and after aerobic exercise in two conditions: (I) aerobic exercise without oxygen supplementation (AE group) and (II) with oxygen supplementation (AE-O2 group). Lymphocytes were collected to perform the alkaline version of the Comet Assay. To assess the susceptibility to exogenous DNA damage, the lymphocytes were treated with methyl methanesulphonate (MMS) for 1-h or 3-h. After 3-h treatment, the percentage of residual damage was calculated assuming the value of 1-h MMS treatment as 100%.

RESULTS

AE group showed lower induced damage (1 h of MMS treatment) and consequently less DNA repair compared to AE-O2 group. AE-O2 group showed an increase in the induced DNA damage (1 h of MMS treatment) and an increased DNA repair capacity. Within the AE-O2 group, in the post-exercise situation the induced DNA damage after 1 h of MMS treatment was higher (p = 0.01) than in the pre-exercise.

CONCLUSION

COPD patients who performed physical exercise associated with oxygen supplementation had a better response to DNA damage induced by MMS and a better DNA repair when compared to the condition of physical exercise without oxygen supplementation.

TRIAL REGISTRATION

UNISC N374.298. Registered 04 JUN 2013 (retrospectively registered).