LTOT Denmark Norway

1. Home Oxygen Therapy: indications,
effects and distribution in Scandinavian
Thomas Ringbæk, Hjerte-lungemed. afd. Hvidovre, København

2. Overview
 Types of home oxygen therapies (terminology)
 Evidence: a) COT
b) STOT (unstable condition)
c) SBOT (short burst of oxygen)
d) NOT (nocturnal oxygen)
e) ambulatory & portable oxygen
 How do we do in practice?
Home Oxygen Therapy in various countries:
a) practice/organisation
b) quality
c) prevalence/incidence
d) survival

3. The Terminology of
Home Oxygen Therapy

4. The Terminology of
Home Oxygen Therapy

5. COT in COPD: effect on survival
PaO2 <7.3 kPa;7.3-8.0: EVF>55% or cor pulmonale)
Post-PaO2 >8.6 kPa; Stabile and optimal treated; Non-smokers
MRC NOTT
N 87 203
Age 58 66
Men% 76 80
FEV1% 30 30
PO2, 6.8 6.8 kPa
PCO2 7.2 6.9 kPa
Htc.% 52 47
Smoking 45% ?
Flow 2 1-3+1
Hours 13.5 17.7/12
Mobile - +/-

6. Effects of COT
 ↓ventilatory work
 ↑hemodynamic ↓PAP
 ↓Htc.: 4-8%
 FEV1: unchanged
 ↑PO2?
 ↑kidney function (↓oedema)
 ↓dyspnoea
 ↑physical capacity
 ↓tiered
 ↑sleep
 ↑cognitive performance
 ↑QoL
 ↑survival: 2 → 4 år
 ↓hospitalisation: 25%

7. COT in non-COPD
Lung fibrosis: 62 patients. No effect on survival.
Unpublished data.
Crockett AJ et al. Domiciliary oxygen for interstitial lung
disease. Cochrane Database Syst Rev 2001; 3:CD002883

8. RCT on moderate hypoxaemic
COPD patients
 1987-92 in Poland1987-92 in Poland
 135 COPD patients with P135 COPD patients with PaaOO22 7.4-8.7 kPa.7.4-8.7 kPa.
 Post-PO2 >8.7 kPa (mean 9.9 kPa)Post-PO2 >8.7 kPa (mean 9.9 kPa)
 >17 hrs/day vs. no oxygen (used 13½ hrs)>17 hrs/day vs. no oxygen (used 13½ hrs)
 Only concentratorOnly concentrator
 Not assessed:Not assessed:
QoLQoL
Daily activity/exerciseDaily activity/exercise
HospitalisationHospitalisation

9. RCT on moderate hypoxaemic
COPD patients (planned study)
 3.200 COPD pts. in USA3.200 COPD pts. in USA
Usual careUsual care
 Sat.OSat.O22 89-93%:89-93%:
LTOT+ portable oxygenLTOT+ portable oxygen
 Outcomes: QoLOutcomes: QoL
Daily activity/exerciseDaily activity/exercise
SurvivalSurvival

10. Oxygen devices

11. Portable Oxygen devices
 Concentrator
 Cylinders
 Liquid ”on-demand” valves

12. Aims of portable and ambulatory oxygen
 Portable Oxygen (hypoxaemic at rest)
↑hrs on oxygen
↑daily activity
 Ambulatory Oxygen (normoxaemic at rest)
Desaturate and/or dyspnoea during exercise
↑exercise tolerance/daily activity

13. Portable oxygen in 159 COPD pts on COT
France 1984-6; presc. >15 hrs/day; 12 MWD>200 m
Flow: 1.7 L/min at rest and 2.2 L/min during exercise. Randomised.
Gr.A=75Gr.A=75 Gr.B=84Gr.B=84
CConc.onc. Conc+small cyl.*(51)Conc+small cyl.*(51) Liquid(33)Liquid(33)
12MWD –O12MWD –O22 407 m407 m 423423
12MWD+O12MWD+O22 485 m485 m 478478
Hrs/day:Hrs/day: 14 hrs14 hrs 17 hrs17 hrs (B1 = B2) <0,01(B1 = B2) <0,01
Outdoor with OOutdoor with O22:: 55%55% 67%67%
Activity outdoor:Activity outdoor: equalequal
 25% did not use portable oxygen, and 15% only indoor.25% did not use portable oxygen, and 15% only indoor.
 Too heavy according to the patient: Cyl.: 50%, Liquid: 33%Too heavy according to the patient: Cyl.: 50%, Liquid: 33%
*) 2½ L cyl. + stroller (used by 10% of the pts) Vergeret J. Eur Respir J

14. Effect and usage of portable oxygen in
COPD pts on COT
COT: 3-12 months
Excluded pts. who were not
expected to live > 1 year.
Conc.: 3 mdr. Conc.
+O2: 3 mdr. Conc.-O2:
3 mdr.
Lacasse Y, ERJ 2005

15. Effects and use of portable (3½ kg) oxygen in
24 COPD pts on LTOT. 3 x 3 months
•No effect on QoL and 6 MWD
Lacasse Y, ERJ 2005

16. The Terminology of
Home Oxygen Therapy

17. STOT (oxygen at home while unstable)
 Re-evaluation:
1 month later: normalised in 30%1
and 70%2
2-3 months later: 30-50% normalised1,3
 PO2<6.7 kPa: only 1 of 23 normalised1
 Despite LTOT: 17% died <2 months4
 No RCT
1) Levi-Valensi et al. Am Rev Respir Dis 1986
2) Andersson et al. Respir Med 2002
3) NOTT study
4) Eaton et al. Respir Med 2001

18. The Terminology of
Home Oxygen Therapy

19. SBOT
(palliation of attacks of dyspnoea)
 Very few studies1,2
 Only mentioned superficially in BTS, ATS, GOLD
 COPD: 6-12 wks: 4 studies (PO2 8.5-10 kPa):
2 showed a small effect compared to air.
 Cancer:
+hypoxaemia at rest: 5 L O2/min > air.
- hypoxaemia at rest: 4 L O2/min= 4 L air/min
1) Booth S et al.Respir Med 2004
2) Booth S et al. Am J Respir Crit Care Med 1996

20. The Terminology of
Home Oxygen Therapy

21. Scenaries with hypoxaemia
% SAT.O2
95
90
85
nat Flyvning anstrengelse/anfald
7 timer 3-8 timer 0,5-2 timer

22. The Terminology of
Home Oxygen Therapy

23. Ambulatory oxygen to pts with desat.
and/or dyspnoea. Prevalence in COPD
 10% desaturate ≥4%10% desaturate ≥4%
5.926 COPD pts with FEV5.926 COPD pts with FEV11 1.5-2 L (1)1.5-2 L (1)
 32% desaturate ≥4% and32% desaturate ≥4% and ≤≤88%88%
81 COPD pts with FEV81 COPD pts with FEV11 =1,29 (2)=1,29 (2)
1. Hadeli KO et al. Chest 2001;120;88-921. Hadeli KO et al. Chest 2001;120;88-92
2. Knower MT et al.2. Knower MT et al. Arch Intern Med 2001;161:732-6Arch Intern Med 2001;161:732-6

24. The clinical relevance of
desaturation during exercise?
 Desat. is poorly assoc. tol 6-MWD (and dyspnoea)Desat. is poorly assoc. tol 6-MWD (and dyspnoea)
1. Mak VH et al. Thorax 1993;48(1):33-81. Mak VH et al. Thorax 1993;48(1):33-8
2. Baldwin DR et al. Respir Med 1995;89(9):599-6012. Baldwin DR et al. Respir Med 1995;89(9):599-601
 Assoc. with increased mortalityAssoc. with increased mortality

25. Acute effect of ambul.oxygen
↓Borg dyspnoea score 0.5-1.0
↑Physical tolerance 5-20%
+
Weight of device
Risk of stumbling over the tube
Ashamed
-
• No effect of oxygen pre- or post-exercise
Killen JWW, Thorax 2000
Lewis CA, ERJ 2003
McKeon JL, Thorax 1988
Stevenson NJ, Thorax. 2004

26. Effect of ambul. oxygen
Combination with rehabilitation
 No effect
 Garrod R, Thorax 2000
 Emtner M, AJRCCM 2003
 Rooyackers JM, ERJ 1997
 Wadell K, J Rehabil Med 2001
Puhan MA Respir Res 2004

27. International criteria for COT
 PaO2 <7.3 kPa (Sat. 88%)
(7.3-8.0: EVF>55% or cor pulmonale)
 Post-PaO2 >8.6 kPa
 Stabile and optimal treated
 Non-smokers
 Used >15 hours daily
 Follow-up after 3 months and then everyFollow-up after 3 months and then every
6 months.6 months.

28. Follow-up in different countries
Country Adherence
rate
Guidelines
Denmark1
60% 3 wks apart then every ½yr
UK2
61% The same
Norway ? 3 wks then every 3 months
Sweden 39% 2 wks then every 6 months
1) Ringbaek et al. Respir Med 2006
2) Walshaw MJ et al. BMJ 1988
Sat.O2 ≥ 92%: stop
Sat.O2: 89-91: a-puncture
Sat.O2 ≤ 88: continous

29. Home visits by a respiratory nurse?
Country Available?
Norway Yes
Denmark Most places with pulm.
physicians
Sweden Recommended
UK Recommended and
available many places

30. Smoking and COT
 Effect? Probably
 15-24 hrs/day? Not possible for heavy smokers
 Safe? Not everybody
 Ethical aspects? Seretide to smokers?

31. Adhere to the hypoxaemic criteria
PPaaOO22 <7.3 kPa (Sat. 88%)<7.3 kPa (Sat. 88%)
(7.3-8.0: EVF>55% or cor pulmonale)(7.3-8.0: EVF>55% or cor pulmonale)
Country Adherence rate
Denmark 60-70%
France 55-80%
UK 60%
Norway1
2002
2004
2005
44% of 25 pts
66% of 32 pts
35% of 48%
Sweden (2006) 81%
1) Glittreklinikken; PO2 <7.3 kPa

32. Use/prescribed oxygen
16-24 hours daily
Country Adherence rate
Denmark 60/82%
UK 60%/?
Norway ?/?
Sweden (2006) ?/97%

33. Prevalence of HOT in
various countries (per 100.000)
0
10
20
30
40
50
60
70
80
90
100
1987 1993 2006 2010
DK
SE
F
N

34. Oxygen devices in different countries
and economy
Country Concentrator Liquid Mobile
unite
Denmark 72% 11% 58%
Sweden 69%
Norway 60% 40%
UK <10% <50%
 Appr. 12.000 Nkr. yearly per patient

35. Survival rates of new COPD patients on COT from
Denmark compared to patients from other countries
0
10
20
30
40
50
60
70
80
90
100
0 3 6 9 12 15 18 21 24 27 30 33 36 39
Months
Cumulativesurvivalproportion(%)%)
Denmark (n=5659)
Sweden (n=403)
Belgium (n=270)
France (n=252)
Australia (n=505)
NOTT, COT (n=101)
Japan (n=4552)

36. Conclusions
 COT improves survival in hypoxaemic
patients
 Most patients started after hospitalisation
 Only about 50% are followed up
 Portable oxygen is still too heavy
 In general, poor survival
Thank you for your attention

37. Test
1. PO2=6.8 kPa at rest; ex-smoker. Start
home oxygen therapy?
2. Portable oxygen to mobile hypoxaemic
patients: - increase activity?
increase hours on oxygen?
3. Ambulatory oxygen improves effect of
pulmonary rehabilitation?