Pulmonary hypertension (2014) dr.tinku josephDr.Tinku Joseph
This document provides information on pulmonary hypertension (PH), including its definition, classification, pathogenesis, diagnosis, and treatment. It begins with defining PH as a mean pulmonary arterial pressure greater than 25 mmHg at rest based on right heart catheterization. PH is classified into 5 groups. The pathogenesis and pathology of each group is described. Diagnostic workup includes labs, imaging like CXR, echocardiogram and right heart catheterization. Treatment involves general measures, diuretics, anticoagulants, oxygen, and PAH-specific therapies like endothelin receptor antagonists, phosphodiesterase inhibitors, prostanoids, and calcium channel blockers in some cases. Prognostic factors and goals of treatment are also discussed.
This document discusses oxygen therapy principles and practice. It outlines the major indications for oxygen therapy as treating hypoxia and hypoxemia. There are four main types of hypoxia - hypoxic, stagnant, anemic, and histotoxic hypoxia. The guidelines for oxygen therapy are to alleviate hypoxemia and end-organ dysfunction while avoiding deleterious effects. Various oxygen delivery systems are described including low flow nasal cannulas and masks, and high flow venturi masks and hoods. Potential hazards of oxygen therapy include drying of mucous membranes, depression of ventilation, and oxygen toxicity in the lungs, eyes, and central nervous system.
Pulmonary hypertension (2014) dr.tinku josephDr.Tinku Joseph
This document provides information on pulmonary hypertension (PH), including its definition, classification, pathogenesis, diagnosis, and treatment. It begins with defining PH as a mean pulmonary arterial pressure greater than 25 mmHg at rest based on right heart catheterization. PH is classified into 5 groups. The pathogenesis and pathology of each group is described. Diagnostic workup includes labs, imaging like CXR, echocardiogram and right heart catheterization. Treatment involves general measures, diuretics, anticoagulants, oxygen, and PAH-specific therapies like endothelin receptor antagonists, phosphodiesterase inhibitors, prostanoids, and calcium channel blockers in some cases. Prognostic factors and goals of treatment are also discussed.
This document discusses oxygen therapy principles and practice. It outlines the major indications for oxygen therapy as treating hypoxia and hypoxemia. There are four main types of hypoxia - hypoxic, stagnant, anemic, and histotoxic hypoxia. The guidelines for oxygen therapy are to alleviate hypoxemia and end-organ dysfunction while avoiding deleterious effects. Various oxygen delivery systems are described including low flow nasal cannulas and masks, and high flow venturi masks and hoods. Potential hazards of oxygen therapy include drying of mucous membranes, depression of ventilation, and oxygen toxicity in the lungs, eyes, and central nervous system.
A presentation by Jacob Greisen at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
1. Yes, the patient meets the criteria for home oxygen therapy with a PO2 <7.3 kPa at rest.
2. Portable oxygen for mobile hypoxemic patients is intended to:
- Increase hours on oxygen
- Increase daily activity
3. Studies have found no effect of adding ambulatory oxygen to pulmonary rehabilitation programs. Ambulatory oxygen alone does not improve exercise tolerance long-term.
1) Home oxygen therapy (HOT) improves survival in patients with hypoxemia, though adherence to guidelines and follow-up is only about 50% in many countries.
2) Continuous oxygen therapy (COT) given for over 15 hours daily increases survival by 2-4 years in COPD patients with low oxygen levels. Portable oxygen allows more activity but devices are still heavy.
3) International guidelines recommend COT for patients with oxygen levels below 7.3 kPa, but adherence varies, from 35-81% of eligible patients receiving treatment across different countries. Follow-up after starting COT is also inconsistent.
This document discusses home oxygen therapy (HOT) in various countries. It provides an overview of the types of HOT, including continuous oxygen therapy (COT), short-term oxygen therapy (STOT), and nocturnal oxygen therapy (NOT). Clinical trials show that COT improves survival in COPD patients with low oxygen levels. Guidelines for COT recommend a minimum daily usage of 15 hours and follow-up every 3-6 months. Adherence to HOT varies significantly between countries, from 60% in Denmark to rates as low as 27% in some studies. Portable oxygen improves mobility and activity levels but is underutilized in many patients.
This document summarizes findings from the Danish Oxygen Register regarding long-term oxygen therapy (LTOT) in Denmark from 1994-2000. Some key findings include:
- The prevalence and incidence of COPD patients on LTOT increased and reached a plateau around 25 and 40 per 100,000 respectively.
- There was an increase in the proportion of cancer patients, older patients, and those using mobile oxygen units starting LTOT. The percentage treated over 15 hours daily and after hospital admission also rose.
- Around 20-25% of COPD patients on LTOT were still smoking despite the therapy.
- Survival rates improved over the period, however remained lower than other countries due to higher 6-
This document discusses home oxygen treatment. It provides an overview of the scientific evidence for indications and effects of oxygen therapy. It also reviews prevalence, devices, side effects, and practical considerations for home oxygen treatment in Denmark. A case study is presented on whether a 65-year-old woman with COPD exacerbation should start chronic oxygen therapy. Guidelines for initiating oxygen are outlined. Survival rates on oxygen are compared between countries.
This document discusses long-term oxygen therapy (LTOT) and home oxygen therapy. It provides an overview of the terminology, scientific background, equipment, indications, and practical considerations of LTOT. It also includes two case studies examining whether a patient should start or continue LTOT. The document summarizes the effects of LTOT including improved survival, decreased hospitalizations, and improved quality of life for COPD patients. It addresses portable oxygen therapy and the prevalence of home oxygen therapy in different countries.
This document discusses long-term oxygen therapy (LTOT). It provides an overview of the terminology, scientific background, equipment, indications, and quality of LTOT treatment. Specifically:
1) It defines various types of home oxygen therapy including LTOT, short-term oxygen therapy (STOT), ambulatory oxygen therapy, and oxygen used for palliation of attacks of dyspnea.
2) It reviews studies showing the effects of LTOT on survival, health outcomes, and hospitalizations for COPD patients. LTOT is shown to increase survival by 2-4 years and decrease hospitalizations by 25% for qualifying patients.
3) It discusses considerations for starting, controlling, and ensuring quality of LT
The document discusses the impact of Denmark's national oxygen register on adherence to guidelines for long-term oxygen therapy (LTOT) in COPD patients. Some key findings from 1994-2000 include an increase in the prevalence and incidence of COPD patients on LTOT, more patients receiving mobile oxygen and starting LTOT after hospitalization. Documentation of hypoxemia improved but only about half of patients received follow-up and 20-25% still smoked. Survival rates increased over time but remained lower than other countries. The register data was not optimally utilized and direct feedback to doctors may help further improve LTOT guideline adherence.
A presentation by Jacob Greisen at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
1. Yes, the patient meets the criteria for home oxygen therapy with a PO2 <7.3 kPa at rest.
2. Portable oxygen for mobile hypoxemic patients is intended to:
- Increase hours on oxygen
- Increase daily activity
3. Studies have found no effect of adding ambulatory oxygen to pulmonary rehabilitation programs. Ambulatory oxygen alone does not improve exercise tolerance long-term.
1) Home oxygen therapy (HOT) improves survival in patients with hypoxemia, though adherence to guidelines and follow-up is only about 50% in many countries.
2) Continuous oxygen therapy (COT) given for over 15 hours daily increases survival by 2-4 years in COPD patients with low oxygen levels. Portable oxygen allows more activity but devices are still heavy.
3) International guidelines recommend COT for patients with oxygen levels below 7.3 kPa, but adherence varies, from 35-81% of eligible patients receiving treatment across different countries. Follow-up after starting COT is also inconsistent.
This document discusses home oxygen therapy (HOT) in various countries. It provides an overview of the types of HOT, including continuous oxygen therapy (COT), short-term oxygen therapy (STOT), and nocturnal oxygen therapy (NOT). Clinical trials show that COT improves survival in COPD patients with low oxygen levels. Guidelines for COT recommend a minimum daily usage of 15 hours and follow-up every 3-6 months. Adherence to HOT varies significantly between countries, from 60% in Denmark to rates as low as 27% in some studies. Portable oxygen improves mobility and activity levels but is underutilized in many patients.
This document summarizes findings from the Danish Oxygen Register regarding long-term oxygen therapy (LTOT) in Denmark from 1994-2000. Some key findings include:
- The prevalence and incidence of COPD patients on LTOT increased and reached a plateau around 25 and 40 per 100,000 respectively.
- There was an increase in the proportion of cancer patients, older patients, and those using mobile oxygen units starting LTOT. The percentage treated over 15 hours daily and after hospital admission also rose.
- Around 20-25% of COPD patients on LTOT were still smoking despite the therapy.
- Survival rates improved over the period, however remained lower than other countries due to higher 6-
This document discusses home oxygen treatment. It provides an overview of the scientific evidence for indications and effects of oxygen therapy. It also reviews prevalence, devices, side effects, and practical considerations for home oxygen treatment in Denmark. A case study is presented on whether a 65-year-old woman with COPD exacerbation should start chronic oxygen therapy. Guidelines for initiating oxygen are outlined. Survival rates on oxygen are compared between countries.
This document discusses long-term oxygen therapy (LTOT) and home oxygen therapy. It provides an overview of the terminology, scientific background, equipment, indications, and practical considerations of LTOT. It also includes two case studies examining whether a patient should start or continue LTOT. The document summarizes the effects of LTOT including improved survival, decreased hospitalizations, and improved quality of life for COPD patients. It addresses portable oxygen therapy and the prevalence of home oxygen therapy in different countries.
This document discusses long-term oxygen therapy (LTOT). It provides an overview of the terminology, scientific background, equipment, indications, and quality of LTOT treatment. Specifically:
1) It defines various types of home oxygen therapy including LTOT, short-term oxygen therapy (STOT), ambulatory oxygen therapy, and oxygen used for palliation of attacks of dyspnea.
2) It reviews studies showing the effects of LTOT on survival, health outcomes, and hospitalizations for COPD patients. LTOT is shown to increase survival by 2-4 years and decrease hospitalizations by 25% for qualifying patients.
3) It discusses considerations for starting, controlling, and ensuring quality of LT
The document discusses the impact of Denmark's national oxygen register on adherence to guidelines for long-term oxygen therapy (LTOT) in COPD patients. Some key findings from 1994-2000 include an increase in the prevalence and incidence of COPD patients on LTOT, more patients receiving mobile oxygen and starting LTOT after hospitalization. Documentation of hypoxemia improved but only about half of patients received follow-up and 20-25% still smoked. Survival rates increased over time but remained lower than other countries. The register data was not optimally utilized and direct feedback to doctors may help further improve LTOT guideline adherence.
4. Case 1 (1)
65-årig kvinde m. KOL eksacerbation.65-årig kvinde m. KOL eksacerbation.
Indlagt på 5. døgn. Overvejer udskrivelse.Indlagt på 5. døgn. Overvejer udskrivelse.
Uden ilttilskud: POUden ilttilskud: PO22=6.5 & PCO=6.5 & PCO22=5.8 kPa=5.8 kPa
Skal hun starte kronisk iltbehandling?Skal hun starte kronisk iltbehandling?
Hvad gør du?Hvad gør du?
5. Case 1 (2)
Hvis JaHvis Ja:
Pt. er motiveret for brug >15 timer dagl.Pt. er motiveret for brug >15 timer dagl.
Ikke-rygerIkke-ryger
Iltflow: eleverer POIltflow: eleverer PO22 >8.0 el. min. 0.7 kPa>8.0 el. min. 0.7 kPa
Sikre sig imod betydende hyperkapniSikre sig imod betydende hyperkapni
IltsystemerIltsystemer
Inform. pt. om evt. temporær LTOT (kontrol)Inform. pt. om evt. temporær LTOT (kontrol)
Kontrol efter 1-3 mdr.Kontrol efter 1-3 mdr.
Hvis Nej:Hvis Nej: Kontrol efter 1-3 mdr.Kontrol efter 1-3 mdr.
6. Case 1 (3)
Ved 3-mdr.-kontrol:Ved 3-mdr.-kontrol:
POPO22=7.6 & PCO=7.6 & PCO22=5.6 kPa.=5.6 kPa.
Dyspnø ved let-moderat anstrengelse.Dyspnø ved let-moderat anstrengelse.
Angiver subjektiv effekt af iltAngiver subjektiv effekt af ilt
Skal LTOT fortsætte?Skal LTOT fortsætte?
10. 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
11. 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
14. 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
15. 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
16. 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
17. Portable oxygen in 930 COPD pts on COT
France before 1996; Presc. 16 hrs/day; COT >3 months
Portable oxygen to 30% of 893 ptt. with a concentrator.
Only used by 52% in a 3 months period
Only used outdoor by 4% –
especially those with liquid oxygen
Pepin JL et al. Chest 1996
19. 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
21. 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
22. The Terminology of
Home Oxygen Therapy
Ingen effekt på overlevelse eller udvikling af PAP el. ”daytime hypoxaemia”
26. Start LTOT
Ca. 80% starter LTOT efter indl.
30-50% har “normaliseret” PO2 efter 3 mdr.
Information
Oxygen-system(er) herunder bærbar ilt
27. Kontrol
Sat. (-OSat. (-O22) (hvis >88%, da a-punktur)) (hvis >88%, da a-punktur)
Bestemme ilt-flowBestemme ilt-flow
Sikre ikke-ryger statusSikre ikke-ryger status
Sikre kompliance (15-24 timer)Sikre kompliance (15-24 timer)
Behov for oxygen-systemerBehov for oxygen-systemer
Evt. hjemme-visitEvt. hjemme-visit
28. Smoking and COT
Effect? Probably
15-24 hrs/day? Not possible for heavy smokers
Safe? Not everybody
Ethical aspects? Seretide to smokers?
29. Effect of oxygen and CO on
12-minute walking distance
Calverley PMA, BMJ 1981
580
600
620
640
660
680
700
720
740
760
Air Oxygen Air+CO Oxygen+CO
12-MWD
meter p<0.01 p<0.01 p<0.01
15 COPD; FEV1=0.56 L; PO2: 5.2-7.7 kPa
30. Kvaliteten af behandlingen (KOL)
Ca. 20% ryger (måske flere)
Ca. 50% har ikke iltmangel konstant
Ca. 60% ses ambulant
0
10
20
30
40
50
60
70
80
90
100
01.11.9431.12.9531.12.9631.12.9731.12.9831.12.9931.12.00
%
Oxygen
concentrator or
liquid oxygen
15-24 hrs/day
Mobile oxygen
31. Patient karakteristika
KOL: ca. 75%
Lungekræft: ca. 10%
Lungefibrose: ca. 5%
Hjertelidelse: ca. 5%
Neuromuskulær-lidelse/kyfoskoliosis: ca. 5%
Kvinder: ca. 60%
Flow: 1.4 L/min.
Alder: 72 år
32. Praktiske forhold ved LTOT
Hvordan ordineres LTOT?
Fugtet luft?
Pulssaturation versus a-punktur?
Rejser inden- og udenlands?
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
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)
37. Conclusions
COT improves survival in hypoxaemic patients
Most patients started after hospitalisation
Only about 50% are followed up
Portable oxygen is still too heavy
↑ incidence and prevalence
In general, poor survival
Thank you for your attention
Editor's Notes
In 1994 the prevalence of COPD was about 27/100.000. I the following years, it increased by about 50% to 42/100.000
The incidence of COPD increased from 20 to 25/100.00 during 5 years