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.

1. Iltbehandling i hjemmet
Thomas Ringbæk, Hvidovre Hospitale

2. Oversigt
 CasesCases
 Videnskabelige baggrund for:Videnskabelige baggrund for:
indikationerindikationer
effekteffekt
 Prævalens, incidens og overlevelse i DKPrævalens, incidens og overlevelse i DK
 IltudstyrIltudstyr
 BivirkningerBivirkninger
 Praktiske forhold (start & kontrol)Praktiske forhold (start & kontrol)
 Kvaliteten af behandlingenKvaliteten af behandlingen
 Mobil iltMobil ilt
 ØkonomiØkonomi

3. 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?

4. Case 1 (2) Start iltterapi (LTOT)
hvis…
 PPaaOO22 <7.3 kPa (Sat. 88%)<7.3 kPa (Sat. 88%)
(7.3-8.0: EVF>55% el. cor pulmonale)(7.3-8.0: EVF>55% el. cor pulmonale)
 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
________________________________________________________________________________
 Tag stilling til iltsystemerTag stilling til iltsystemer
 Inform. pt. om evt. temporær LTOT (kontrol)Inform. pt. om evt. temporær LTOT (kontrol)
 Kontrol efter 1-3 mdr.Kontrol efter 1-3 mdr.

5. 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?

6. Indikationer for LTOT (1)
 KOL med kronisk hypoxæmi
 Andre hjerte-lungelidelser inkl. cancer
med kronisk hypoxæmi
 Hjerte-lungelidelser med anfaldsvis
hypoxæmi (relativ indikation)

7. Effekt af LTOT på overlevelsen
MRCMRC NOTTNOTT
NN 8787 203203
AlderAlder 5858 6666
Mænd%Mænd% 7676 8080
FEVFEV11%% 3030 3030
POPO22 6.86.8 6.86.8
PCOPCO22 7.27.2 6.96.9
Htc.%Htc.% 5252 4747
Tobak%Tobak% 4545 ??
IltflowIltflow 22 1-3+11-3+1
TimerTimer 13.513.5 17.7/1217.7/12
MobililtMobililt -- +/-+/-

8. Effekt af iltbehandling
 ↓↓vejrtræningsarbejdevejrtræningsarbejde
 ↓↓åndenødåndenød
 ↑↑fysisk formåenfysisk formåen
 ↑↑hæmodynamikhæmodynamik ↓↓PAPPAP
 ↓↓Htc.: 4-8%Htc.: 4-8%
 FEVFEV11: uændret: uændret
 ↑↑POPO22::
 ↑↑nyrefunktion (nyrefunktion (↓↓ødem)ødem)
 ↓↓trættræt
 ↓↓søvnsøvn
 ↑↑tænker klart (IQ)tænker klart (IQ)
 ↑↑QoLQoL
 ↑↑overlevelse:overlevelse: 22 →→ 4 år4 år
 ↓↓indlæggelse: 25%indlæggelse: 25%

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

10. 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

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.
 >17 hrs/day vs. no oxygen>17 hrs/day vs. no oxygen

12. Oxygen devices
”on-demand” valves

13. 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

14. 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

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

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. with 6-MWD (and dyspnoea)Desat. is poorly assoc. with 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. Patient karakteristika
 KOL: ca. 70%
 Lungekræft: ca. 15%
 Lungefibrose: ca. 5%
 Hjertelidelse: ca. 5%
 Neuromuskulær-lidelse/kyfoskoliosis: ca. 5%
 Kvinder: ca. 60%
 Flow: 1.4 L/min.
 Alder: 72 år

28. 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.

29. 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

30. Praktiske forhold ved LTOT
 Hvordan ordineres LTOT?
 Fugtet luft?
 Pulssaturation versus a-punktur?
Sat.O2 ≥ 92%: stop
Sat.O2: 89-91: a-punktur
Sat.O2 ≤ 88: fortsæt

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

32. Prevalence and Incidence of LTOT 1994-
2000
0
10
20
30
40
50
60
70
per100.000
31.10.94 31.12.95 31.12.96 31.12.97 31.12.98 31.12.99 31.12.00
Prevalence
Missing
Others
Cancer
COPD
0
10
20
30
40
50
60
70
per100.000
1995 1996 1997 1998 1999 2000
Incidence
Missing
Others
Cancer
COPD

33. 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. 10.000 dkr. yearly per patient

34. 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)

35. 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

36. Tak for opmærksomheden