|Year : 2015 | Volume
| Issue : 2 | Page : 36-37
Long-term oxygen therapy - is the current practice sufficient?
Department of Pulmonary Medicine, College of Medicine and Sagar Dutta Hospital, Kamarhati, Kolkata, West Bengal, India
|Date of Web Publication||16-Jun-2015|
607, Purbalok, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Biswas D. Long-term oxygen therapy - is the current practice sufficient?. J Assoc Chest Physicians 2015;3:36-7
The first recorded use of oxygen during the management of acute bacterial pneumonia was in Pennsylvania (1885), almost 100 years after Joseph Priestley first reported to press the discovery of a colorless gas by heating mercuric oxide (1774). Alvan Barach (1958), who was the first to emphasize the role of oxygen in relieving dyspnea during exercise, designed a small transfillable oxygen cylinder suitable for use during exercise. In 1980s, the two milestone multicenter trials, the nocturnal oxygen therapy trial and the medical research council trial, showed that the long-term oxygen therapy (LTOT) was the only available treatment to improve survival in patients of chronic obstructive pulmonary disease (COPD) with chronic respiratory failure. LTOT refers to the provision of oxygen therapy for continuous use at home, usually for at least 18 h a day or even 24 h a day, in patients with chronic hypoxemia. LTOT not only corrects hypoxemia but also reverses the complications of chronic hypoxemia. Oxygen cylinders were the only modality of oxygen delivery during the initial days. Later, numerous experimentations and researches were conducted to improve the designing of not only home oxygen delivery system but also ambulatory oxygen delivery system.
| Indications For Long Term Oxygen Therapy|| |
0Patients suffering from COPD on full medical regime but PaO 2 <55 mmHg (or SaO 2 <88%) or, PaO 2 55-59 mmHg (SaO 2 89%) with signs of polycythemia or pulmonary hypertension or congestive cardiac failure, confirmed twice in a 3-week period, are benefited by LTOT. The indications for LTOT has broadened to include chronic hypoxemic condition in patients with advanced lung disease e.g., interstitial lung disease, pulmonary hypertension, bronchiectasis, cystic fibrosis, patients with nocturnal hypoventilation and also palliation of dyspnea due to terminal disease condition like lung malignancy.
| Prescribing Home Oxygen Therapy|| |
The home oxygen therapy is prescribed for patients who fit the criteria for LTOT, with target resting PaO 2 >60 mmHg (or SpO 2 >90%). The flow rate need to be titrated during exercise or sleep by increasing flow rate by 1 L/min, with a goal of maintaining SpO 2 >90%.
The prescription for oxygen is usually a lifetime commitment. However, a few patients who are prescribed home oxygen therapy following an episode of exacerbation often heal to the point of not requiring oxygen. These patients should be reassessed after 30-90 days, and if found not satisfying the criteria for LTOT at that time, the therapy may be discontinued.
The patients should ideally be prescribed with devices to be used at home as well as during outdoor activities. The exceptions to continuous administration 24 hours a day with ambulatory capacity are those who are: (1) Unwilling or incapable to be mobile, (2) requiring oxygen only during sleep or exercise, (3) refuses to use portable devices for ambulation.
| Home and Ambulatory Oxygen Source And Delivery Devices|| |
The sources of stationary oxygen are compressed gas, concentrator or liquid oxygen. For the patients who move only occasionally, large portable oxygen system like steel cylinders on wheel may be used. However, those who seek further freedom and independent movements, a much lighter weight ambulatory oxygen system, which may be carried by the patient with satisfactory duration of support may be used. The choice of the system depends on the cost, availability and the need of the patient. The delivery devices may be nasal cannulae, prong or mask. A humidifier may or may not be attached to the system with its inherent advantages and disadvantages. In recent years, different oxygen-conserving devices are designed in order to improve portability of oxygen therapy so that an ambulatory device can be used for a longer period of time and also reduce the total cost of LTOT by reducing wastage of oxygen.
| Benefits|| |
Long-term oxygen therapy improves the exercise capacity, survival, quality of life and intellectual functioning of the patient both inside and outside the home. Czajkowska-Malinowska et al. demonstrated significant decrease in hematocrit value, improvement in 6 min walk distance with improved quality of life as assessed by St. George Respiratory Questionnaire after first 6 months of initiation of home-based oxygen therapy using stationary oxygen concentrator. The use of portable liquid oxygen therapy during the following 6 months further improved the parameters significantly (P < 0.0001). This improvement was attributed to the increase in daily oxygen breathing hours from 13.7 to 18.9 h (P < 0.0001).  Su et al. showed almost similar findings where patients on liquid ambulatory oxygen therapy used oxygen for significantly longer hours and involved in significantly more outdoor activities than those on stationary oxygen concentrators.  However, Cedano et al. showed that the quality of life of caregivers of patients with COPD who were on LTOT were compromised significantly as observed in different dimensions of short form-36 questionnaire and they were over-burdened with the care task (caregiver burden scale).  The carers' mean age was below the mean age of patients, mostly female members of the family and serving on an average 5 years for an average 13.1 h a day.
The chronic obstructive pulmonary disease contributes the majority of the patient population who require LTOT. The National Commission on Macroeconomics and Health has estimated around 17 million COPD patients in India in 2006, which is estimated to reach around 22 million in next 10 years. The majority of the burden is contributed by rural India. COPD has topped the list of leading causes of morbidity and mortality of India from noncommunicable diseases with the exception of injury. The mortality and morbidity is not comparable to rest of the world even with the availability of most of the inhaler medications and life-saving equipments like home oxygen delivery devices, may be due to inequality in the quality of service between urban and rural centers, healthcare system, poor adherence to treatment guideline both national and international, cost of therapy and minimum allotment of national gross domestic product for health purposes.  We definitely hope the improvement in all the sectors of constraints in the management of these patients. As a respiratory physician, we have a long way to go till we can see smile in faces of millions of patients with chronic respiratory diseases including those requiring LTOT who could be seen with portable oxygen cylinder in bag, enjoying free movement in work or leisure, collecting his daily needs from market and enjoying outing with his family. Then only we could improve the quality of life of the patients as well as their caregivers.
| References|| |
Czajkowska-Malinowska M, Poltyn B, Ciesielska A, Kruza K, Jesionka P. Comparison of the results of long term oxygen therapy in patients treated sequentially using stationary or a portable source of oxygen. Pneumonol Alergol Pol 2012;80:308-16.
Su CL, Lee CN, Chen HC, Feng LP, Lin HW, Chiang LL. Comparison of domiciliary oxygen using liquid oxygen and concentrator in northern Taiwan. J Formos Med Assoc 2014;113:23-32.
Cedano S, Bettencourt AR, Traldi F, Machado MC, Belasco AG. Quality of life and burden in carers for persons with chronic obstructive pulmonary disease receiving oxygen therapy. Rev Lat Am Enfermagem 2013;21:860-7.
Bhome AB. COPD in India: Iceberg or volcano? J Thorac Dis 2012;4:298-309.