Long-term Oxygen Treatment in Chronic Obstructive Pulmonary Disease: Recommendations for Future Research

Abstract

Long-term oxygen treatment (LTOT) prolongs life in patients with chronic obstructive pulmonary disease (COPD) and severe resting hypoxemia. Although this benefit is proven by clinical trials, scientific research has not provided definitive guidance regarding who should receive LTOT and how it should be delivered. Deficiencies in knowledge and in current research activity related to LTOT are especially striking in comparison to the importance of LTOT in the management of COPD and the associated costs. The National Heart, Lung, and Blood Institute, in collaboration with the Centers for Medicare and Medicaid Services, convened a working group to discuss research on LTOT. Participants in this meeting identified specific areas in which further investigation would likely lead to improvements in the care of patients with COPD or reductions in the cost of their care. The group recommended four clinical trials in subjects with COPD: (1 ) efficacy of ambulatory O 2 supplementation in subjects who experience oxyhemoglobin desaturation during physical activity but are not severely hypoxemic at rest; (2 ) efficacy of LTOT in subjects with severe COPD and only moderate hypoxemia; (3 ) efficacy of nocturnal O 2 supplementation in subjects who show episodic desaturation during sleep that is not attributable to obstructive sleep apnea; and (4 ) effectiveness of an activitydependent prescription for O 2 flow rate that is based on clinical tests performed at rest, during exercise, and during sleep.

Nonpharmacological treatment and relief of symptoms in COPD: Table 1—

“…Healthcare systems in many countries include public funding of LTOT for eligible applicants [55]. The role of LTOT and of acute oxygen supplementation during an AECOPD are described elsewhere in the current series [56].…”

Automated Closed Loop Control of Inspired Oxygen Concentration

“…In these patients the primary goal of oxygen therapy is the avoidance of hypoxemia, and the use of oxygen is quite liberal, because the risks of side effects associated with hyperoxemia or exposure to high F IO 2 are generally considered to be small. There are, however, emerging concerns, including the association between both hyperoxemia and hypoxemia, with increased risk of death post cardiac arrest 20 and increased death or worse outcome in severe head trauma. 21 Clinicians suggest potential benefits of F IO 2 titration in lieu of a continuously high F IO 2 , independent of the arterial oxygen levels, 22,23 and potential risks due to masking of the onset of worsening in lung function by hyperoxemia.…”

Right Versus Left Prong Nasal Cannula Flow Delivery and the Effects of Nasal Cycling on Inspired FIO2in an Adult Anatomic Model

“…The NHLBI working group reported that approximately 1 million patients receive LTOT through the Medicare program with reimbursements for oxygen exceeding $2 billion/y. 25 The working group also reported that reimbursements for oxygen were increasing by 12-13%/y. 25 In our model, we can assume that nearly half of the oxygen delivered from the flow meter was not delivered to the lower airway.…”

“…25 The working group also reported that reimbursements for oxygen were increasing by 12-13%/y. 25 In our model, we can assume that nearly half of the oxygen delivered from the flow meter was not delivered to the lower airway. Given this same scenario for the LTOT patient, it seems reasonable to conclude that an undetermined amount of oxygen and health-care dollars are actually providing incomplete benefits.…”

“…This scenario could impact any patient receiving oxygen by nasal cannula, but it is the long-term oxygen therapy (LTOT) patient who carries a larger economic burden of wasted oxygen. Croxton et al 25 published the results of a National Heart, Lung, and Blood Institute (NHLBI) Workshop on LTOT. The NHLBI working group reported that approximately 1 million patients receive LTOT through the Medicare program with reimbursements for oxygen exceeding $2 billion/y.…”