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Due to the generosity of EFFORTS, I was able to attend a Symposium in Orlando during
the week of March 31, 2011, titled Long Term Oxygen
Therapy: Separating Fact from Fiction. This event was jointly sponsored by Tufts University School of Medicine and
Ganesco, Inc, which is a provider of continuing education events.
Long Term Oxygen Therapy: Separating Fact From Fiction
March 31 - April 1, 2011
This symposium was sponsored by Tufts University of Medicine
and Genesco (a continuing education company) and the speakers were a mix of practicing
and teaching physicians and RTís and an RN.
There were 9 presentations, plus 3 workshops during this
1 Ĺ day event, with some of the discussions more technical than others,
Iíll do my best to summarize each speakerís presentation.
Dr. Barry Make - Overview of Current Obstacles and
Challenges in Oxygen Therapy:
LTOT usage must start with the user - Reasons to use = ďGood
life, longer life, reduce burden of disease, more active, feel betterĒ
So - why do COPD patients NOT use: ďNo instruction given, donĎt
understand why they need it, afraid to run out when using portable devices, embarrassed
to be seen, too heavy to carry, carts too bulky, etcĒ
27,000 to 54,000 deaths per year could be prevented if patients
would use their O2
Only 32% of hypoxic patients even receive O2
There are 1 million Medicare patients on O2 costing $2 billion
a year (and 71% of Medicare patients are on O2) - but why should insurance companies
continue to pay if patient not going to use ambulatory O2?
No real guidelines to prescribing liter flow - from the NOTT
trial, determined that saturation at rest should be over 90%, so whatever that liter
flow works out to be; need to add one liter to that for night; add another when
But - cannot ethically perform another NOTT trial to see if
those are still valid liter flow guidelines (for NOTT patients were randomly assigned
to either 24 hr/day O2, or nocturnal O2 only) since we now know that O2 is beneficial
- could be harmful to those only receiving nocturnal O2.
Patient outcomes with O2 use are less dyspnea, better quality
of life and more activity.
The 6th O2 Conference Consensus was that there must
be more conprehensive education, more patient caregiver education, greater access
to LTOT, clinical practice guidelines and titrating flow devices
Dr. Nicholas Hill - Pathophysiology of Chronic Hypoxemia
This presentation used lots of diagrams and slides to
explain the way that O2 is transported through our body - stresses on the O2 pathway
are exercise, respiratory and/or cardiovascular failure.
With COPD we have hypoventilation, a ventilation/perfusion
mismatch and a diffusion abnormality.
Pulmonary Rehab and supplemental O2 should be prescribed.
Chronic hyopoxia causes inflammation, which in turn causes
other organ damage and eventually mortality
Hypoxic Pulmonary Hypertension is partially reversible in patients
with COPD. Chronic Hypoxia activates
TNF in underweight COPD patients - he called it the anorexic factor.
Physicians donít know what to monitor to determine if O2 is
adequate to do sufficient tissue oxygenation.
Eventually chronic hypoxia leads to cardiovascular adaptations leads to pulmonary
Dean Hess, Phd, RRT - Current Indications for Oxygen
- looking at the evidence
In the NOTT Trial,
all were also on theophylline and an inhaled beta-2 agonist
Showed that continuous
(described as 17-18 hours per day) O2 had greater survival rate than nocturnal only
LTOT is the most cost effective therapy for COPD patients with
severe hypoxemia - cost of $16,124 as opposed to $140,000 for LVRS (Lung volume
Do patients need to be on O2 forever, once prescribed? Some do not, but most never get retested,
so stay on for life. If patient is
not hypoxic at rest, maybe they donít need LTOT?
Maybe only if stats drop when ambulatory?
The evidence isnít there to show whether OP2 is beneficial for exertional
desaturation or not.
Thereís NO benefit if patients arenít motivated to use, if
equipment is too cumbersome.
No data to show what causes nocturnal desaturation - we donít
know what itís due to. There are no
studies that are able to show any benefit for COPD patients using only nocturnal
O2. Doesnít mean there IS no
benefit - just that there arenít any studies.
Dr. James K Stoller - Overview of Oxygen Delivery
Mentioned Stationery Concentrators & POCís, Compressed
Gas & Liquid Systems and Transfilling Systems.
Gas - somewhat expensive for provider; Liquid - most expensive;
and concentrators (least expensive in long run, but can run up to $168 to $360 a
year for patient because of electricity)
When prescribing, script should specify type of delivery and
liter needed for rest, sleep and exercise.
Medicare requires yearly recertification but NOT retesting
When patient retested 2 months after exacerbation, in 43% of
the time, they needed a lower rate of O2.
Patients should be retested 90 days after discharge from hospital.
Intermittant flow devices (pulse) must be titrated, as not all are equivalent.
Recommendation - patients be evaluated for a SPECIFIC device
- should be the same one they use at home.
Dr. Richard Casaburi - Can Oxygenation be Maintained over 24
Hours - What is the Reality?
How to tell if patient really is using their O2?
Hours concentrator is running not accurate, since it does not mean itís being
used - could be just left on but not in use.
Gas tank usage requires counting number of tanks, knowing if tank was totally
full when delivered, if it was totally empty when returned to DME, and what type
of pulse device and liter flow. Liquid
- would need to know the weight and what might have evaporated.
So - almost impossible to measure if O2 being used continuously.
One study followed 22 patients.
Average used O2 18.9 hours a day.
Of that time, 16.4 hours were stationary - only 2.5 hours were ambulatory.
A concentrator keeps patients saturated better than ambulatory devices.
Must educate patients via pulmonary rehab.
And if way is found to monitor adherence, need to remove ambulatory O2 from
those who are not using it - would be more cost effective.
Need to assure proper scripts, need testing centers, more reliable
conserving devices - must test on a WIDE variety of patients
And - this physician believes in increasing the availability
of personal oximeters.
Dan Easley & Kim Wiles, BS, RRT - Decreasing COPD
Rehospitalizations - what the data tells us
MedPac recommendations are to hold back payments to hospitals
when patients are readmitted for the same diagnosis within a certain time frame
(canít remember what that was - 30 days?)
$10 million has been allotted to chronic disease management
to help patients live a good life and reduce the burden of their disease (on them
and on society)
In PA, COPDíers are the 2nd largest group who are
readmitted to hospitals. Should be
more follow-up of patients in-home.
DMEís should provide devices that are matched to each patient - not all are alike
At discharge, patients should be referred to rehab and followed
Home Health Care - RTís need to be able to go into homes with
the goal of educating and enforcing good breathing skills, exacerbation control,
Itís important to have accurate titration for O2 saturation
- assess dyspnea, encourage independence.
Important to have way to monitor patient at several times after
discharge - DASH software program, in use in PA (?) does that
***An active patient is an independent patient**
The RT should be able to be an educator, motivator, coach and
How to get patients into pulmo rehab soon after hospital discharge? Nutrition training needed for those patients
with BMI <22 - they comprise Ĺ of rehospitalizations
The future of home care should be patient centered vs. equipment
Friday morning began with 3 workshops - we patients
were asked to participate in one titled ďOxygen Conserving SyatemsĒ moderated by
Dean Hess PhD, RRT and Kim Wiles, BS, RRT
Thursday afternoon, while sitting and listening to the various
speakers, I had been hooked up to a
device that was measuring the following:
size of O2 dose being delivered from my SeQual, heart rate, O2 saturation, pulse,
# of breaths per minute, etc.
Friday morning they hooked me up again and asked me to take
a walk. The device showed that my SeQual
was very good at delivering 2 lpm, but that my heart rate was increasing, and that
my saturation was decreasing (to below 88 at some points)
Then - I took
the same walk while using a gas canister with a ďSmart DoseĒ regulator.
Very same walk - but as my heart rate increased, the device increased my
liter flow, decreased when it sensed I didnít need as much,
and I never was desaturated!!
I WANT THIS!!
Seriously - itís awesome, and I do intend to look into it.
There were several companies exhibiting various devices - gas,
liquid and POCís. The symposium participants
were each given a cannula and asked to hook up to the devices to experience the
different feel. I am used to a fairly
forceful pulse, and felt as if I wasnít
getting any O2 from some of the devices, but the manufacturers are trying to reduce
the sound of the pulse, since it bothers some people.
Dr. Casaburi and Dr. Frank Sciurba debated ďLong-Term O2 Therapy
- We know enough to treat effectivelyĒ
Are the LOTT and MRC Trials of the 1980ís sufficient
- Yes. while we are unaware of HOW
the mechanism works to prolong lives, it does work and it would be unethical to
test groups without O2. BUT - more
US patients in the US are on LTOT then anywhere else in the world, costing $3 billion
a year. So - we MUST recertify patients
and if they donít qualify again, remove them from O2.
Must monitor adherence, also - if not ambulating, remove portable O2
Many LTOT patients arenít adequately oxygenated.
Need recertification centers to recertify and to test on dev ice that patient
O2 conserving devices need a WIDE range of patient trials -
not happening now
Right now, patients donít adhere to O2 therapy.
Should be encouraged, maybe even required, to attend classes that feature
O2 education so will understand importance.
Pulmonary Rehab very important
standards are based upon a very SMALL number of very severe males.
Not many women in trial - there are many different types of COPD - need to
do testing on similar groups to see which patients improve with O2
There are so many co-morbidities, such as weight loss, muscle
dysfunction, cardiovascular disease, osteoporosis, depression and cancer that need
to group similar patients together to do testing
COPDíers are more likely to die of a comorbidity than of COPD
COPDíers with more emphysema to their diagnosis are more apt
to die from COPD
Feels we donít know enough yet about hypoxemia in COPD
***Vascular disease can be caused by increases of supplemental
O2 and that then kills more COPD patients***
O2 at 2 lpm for 18 hours increases oxidative stress in COPD
O2 can harm some subgroups (didnít specify which) and some
studies indicate that not all nocturnal O2 patients benefit
Benefits of O2 are poorly defined in moderate hypoxemia, in
those who desat during exercise only and in nocturnal desaturation
Trina Limberg, B, RRT & Andrew Ries MD (with John
Walsh, COPD Foundationand Kathleen Lindell,
recommendations from the Consensus Conferences regarding education.
Clinicians and patients need to clearly understand the problem and know of
options for solutions. Physicians and other health care professionals must know
more about how equipment works, what options and available and how to monitor and
ensure quality LTOT
Writing the proper O2 script is difficult without testing -
need standard protocols to test at rest, at exertion, when going about daily living
tasks, and at exercise. None exist
Patients are poorly educated on use of O2 - complying with
the script is difficult.
Need to assess patient expectations for reducing dyspnea
Need to address myths about O2 ďI must be closer to death -canít
leave homeĒ address public embarrassment & logistics of storage & portage
Writing an order doesnít make it happen - needing O2 doesnít
make it any easier to use. Patients
must receive acknowledgement, respect, compassion and need to practice.
Need to learn and need support
Should patients be told itís OK to self-titrate?
And when? Are there patients
who should NOT do self-monitoring
When should patients be re-assessed?
John Walsh took a little survey of the total 5 patients present. NONE of us had had any instruction in
use of our O2. 3 use liquid, one uses
canisters and 1 uses POC to ambulate.
All patients learned from patient support sites, such as EFFORTS, and none have
been retested recently.
Patient organizations must continue to work with clinicians,
RTís and DMEís etc. to educate patients
COPD Foundation is willing to try to help with clinical trial
Onward - What can and should we be doing?
All faculty members participated in this
Important to continue to work on getting respiratory care paid
for in the home
Need to set goals of LTOT given current evidence.
What endpoints to target for O2 script?
What technology in order to achieve those endpoints most cost-effectively
How best to establish that targets are being reached
And - since there are fewer and fewer smokers, in the
future the average COPD patient is predicted to be poor, with no insurance and may
not be able to get equipment, etc.
How to plan for this?
Dr. Hill & Dr. Make - Closing remarks - went over