Iltbehandling i hjemmet

Thomas Ringbæk, Hvidovre Hospitale

Oversigt CasesCases Videnskabelige baggrund for:Videnskabelige baggrund for:

indikationer indikationer effekt effekt

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 ilt Mobil ilt ØkonomiØkonomi

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?

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.

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?

Indikationer for LTOT (1)

KOL med kronisk hypoxæmi Andre hjerte-lungelidelser inkl. cancer

med kronisk hypoxæmi Hjerte-lungelidelser med anfaldsvis

hypoxæmi (relativ indikation)

Effekt af LTOT på overlevelsen

MRCMRC NOTTNOTTNN 8787 203203AlderAlder 5858 6666Mænd%Mænd% 7676 8080FEVFEV11%% 3030 3030

POPO22 6.86.8 6.86.8

PCOPCO22 7.27.2 6.96.9

Htc.%Htc.% 5252 4747Tobak%Tobak% 4545 ??IltflowIltflow 22 1-3+11-3+1TimerTimer 13.513.5 17.7/1217.7/12MobililtMobililt - - +/-+/-

Effekt af iltbehandling

vejrtræningsarbejdevejrtræningsarbejde åndenødåndenød fysisk formåenfysisk formåen hæmodynamik hæmodynamik 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: 2 2 4 år 4 år indlæggelse: 25%indlæggelse: 25%

Smoking and LTOT

Effect? Probably 15-24 hrs/day? Not possible for heavy

smokers Safe? Not everybody Ethical aspects? Seretide to smokers?

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

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

Oxygen devices

”on-demand” valves

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

Portable oxygen in 159 COPD pts on COTFrance 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 hrs 17 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 1989

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

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

Portable oxygen in 930 COPD pts on COTFrance 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

The Terminology of Home Oxygen Therapy

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 20042) Booth S et al. Am J Respir Crit Care Med 1996

The Terminology of Home Oxygen Therapy

Scenaries with hypoxaemia

% SAT.O2

95 90 85

nat Flyvning anstrengelse/anfald

7 timer 3-8 timer 0,5-2 timer

The Terminology of Home Oxygen Therapy

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% and 32% 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;88-92 1. 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

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):33-82. 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

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-exerciseKillen JWW, Thorax

2000Lewis CA, ERJ 2003McKeon JL, Thorax

1988Stevenson NJ, Thorax.

2004

Effect of ambul. oxygenCombination 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

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

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 every Follow-up after 3 months and then every

6 months. 6 months.

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

%

Oxygenconcentrator orliquid oxygen

15-24 hrs/day

Mobile oxygen

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

Prevalence of HOT in various countries (per 100.000)

0102030405060708090

100

1987 1993 2006

DK

SE

F

N

Prevalence and Incidence of LTOT 1994-2000

0

10

20

30

40

50

60

70

per

100

.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

per

100

.000

1995 1996 1997 1998 1999 2000

Incidence

Missing

Others

Cancer

COPD

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

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

Cu

mu

lativ

e s

urv

iva

l pro

po

rtio

n (

%)

%)

Denmark (n=5659)

Sweden (n=403)

Belgium (n=270)

France (n=252)

Australia (n=505)

NOTT, COT (n=101)

Japan (n=4552)

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

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