Oxygen therapy in ILD: What is the evidence? Matt
Description: Oxygen therapy in ILD: What is the evidence? Matt Dickson ST5 NUTH Why do we use oxygen? The hope Lengthen life Alleviate breathlessness Improve function and QoL Does it do any of the above? Does it simply improve the numbers? Who are we
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slide1. Oxygen therapy in ILD: What is the evidence? Matt Dickson
ST5
NUTH<br>
slide2. Why do we use oxygen? The hope…
Lengthen life
Alleviate breathlessness
Improve function and QoL
Does it do any of the above?
Does it simply improve the numbers?
Who are we treating?<br>
slide3. Introduction BTS guidance for home oxygen in ILD (2017)1
Evidence for use:
Survival
QoL
Dyspnoea
Exercise capacity
Discussion<br>
slide4. BTS Guidance (in a nutshell) LTOT should be ordered for patients with ILD with a resting PaO2 ≤7.3 kPa/ ≤8 kPa in the presence of peripheral oedema, polycythaemia (haematocrit ≥55%) or evidence of pulmonary hypertension (Grade D)
AOT should not be routinely offered in those not eligible for LTOT (if offered, should be proven improvement in endurance e.g.6MWT) (√)<br>
slide5. BTS Guidance (in a nutshell) POT not recommended if not hypoxaemic or have mild levels of hypoxia (SpO2 ≥92%) above LTOT thresholds (trial opiates/non-pharmacologicals) (Grade A)
SBOT not recommended (Grade A)
NOT not recommended for nocturnal hypoxaemia alone who do not fulfill LTOT criteria (Grade B)<br>
slide6. Does long-term oxygen therapy improve survival in ILD?<br>
slide7. LTOT and survival in ILD BTS Guidance Home Oxygen: “… may improve survival and tissue oxygenation, and prevent complications associated with hypoxaemia such as worsening pulmonary hypertension”
Expert opinion only
Extrapolated from evidence in COPD
BTS ILD Guidance2: there is no evidence that oxygen therapy influences quality of life or long-term survival in patients with IPF or other ILD.<br>
slide8. LTOT and survival in ILD Cochrane review 20103: Domiciliary oxygen for interstitial lung disease
Only ONE RCT identified (unpublished)
long-term oxygen vs. control group
37 on LTOT vs 25 controls
No difference in mortality at 12,24 or 36 months (91% at 3 years)
QoL not reported
Patients will gain a benefit in terms of survival if used for >500 days continuously for a minimum of 15hrs per day (chronic bronchitis/emphysema with cor pulmonale) 4<br>
slide9. LTOT and survival in ILD Retrospective analysis 2000: Idiopathic Pulmonary Fibrosis - Impact of Oxygen and Colchicine, Prednisone, or No Therapy on Survival5
Univariate analysis – increased mortality in oxygen group
Multivariate analysis – no difference in mortality<br>
slide10. Does long-term oxygen therapy improve quality of life in ILD?<br>
slide11. LTOT and HRQoL Longitudinal study of HRQoL in IPF6:
QoL (physical and psychosocial) declined more significantly in those requiring oxygen
Unclear if reflecting disease severity
Not controlled for severity of disease
Providing oxygen did not improve QoL
Self conscious, social withdrawal, trapped<br>
slide12. Does ambulatory oxygen therapy improve dyspnoea in ILD? NICE guidance (IPF in Adults 2015)7: “Oxygen therapy relieves symptoms of breathlessness”<br>
slide13. What causes dyspnoea? Respiratory mechanics
Impaired gas exchange
Cardiovascular abnormalities
Peripheral muscle dysfunction<br>
slide14. AOT and dyspnoea in ILD Oxygen therapy for interstitial lung disease: a systematic review (2017) 8
Two studies included in review which showed no benefit in dyspnoea during exercise
Supplemental oxygen users with pulmonary fibrosis perceive greater dyspnea than oxygen non-users (2015) 9
6MWT on O2 vs. RA
Dyspnoea ratings (BORG score) higher amongst oxygen users<br>
slide15. Does ambulatory oxygen therapy improve exercise capacity in ILD?<br>
slide16. AOT and exercise capacity in ILD Oxygen therapy for interstitial lung disease: a systematic review (2017) 8
Only randomised trial to assess 6MWD – no benefit
Laboratory based trials – some benefit<br>
slide17. AOT and exercise capacity in ILD<br>
slide18. AOT and exercise capacity in ILD 6 MWT Distance<br>
slide19. AOT and exercise capacity in ILD Results:
23 patients
Average increase in 6 MWT distance of 7.3%
Walked on average 23 metres further on oxygen than RA from 297 to 320<br>
slide20. AOT and exercise capacity in ILD<br>
slide21. Controversy Ethics of performing RCT (giving oxygen vs control group)
Guidelines based on extrapolated data
Patient’s receive oxygen with little justification
Patient expectation
Provider feels better
Can cause harm and poorer outcomes
Many studies of poor quality/small cohorts<br>
slide22. But watch this space… AmbOx study:
Prospective, multicentre, randomised controlled crossover UK study
Ambulatory O2 against control over 4 weeks
Does it improve health status?
Does it improve dyspnoea during ADLs?
Secondary outcomes:
QoL
HADS
Economic evaluation<br>
slide23. Over to you!<br>
slide24. Any Questions?<br>
slide25. References BTS Guidelines for Home Oxygen Use in Adults. BTS Home Oxygen Guideline Group. 2017
BTS Interstitial Lung Disease Guideline. British Thoracic. BTS ILD Guideline Group. 2008
Crockett AJ, Cranston JM, Antic N. Domiciliary oxygen for interstitial lung disease. Cochrane Database Syst. Rev. 2001: CD002883.
Long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema. Report of the Medical Research Council Working Party. Lancet. 1981 Mar 28;1(8222):681-6.
Douglas WW, Ryu JH, Schroeder DR. Idiopathic pulmonary fibrosis: Impact of oxygen and colchicine, prednisone, or no therapy on survival. Am J Respir Crit Care Med. 2000 Apr;161(4 Pt 1):1172-8.
Tomioka H, Imanaka K, Hashimoto K, et al. Health-related quality of life in patients with idiopathic pulmonary fibrosis – cross-sectional and longitudinal study. Intern Med 2007; 46: 1533–1542
NICE Guidance for IPF in Adults (2013)
Emily C. Bell, Narelle S. Cox, Nicole Goh, Ian Glaspole, Glen P. Westall, Alice Watson, Anne E. Holland. Oxygen therapy for interstitial lung disease: a systematic review. European Respiratory Review Mar 2017, 26 (143)
Cao M, Wamboldt FS, Brown KK, et al. Supplemental oxygen users with pulmonary fibrosis perceive greater dyspnea than oxygen non-users. Multidiscip Respir Med 2015; 10: 37<br>
ST5
NUTH<br>
slide2. Why do we use oxygen? The hope…
Lengthen life
Alleviate breathlessness
Improve function and QoL
Does it do any of the above?
Does it simply improve the numbers?
Who are we treating?<br>
slide3. Introduction BTS guidance for home oxygen in ILD (2017)1
Evidence for use:
Survival
QoL
Dyspnoea
Exercise capacity
Discussion<br>
slide4. BTS Guidance (in a nutshell) LTOT should be ordered for patients with ILD with a resting PaO2 ≤7.3 kPa/ ≤8 kPa in the presence of peripheral oedema, polycythaemia (haematocrit ≥55%) or evidence of pulmonary hypertension (Grade D)
AOT should not be routinely offered in those not eligible for LTOT (if offered, should be proven improvement in endurance e.g.6MWT) (√)<br>
slide5. BTS Guidance (in a nutshell) POT not recommended if not hypoxaemic or have mild levels of hypoxia (SpO2 ≥92%) above LTOT thresholds (trial opiates/non-pharmacologicals) (Grade A)
SBOT not recommended (Grade A)
NOT not recommended for nocturnal hypoxaemia alone who do not fulfill LTOT criteria (Grade B)<br>
slide6. Does long-term oxygen therapy improve survival in ILD?<br>
slide7. LTOT and survival in ILD BTS Guidance Home Oxygen: “… may improve survival and tissue oxygenation, and prevent complications associated with hypoxaemia such as worsening pulmonary hypertension”
Expert opinion only
Extrapolated from evidence in COPD
BTS ILD Guidance2: there is no evidence that oxygen therapy influences quality of life or long-term survival in patients with IPF or other ILD.<br>
slide8. LTOT and survival in ILD Cochrane review 20103: Domiciliary oxygen for interstitial lung disease
Only ONE RCT identified (unpublished)
long-term oxygen vs. control group
37 on LTOT vs 25 controls
No difference in mortality at 12,24 or 36 months (91% at 3 years)
QoL not reported
Patients will gain a benefit in terms of survival if used for >500 days continuously for a minimum of 15hrs per day (chronic bronchitis/emphysema with cor pulmonale) 4<br>
slide9. LTOT and survival in ILD Retrospective analysis 2000: Idiopathic Pulmonary Fibrosis - Impact of Oxygen and Colchicine, Prednisone, or No Therapy on Survival5
Univariate analysis – increased mortality in oxygen group
Multivariate analysis – no difference in mortality<br>
slide10. Does long-term oxygen therapy improve quality of life in ILD?<br>
slide11. LTOT and HRQoL Longitudinal study of HRQoL in IPF6:
QoL (physical and psychosocial) declined more significantly in those requiring oxygen
Unclear if reflecting disease severity
Not controlled for severity of disease
Providing oxygen did not improve QoL
Self conscious, social withdrawal, trapped<br>
slide12. Does ambulatory oxygen therapy improve dyspnoea in ILD? NICE guidance (IPF in Adults 2015)7: “Oxygen therapy relieves symptoms of breathlessness”<br>
slide13. What causes dyspnoea? Respiratory mechanics
Impaired gas exchange
Cardiovascular abnormalities
Peripheral muscle dysfunction<br>
slide14. AOT and dyspnoea in ILD Oxygen therapy for interstitial lung disease: a systematic review (2017) 8
Two studies included in review which showed no benefit in dyspnoea during exercise
Supplemental oxygen users with pulmonary fibrosis perceive greater dyspnea than oxygen non-users (2015) 9
6MWT on O2 vs. RA
Dyspnoea ratings (BORG score) higher amongst oxygen users<br>
slide15. Does ambulatory oxygen therapy improve exercise capacity in ILD?<br>
slide16. AOT and exercise capacity in ILD Oxygen therapy for interstitial lung disease: a systematic review (2017) 8
Only randomised trial to assess 6MWD – no benefit
Laboratory based trials – some benefit<br>
slide17. AOT and exercise capacity in ILD<br>
slide18. AOT and exercise capacity in ILD 6 MWT Distance<br>
slide19. AOT and exercise capacity in ILD Results:
23 patients
Average increase in 6 MWT distance of 7.3%
Walked on average 23 metres further on oxygen than RA from 297 to 320<br>
slide20. AOT and exercise capacity in ILD<br>
slide21. Controversy Ethics of performing RCT (giving oxygen vs control group)
Guidelines based on extrapolated data
Patient’s receive oxygen with little justification
Patient expectation
Provider feels better
Can cause harm and poorer outcomes
Many studies of poor quality/small cohorts<br>
slide22. But watch this space… AmbOx study:
Prospective, multicentre, randomised controlled crossover UK study
Ambulatory O2 against control over 4 weeks
Does it improve health status?
Does it improve dyspnoea during ADLs?
Secondary outcomes:
QoL
HADS
Economic evaluation<br>
slide23. Over to you!<br>
slide24. Any Questions?<br>
slide25. References BTS Guidelines for Home Oxygen Use in Adults. BTS Home Oxygen Guideline Group. 2017
BTS Interstitial Lung Disease Guideline. British Thoracic. BTS ILD Guideline Group. 2008
Crockett AJ, Cranston JM, Antic N. Domiciliary oxygen for interstitial lung disease. Cochrane Database Syst. Rev. 2001: CD002883.
Long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema. Report of the Medical Research Council Working Party. Lancet. 1981 Mar 28;1(8222):681-6.
Douglas WW, Ryu JH, Schroeder DR. Idiopathic pulmonary fibrosis: Impact of oxygen and colchicine, prednisone, or no therapy on survival. Am J Respir Crit Care Med. 2000 Apr;161(4 Pt 1):1172-8.
Tomioka H, Imanaka K, Hashimoto K, et al. Health-related quality of life in patients with idiopathic pulmonary fibrosis – cross-sectional and longitudinal study. Intern Med 2007; 46: 1533–1542
NICE Guidance for IPF in Adults (2013)
Emily C. Bell, Narelle S. Cox, Nicole Goh, Ian Glaspole, Glen P. Westall, Alice Watson, Anne E. Holland. Oxygen therapy for interstitial lung disease: a systematic review. European Respiratory Review Mar 2017, 26 (143)
Cao M, Wamboldt FS, Brown KK, et al. Supplemental oxygen users with pulmonary fibrosis perceive greater dyspnea than oxygen non-users. Multidiscip Respir Med 2015; 10: 37<br>