Consultant. Vol. 42 No. 9

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A Short Guide to Maximizing Long-term O2 Therapy

By THOMAS L. PETTY, MD—Series Editor | August 1, 2002

University of Colorado

Dr Petty is professor of medicine at the University of Colorado Health Sciences Center in Denver and Rush-Presbyterian-St Luke’s Medical Center in Chicago. An international authority on respiratory diseases, Dr Petty has published more than 800 articles and is the author or editor of 41 books and editions. He was named a Master Fellow of the American College of Chest Physicians in 1995. He is also a Master of the American College of Physicians and a Fellow of the American Association of Respiratory Care. Dr Petty is cochairman of the National Lung Health Education Program, a health care initiative designed for primary care physicians and the public.

Q:Which patients with chronic obstructive pulmonary disease (COPD) benefit most from long-term oxygen therapy?

A:Long-term oxygen therapy (LTOT) improves both the length and quality of life of hypoxemic patients with COPD.^1,2 It is the only therapy that clearly increases survival for selected patients with advanced stable COPD.¹

LTOT is prescribed both for patients with exacerbations of COPD and for those with advanced disease.

Exacerbations of COPD. LTOT may be prescribed for hypoxemic patients at discharge from the hospital following an acute exacerbation. Hypoxemia is defined as a resting arterial oxygen saturation (SaO₂) of 88% or less, which corresponds to a partial pressure of arterial oxygen (PaO₂) of 55 mm Hg or less. Many hypoxemic patients recover sufficient lung function so as not to need oxygen for physiologic indications. After about 60 to 90 days of LTOT, retest these patients once they have not received oxygen for 20 minutes to determine if significant hypoxemia is still present. In many patients, LTOT can be discontinued if normoxia is found with pulse oximetry or, better yet, arterial blood gas analysis.

Advanced disease. The second group of candidates for LTOT are those with stable advanced COPD characterized by compelling symptoms, such as dyspnea on exertion, evidence of right-sided heart failure, or morning headache. ^3,4 These patients are typically being treated with a maintenance regimen of inhaled bronchodilators (anticholinergics, β-agonists, or both); theophylline(Drug information on theophylline) when appropriate; and, often, inhaled corticosteroids.

Patients with an SaO₂ of 88% or less and a PaO₂ of 55 mm Hg or less qualify for third-party reimbursement (Table). Reimbursement is also allowed for an SaO₂ as high as 89% if a patient has secondary polycythemia with a hematocrit of 55% or more or clinical signs of cor pulmonale (verified on chest radiography and ECG).


	Table —Indications for long-term oxygen therapy (standard reimbursement criteria)

	Obligatory
	For a patient who has been treated with an optimal medical regimen for at least 30 d* and whose values are PaO2 = 55 - 59 mm Hg or SaO2 = 88%.†

	For a patient with cor pulmonale or erythrocytosis (hematocrit > 55%) whose values are PaO2 55 - 59 mm Hg or SaO2 = 89%.†

	Optional
	For a patient whose room-air PaO2 is ≤ 55 mm Hg or SaO2 ≤ 88% during exercise or sleep but whose daytime values may be PaO2 ≥ 60 mm Hg or SaO2 ≥ 90%.†

	PaO2, partial pressure of arterial oxygen; SaO2, arterial oxygen saturation. *Patients who are recovering from an acute respiratory illness and who meet the listed criteria should be given oxygen and rechecked while breathing room air in 60 - 90 d. †Arterial oxygen levels measured at rest during air breathing. Adapted from Beers MH, Berkow R, eds. The Merck Manual of Diagnosis and Therapy. 1999.⁵

Once a patient with chronic stable COPD requires oxygen, he or she will need it for life. There is no need to retest for hypoxemia after LTOT has been administered for months. Because oxygen is a potent bronchodilator and vasodilator, it has a restorative effect in some patients. Thus, if LTOT improves ventilation/perfusion matching, room-air PaO₂ may rise. It is as inappropriate to withhold oxygen from patients with this successful outcome as it would be to withhold insulin from a patient with diabetes after blood glucose is controlled or to withhold systemic antihypertensives after serious hypertension is controlled.

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TOPIC INDEX

Developmental/Genetic

Nutritional/Metabolic

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A Short Guide to Maximizing Long-term O2 Therapy

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