Long-term Home Oxygen Therapy Research Articles

A home telehealth program for patients with severe COPD: The PROMETE study

Acute exacerbations of chronic obstructive pulmonary disease (AECOP) are key events in the natural history of the disease. Patients with more AECOPD have worse prognosis. There is a need of innovative models of care for patients with severe COPD and frequent AECOPD, and Telehealth (TH) is part of these programs. In a cluster assignment, controlled trial study design, we recruited 60 patients, 30 in home telehealth (HT) and 30 in conventional care (CC). All participants had a prior diagnosis of COPD with a post-bronchodilator forced expiratory volume (FEV1)% predicted <50%, age ≥ 50 years, were on long-term home oxygen therapy, and non-smokers. Patients in the HT group measured their vital signs on a daily bases, and data were transmitted automatically to a Clinical Monitoring Center for followed-up, and who escalated clinical alerts to a Pneumologist. After 7-month of monitoring and follow-up, there was a significant reduction in ER visits (20 in HT vs. 57 in CC), hospitalizations (12 vs. 33), length of hospital stay in (105 vs. 276 days), and even need for non-invasive mechanical ventilation (0 vs. 8), all p < 0.05. Time to the first severe AECOPD increased from 77 days in CC to 141 days in HT (K-M p < 0.05). There was no study withdrawals associated with technology. All patients showed a high level of satisfaction with the HT program. We conclude that HT in elderly, severe COPD patients with multiple comorbidities is safe and efficacious in reducing healthcare resources utilization.

Effect of follow-up nursing on chronic obstructive pulmonary disease patients with long-term home oxygen therapy

Objective To explore the effect of the follow-up nursing on compliance in chronic obstructive pulmonary disease （COPD） patients with long-term home oxygen therapy.Methods Eighty-five COPD patients who needed the long-term home oxygen therapy after discharge from June 2011 to June 2012 were randomly divided into the observation group （ n =43） and the control group （ n =42）.The control group received discharge instructions, and the observation group received the telephone follow-up, home visits, outpatient follow-up and other forms of follow-up nursing on the basis of discharge instructions , and the follow-up time was six months.The quality of life, long-term home oxygen therapy compliance and adverse reactions were evaluated by the quality of life of COPD score sheet （QLICD-COPD）.Results The rate of compliance in the observation group was 95.3%after intervention, and was 45.2% in the control group, and the difference was statistically significant （χ2 =25.699, P〈0.01）.The rate of adverse reactions for patients with oxygen therapy was 6.97%in the observation group, and was 54.76%in the control group, and the difference was statistically significant （χ2 =5.362, P〈0.01）.The overall score of QLICD-COPD was （83.69 ±5.41） in the observation group, and was （73.63 ±7.78） in the control group, and the difference was statistically significant （t=6.935,P〈0.01）.Conclusions The implementation of follow-up nursing on long-term home oxygen therapy in patients with COPD can improve compliance , reduce the rate of adverse reactions for patients with oxygen therapy , and improve patients＇ self-efficacy and quality of life. Key words: Chronic obstructive pulmonary disease; Follow-up nursing; Long-term home oxygentherapy; Compliance

The Evaluation of General Practitioners’ Awareness/Knowledge and Adherence to the GOLD Guidelines in a Shanghai Suburb

The aim of this study was to determine levels of awareness of basic knowledge concerning control and prevention of chronic obstructive pulmonary disease (COPD) among general practitioners (GPs) in a Shanghai suburb and to evaluate adherence to GOLD (COPD) guidelines in primary care. All 593 practitioners, including rural and urban community GPs at 15 primary care centers in the Songjiang district of Shanghai, were questioned, comprising 331 from urban communities and 262 from rural. Only 115 GPs (19.4%) understood that COPD is categorized into acute exacerbation and stable stages, and 328 GPs (55.3%) recognized that treatment for COPD patients was still required during stable stages. A total of 235 GPs (39.6%) knew that oxygen therapy should be administered for >15 h/d as regular home therapy. In 97 cases of stage III and IV COPD, only 1 patient had accepted long-term home oxygen therapy. Prescriptions that conformed with the GOLD recommendations occurred in approximately 8% of patients according to GOLD COPD severity staging. Basic knowledge of prevention and treatment of COPD was seriously lacking in GPs. Additional training is clearly needed.

Recommendations for long-term home oxygen therapy in children and adolescents

ObjectiveTo advise pediatricians, neonatologists, pulmonologists, pediatric pulmonologists, and other professionals in the area on the main indications and characteristics of long-term home oxygen therapy in children and adolescents. Data sourceA literature search was carried out in the MEDLINE/PubMed database (1990 to 2011). Additionally, references from selected studies were included. As consistent scientific evidence does not exist for many aspects, some of the recommendations were based on clinical experience. Data synthesisLong-term home oxygen therapy has been a growing practice in pediatric patients and is indicated in bronchopulmonary dysplasia, cystic fibrosis, bronchiolitis obliterans, interstitial lung diseases, and pulmonary hypertension, among others. The benefits are: decrease in hospitalizations, optimization of physical growth and neurological development, improvement of exercise tolerance and quality of sleep, and prevention of pulmonary hypertension/cor pulmonale. The levels of oxygen saturation indicative for oxygen therapy differ from those established for adults with chronic obstructive pulmonary disease, and vary according to age and disease. Pulse oximetry is used to evaluate oxygen saturation; arterial blood gas is unnecessary. There are three available sources of oxygen: gas cylinders, liquid oxygen, and oxygen concentrators. The flows used are usually smaller, as are the number of hours/day needed when compared to the use in adults. Some diseases show improvement and oxygen therapy discontinuation is possible. ConclusionsLong-term home oxygen therapy is increasingly common in pediatrics and has many indications. There are relevant particularities when compared to its use in adults, regarding indications, directions for use, and monitoring.

Recommendations for Long-term Home Oxygen Therapy in Children and Adolescents

ObjectiveTo advise pediatricians, neonatologists, pulmonologists, pediatric pulmonologists, and other professionals in the area on the main indications and characteristics of long-term home oxygen therapy in children and adolescents. Data sourceA literature search was carried out in the MEDLINE/PubMed database (1990 to 2011). Additionally, references from selected studies were included. As consistent scientific evidence does not exist for many aspects, some of the recommendations were based on clinical experience. Data synthesisLong-term home oxygen therapy has been a growing practice in pediatric patients and is indicated in bronchopulmonary dysplasia, cystic fibrosis, bronchiolitis obliterans, interstitial lung diseases, and pulmonary hypertension, among others. The benefits are: decrease in hospitalizations, optimization of physical growth and neurological development, improvement of exercise tolerance and quality of sleep, and prevention of pulmonary hypertension/cor pulmonale. The levels of oxygen saturation indicative for oxygen therapy differ from those established for adults with chronic obstructive pulmonary disease, and vary according to age and disease. Pulse oximetry is used to evaluate oxygen saturation; arterial blood gas is unnecessary. There are three available sources of oxygen: gas cylinders, liquid oxygen, and oxygen concentrators. The flows used are usually smaller, as are the number of hours/day needed when compared to the use in adults. Some diseases show improvement and oxygen therapy discontinuation is possible. ConclusionsLong-term home oxygen therapy is increasingly common in pediatrics and has many indications. There are relevant particularities when compared to its use in adults, regarding indications, directions for use, and monitoring.

Palliative care in COPD patients: is it only an end-of-life issue?

The presence of acute or chronic respiratory failure is often seen as a terminal phase of chronic obstructive pulmonary disease. A great variability in end-of-life practice is observed in these patients mainly because physicians are not always able to correctly predict survival. There is a need for a clear discussion about decision making earlier than when acute respiratory failure ensues. Indeed, a perceived poor quality of life does not necessarily correlate with a clear willingness to refuse invasive or noninvasive mechanical ventilation. It has been suggested to start palliative care earlier, together with curative and restorative care, when there is an increased intensity of symptoms. The patients eligible for palliative care are those complaining of breathlessness, pain, fatigue and depression, which in some studies accounted for a prevalence much higher than 50%. Among comfort measures for palliation, oxygen is frequently prescribed even when the criteria for long-term home oxygen therapy are not met; however, when compared with air, no benefits on dyspnoea have been found. The only drug with a proven effect on dyspnoea is morphine, but not when it is delivered with a nebuliser. Finally, noninvasive ventilation may be used only as a comfort measure for palliation to maximise comfort by minimising adverse effects.

Comparison of domiciliary oxygen using liquid oxygen and concentrator in northern Taiwan

Long-term oxygen therapy has become standard treatment for patients with chronic respiratory insufficiency. However, patterns of long-term home oxygen therapy have not been well studied in Taiwan. Oxygen concentrator systems are commonly used in Taiwan, but liquid oxygen delivery systems are portable and may provide advantages over the concentrator system. This study compared oxygen usage between patients from a liquid oxygen group (LOG) and an oxygen concentrator group (OCG). The authors also assessed the physiologic responses of patients with chronic obstructive pulmonary disease (COPD) to ambulatory oxygen use at home. The study used a retrospective, cross-sectional, observational survey design. The LOG comprised 42 patients, and the OCG comprised 102 patients. We recruited participants in northern Taiwan from July 2009 to April 2010. The questionnaire instruments that were used to collect data consisted of three parts: demographic characteristics, devices used in respiratory care, and activity status with portable oxygen. Two-minute walking tests were performed on COPD patients in their homes. COPD was the most common diagnosis in our study, with more than 50% of patients who received oxygen long term in both groups having received this diagnosis. The LOG used oxygen for an average of 21.7 hours per day, whereas OCG averaged 15.2 hours per day (p<0.001). In the OCG, 92.2% of patients used a concentrator alone, whereas 23.8% of the LOG used liquid oxygen alone (p<0.001). The LOG patients were involved in significantly more outdoors activities (p=0.002) and reported traveling with oxygen more often (p<0.001) than the OCG patients. For patients with the same dyspnea level of COPD severity, those using liquid oxygen had a lower increase in pulse rate after the walking test, in comparison with the concentrator users. Patients in the LOG used oxygen for longer hours, went on more outings, and were more likely to travel with oxygen than patients in the OCG. Being ambulatory with liquid oxygen might enable patients with COPD to walk more effectively.

Influência das características sociodemográficas e clínicas e do nível de dependência na qualidade de vida de pacientes com DPOC em oxigenoterapia domiciliar prolongada

To evaluate and correlate the quality of life (QoL) of COPD patients on long-term home oxygen therapy (LTOT) with their sociodemographic/clinical characteristics and level of dependence. This was a cross-sectional analytical study involving COPD patients on LTOT followed at the Oxygen Therapy Outpatient Clinic of the Federal University of São Paulo Hospital São Paulo, in the city of São Paulo, Brazil. Sociodemographic, clinical, and biochemical data were collected. We assessed QoL and level of dependence using the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) and the Katz index, respectively. Multiple linear regression models were constructed in order to determine the influence of these variables on QoL. We included 80 patients in the study. The mean age was 69.6 ± 9.1 years, and 51.3% were female. The lowest SF-36 scores were for the physical functioning and role-physical domains. All sociodemographic characteristics (except gender) were found to correlate significantly with the SF-36 domains mental health, vitality, role-physical, and social functioning. We also found that body mass index, PaO2, post-bronchodilator FEV1, hemoglobin, and Katz index correlated significantly with the physical functioning, mental health, role-physical, and bodily pain domains. In addition, oxygen flows were found to correlate negatively with the physical functioning, mental health, vitality, and role-emotional domains. Low scores for SF-36 domains, as well as the variables that negatively influence them, should be considered and analyzed during the development and implementation of strategies for improving the QoL of COPD patients on LTOT.

Review of Burn Injuries Secondary to Home Oxygen

The use of long-term home oxygen therapy (HOT) has become increasingly common for treatment of chronic pulmonary diseases. Although illegal to smoke while on HOT, there is an increasing incidence of burn injuries in those patients who smoke while on HOT. The importance of recognition of the prevalence of this injury, the obstacles faced when treating these patients, and understanding the proposed algorithmic approach to be taken with patients on HOT, including prescription, reassessment, and prevention of burn injury are outlined in this review. Retrospective epidemiological data including circumstances, admission, treatment, and disposition were collected and reviewed on the patients treated from 1999 to 2008 with burns secondary to smoking while on HOT. Seventeen patients sustained injuries secondary to smoking on HOT over the 9-year period; 9 patients were female and 8 were male. All the patients were on HOT for chronic obstructive pulmonary disease. Mean patient age was 69.1 ± 2.5 years and mean TBSA 2.8 ± 0.4%; 11.8% (2/17) sustained inhalation injury requiring intubation and 23.5% (4/17) required wound debridement and skin grafting. Mean hospital stay was 42.8 ± 12.5 days; 10.3 ± 5.4 days in the burn intensive care unit and 32.5 ± 11.0 days in the ward. Before the burn injury, 23.5% (4/17) lived in long-term care facilities. On discharge from hospital, 47.1% (8/17) were transferred to extended care facilities or other acute care hospitals, and 11.8% (2/17) died during their hospitalization. After recovery, there was a 35.3% reduction in patients able to return home and/or live independently. A significant number of burn injuries secondary to smoking while on HOT was observed. These patients differ from standard burn patients because they are older in age, have higher rates of inhalation injury, and have much longer lengths of hospitalization, despite smaller TBSA injuries. Prevention of this injury would improve the safety of the patient and those around them as well as healthcare resource allocation. A proactive multidisciplinary algorithmic approach is presented which can be used to manage patients on HOT at risk for continued smoking to decrease the incidence and the impact of burn injuries in this patient population.

Long-term home oxygen therapy in children and adolescents: analysis of clinical use and costs of a home care program

To describe the clinical and laboratory characteristics of patients on long-term home oxygen therapy followed up by the home care program of Hospital das Clínicas, School of Medicine, Universidade de São Paulo, during a period of 8 years; to compare groups with and without secondary pulmonary hypertension; and to estimate the cost of the program using oxygen concentrators vs. oxygen cylinders provided by the hospital. A descriptive, retrospective cohort study of patients on long-term home oxygen therapy followed up from 2002 to 2009 at the Unit of Pulmonology, Children's Institute, Hospital das Clínicas, School of Medicine, Universidade de São Paulo. We studied 165 patients, of whom 53% were male, with the following medians: age at the beginning of oxygen therapy--3.6 years; duration of oxygen therapy--7 years; and survival time after beginning of oxygen therapy--3.4 years. The main diagnoses were: cystic fibrosis (22%), bronchopulmonary dysplasia (19%), and bronchiolitis obliterans (15%). Of the 33 patients who underwent spirometry, 70% had severe obstructive lung disease. Echocardiogram was performed in 134 patients; 51% of them had secondary pulmonary hypertension. There was a statistically significant association between pulmonary hypertension and need of higher oxygen flows (chi-square, p = 0.011), and between pulmonary hypertension and longer duration of oxygen therapy (Logrank, p = 0.0001). There was no statistically significant difference between survival time after the beginning of oxygen therapy and pulmonary hypertension. The average monthly costs of the program were US$ 7,392.93 for concentrators and US$ 16,630.92 for cylinders. Long-term home oxygen therapy was used to treat different chronic diseases, predominantly in infants and preschool children. There was a high frequency of pulmonary hypertension associated with longer periods of oxygen use and greater oxygen flow, without association with survival rate. The use of concentrators instead of cylinders may reduce costs significantly.

Compliance with long-term home oxygen therapy

Long-term home oxygen therapy has been shown to benefit patients with hypoxemic chronic obstructive pulmonary disease. However, to obtain the expected maximal benefit it is important for the oxygen to be used correctly and for a sufficient length of time. We examined compliance with home oxygen therapy in patients with chronic obstructive pulmonary disease, pulmonary fibrosis, late sequelae of pulmonary tuberculosis, and pulmonary hypertension who used oxygen concentrations. Compliance was defined as the ratio of the amount of oxygen used to the amount prescribed. The average daily length of time the concentrator actually ran was measured from the concentrator meters. These were read every 6 months by an engineer from the company that installed the concentrator. Factors thought to affect compliance were studied. These factors included age, the degree of dyspnea, arterial blood gases, and pulmonary function. Weak positive correlations were found between compliance and age and between compliance and PaCO2. A weak negative correlation was observed between compliance and PaO2. Compliance in patients with chronic obstructive pulmonary disease was higher than in patients with pulmonary fibrosis or pulmonary hypertension. Among those given prescriptions for 24-hr oxygen therapy, compliant patients had more severe dyspnea on excertion than did noncompliant patients. These data suggest that the compliant patients had more severe gas exchange problems.

Study of Prevalence and Attitudes on Smoking in Patients on Continuous Home Oxygen Therapy. Toma Study

Introduction The objective of this study was to analyse the prevalence, attitudes and characteristics of smoking in the population of patients subjected to Long Term Home Oxygen Therapy (LTOT) in the Community of Madrid. Patient and methods A representative sample of 845 subjects (461 male, 46%) was obtained from a total of 11 174 who fulfilled the inclusion criteria. The mean age was 78.25 years (95% Confidence Interval, CI, 77.55-78.95; SD=10.36). A descriptive cross-sectional study was conducted based on questionnaires as well as CO-oximetry. Results Forty-eight subjects were smokers (5.7%; 95% CI, 4.3-7.5) while 438 (51.8%; 95% CI, 48.5-55.2) were ex-smokers. The percentage of active smokers was higher in the 60 years or less subject group (χ 2; P<.001). The large majority (75%) of smokers were men, their proportion being significantly higher than that of current non-smokers (χ 2; P<.003). The mean score in the Fagerström Test was 3.6. More than 65% of smokers had their first cigarette within 30 min of getting up in the morning, and 45% of these were in a preparation stage. Seventeen percent of these subjects said they had not received advice on quitting smoking. Conclusions There is a high rate of smoking in patients on LTOT, with a higher probability of males and younger subjects continuing to smoke. There is a high level of physical dependence on nicotine.

Survie à long terme des bronchopathes chroniques obstructifs après la réanimation

To compare the one year survival after discharge from ICU of patients with chronic obstructive pulmonary disease (COPD) admitted for acute hypercapnic respiratory failure and who required mechanical ventilation. Retrospective cohort study on 130 patients, 52 patients were treated with non-invasive ventilation (NIV) and 78 patients with conventional mechanical ventilation (CMV). In 73 patients the cause for respiratory failure could not be identified. Long-term survival was significantly better following NIV than with CMV (p=0.02 by log-rank testing), but the better prognosis associated with use of NIV was not found in patients with no documented cause for the respiratory failure. After adjusting for male gender, age>65 years, simplified acute physiology score II>35, prior long-term home oxygen therapy, treatment with steroids, FEV1<30% of predicted value, body-mass index<21 kg/m2, albumin level<30 g/L, right ventricular failure, ventilator-associated pneumonia and cause of respiratory failure, NIV remained independently associated with better outcomes (adjusted hazard ratio 0.55; 95% CI 0.31-0.97; p=0.04). Our results suggest that in COPD patients requiring mechanical ventilation and who survived after an ICU stay, the use of NIV is an independent factor associated with a better long-term survival, especially in those with a documented cause of respiratory failure.

Do Terminally Ill People who Live Alone Miss Out on Home Oxygen Treatment? An Hypothesis Generating Study

Oxygen for refractory dyspnea at the end of life is commonly prescribed, even when the criteria for long-term home oxygen therapy are not met. Is palliative oxygen less likely to be prescribed when a person lives alone at the end of life? Three years of consecutively collected clinical data from a regional community palliative care program in Western Australia were used in univariate analyses utilizing chi(2) and analysis of variance, as appropriate. Multivariable logistic regression was used to identify characteristics of people for who oxygen has been prescribed. Of the study population (n = 5203), 9.8% (n = 507) did not have a caregiver. Oxygen was less likely to be prescribed for patients living alone (11.8% versus caregiver 20.6%; p < 0.001), those with cancer (18.8% versus noncancer 26.5%; p < 0.001), and older people (oxygen 68.1 years versus no oxygen 69.6 years; p = 0.005), and more likely to be prescribed for those with worse dyspnea (mean score 7/10, oxygen 7.6 versus no oxygen 4.2; p < 0.001). With severe dyspnea (= 7/10), people who lived alone had twice as many clinician visits before oxygen was prescribed (4.2 versus caregiver 1.7; p = 0.03). In multifactor analyses lung disease, dyspnea severity, and female gender predicted oxygen prescription, while not having a caregiver reduced the likelihood significantly (odds ration [OR] 0.51, 95% confidence interval [CI] 0.35-0.74; p < 0.001). Presence of a caregiver in the home is associated with palliative oxygen prescription having controlled for time in hospital. This study raises questions about the reasons for oxygen prescription, and the role caregivers may play in initiating requests for therapy.

Accuracy and reliability of pulse oximetry at different arterial carbon dioxide pressure levels

The present study aimed to assess whether arterial carbon dioxide pressure (Pa,CO(2)) has an impact on agreement between oxygen saturation measured with pulse oximetry (Sp,O(2)) or arterial blood gas co-oximetry (Sa,O(2)). Sa,O(2) and Sp,O(2) determinations were obtained simultaneously from 846 patients under assessment for long-term home oxygen therapy in a specialised outpatient clinic. Both measurements were taken with patients seated and breathing room air. Agreement between Sa,O(2) and Sp,O(2) results was analysed by the Bland-Altman method and the Lin concordance coefficient. In addition, potential interactions of arterial oxygen tension (Pa,O(2)) or Pa,CO(2) on agreement were analysed by adjusted multivariate analysis. Upon comparison of Sa,O(2) and Sp,O(2) results, the Bland-Altman technique yielded a bias (95% confidence interval (CI)) of -1.24 (-6.86-4.38) and -1.32 (-7.78-5.15) when Pa,CO(2) >48 mmHg (6.39 kPa) or Pa,O(2) <54 mmHg (7.20 kPa), respectively. Estimate by Lin's coefficient (95% CI) in these cases was 0.88 (0.85-0.90) and 0.81 (0.77-0.85). Adjusted multivariate analysis, performed to assess the impact of pH, Pa,O(2), Pa,CO(2) and bicarbonate on bias, showed that Pa,O(2), Pa,CO(2) and their interaction terms were the most important predictors of the bias (standardised estimates of -0.54, -0.94, and 0.85, respectively). The effect of pH, although statistically significant, was small, and bicarbonate had no significant effect. Arterial carbon dioxide pressure status can contribute to impaired agreement between arterial oxygen saturation and arterial oxygen saturation measured with pulse oximetry, particularly in patients with hypercapnia.

Inhaled corticosteroids and survival in COPD patients receiving long-term home oxygen therapy: Respir Med 2005. Published online 18 August 2005 as doi:10.1016/j.rmed.2005.07.007

Inhaled corticosteroids and survival in COPD patients receiving long-term home oxygen therapy: Respir Med 2005. Published online 18 August 2005 as doi:10.1016/j.rmed.2005.07.007

Inhaled corticosteroids and survival in COPD patients receiving long-term home oxygen therapy

Several observational studies suggest that therapy with inhaled corticosteroids (ICS) is associated with reduced mortality in patients with chronic obstructive pulmonary disease (COPD). However, none of these has reported survival data in COPD patients with respiratory insufficiency who require domiciliary oxygen therapy. The present study was conducted to examine the association between ICS and all-cause mortality in patients with severe COPD and chronic hypoxemia. From a tertiary referral clinic, we identified 145 consecutive COPD patients who met the criteria for long-term oxygen therapy between 1996 and 2002. We compared the hazard ratio (HR) for all-cause mortality over 1 year between patients who were (n=55) and were not treated with ICS (n=90). In a crude analysis, the use of ICS was associated with a HR of 0.38 (95% confidence interval (CI)=0.18-0.79). After adjustments for age, sex, use of oral steroids, and beta2-agonists, PaO2 and PaCO2, the HR was 0.46 (95% CI=0.21-0.98). Our findings indicate that ICS may reduce all-cause mortality in patients with severe COPD and chronic hypoxemia, who require long-term domiciliary oxygen therapy. These data suggest that ICS may play an important role in improving clinical outcomes in patients with advanced COPD.

Factores pronósticos de reingreso en la enfermedad pulmonar obstructiva crónica

Forced respiratory volume in first second spirometry is currently used to diagnose chronic obstructive pulmonary disease. However, this technique does not always provide a reliable short-term prognosis, especially in patients with associated morbidity. We propose that specific health-related quality of life questionnaires are a better tool to estimate the prognosis of chronic obstructive pulmonary disease. A total of 93 patients who had been admitted to Unit 1 of the Department of Internal Medicine at the Reina Sofia Hospital for chronic obstructive pulmonary disease exacerbation were followed up for one year after discharge. The number of hospital readmissions were recorded. A prospective cohort design and logistic regression analysis were used. Mean age was 70.8, 83% were males, 89.2% presented with an associated illness, and 59.1% had been hospitalized previously. The mean forced respiratory volume in first second was 34% and the overall score for the St George's Respiratory Questionnaire was 58.2. After one year, 40.4% of patients were readmitted to hospital. The regression model included scores for the St George's Respiratory Questionnaire activity scale (OR 1.05) and long-term home oxygen therapy (OR 5.18). The St George's Respiratory Questionnaire score better predicts hospital readmission after one year than the forced respiratory volume in first second. The activity scale is the best predictor of readmission. Long-term home oxygen therapy is associated with an increase in the number of hospitalizations.

Cardiopulmonary complications during gastroscopy in patients with chronic respiratory failure undergoing long-term home oxygen therapy.

Gastric ulcer and hemorrhage are major complications in patients with chronic respiratory failure, but upper GI endoscopy tends to be avoided because of possible cardiopulmonary events. This study was designed to evaluate hypoxemia and subsequent cardiac complications during gastroscopic procedures in patients with chronic respiratory failure undergoing long-term home oxygen therapy (LHOT). Gastroscopy was carried out in 10 patients undergoing LHOT and 10 age-matched control subjects without pulmonary diseases. Oxygen saturation and cardiac arrhythmias before and during gastroscopy were monitored. Patients were given 10 mg intramuscular scopolamine butylbromide and local anesthesia using 100-300 mg lidocaine gel 15 minutes before the procedure. Each patient continued to receive oxygen via a nasal cannula in the same dosage as their daily use. Decrease in oxygen saturation during endoscopic procedure was significantly greater in patients undergoing LHOT (from 95.9+/-0.9 to 93.4+/-1.7%) compared with control subjects (from 96.7+/-0.4 to 96.2+/-0.4%). There was a significant correlation between the degree of hypoxemia and the oxygen dosage required for their daily treatment in the patients (r = 0.727, P<0.02). These results indicate that the degree of respiratory failure influences the degree of decrease in oxygen saturation during gastroscopy. It is suggested that use of the nasal route for oxygen supply may be one of the major causes of the hypoxemia.

Lung volume reduction surgery for a patient receiving mechanical ventilation after a complex cardiac operation

Lung volume reduction surgery (LVRS) may be indicated after cardiac operations to improve pulmonary mechanics in patients with severe emphysema who are receiving mechanical ventilation. This intervention facilitates successful weaning. History. A 57-year-old woman who formerly smoked cigarettes had severe mitral stenosis and pulmonary emphysema and was evaluated for mitral valve replacement. She had been receiving long-term home oxygen therapy for 7 months. The patient had been repeatedly hospitalized during the previous year because of exacerbation of chronic obstructive pulmonary disease. At a previous anesthesiologic evaluation, the patient had been considered to be ineligible for operation because a reduction of respiratory function of at least 30% is to be expected in the early postoperative phase after mitral valve replacement. Preoperative cardiac findings. Echocardiograpy documented severe mitral stenosis (mitral valve area 0.8 cm) with an almost immobile mitral valve. The left ventricular ejection fraction was normal (64%). Both atria were dilated. Coronary angiography revealed a normal coronary circulation. Catheterization of the left side of the heart demonstrated slight mitral and aortic insufficiency (regurgitation 20%). The diastolic pressure gradient across the mitral valve was 13 mm Hg. Preoperative pulmonary findings. The patient was extremely limited in her everyday activities. The data on her preoperative pulmonary function are summarized in Table I. Blood gas analysis while she was receiving medical therapy showed an oxygen tension of 54 mm Hg, a carbon dioxide tension of 44.4 mm Hg, and an oxygen saturation of 89% without supplemental oxygen. Computed tomographic scan of the chest revealed moderately heterogenous bilateral distribution of the emphysema, with predominance in the apical segments of the lower lobes and the right upper lobe. Operative procedures and postoperative course. The initial plan was to perform mitral valve replacement with the patient in ventricular fibrillation and without crossclamping of the aorta. This operation was to be followed by bilateral LVRS. During cannulation of the ascending aorta, however, a type A dissection occurred. Therefore, not only was the mitral valve replaced (CarboMedics mitral valve, 27 mm; Sulzer CarboMedics, Inc., Austin, Texas), but the ascending aorta (Vascutec-Gelvave, 26 mm) was as well, with deep hypothermic circulatory arrest (16° C for 17 minutes) and retrograde cerebral perfusion. LVRS was postponed to optimize hemostasis and stabilize hemodynamics. Eight hours after the operation, an unstable early postoperative course necessitated reoperation for pericardial tamponade. Bilateral pneumothorax developed on the first postoperative day, and extubation was impossible. On the left side, a severe air leak persisted. Mechanical ventilation with an inspired oxygen fraction of 1.0 was needed. Bilateral LVRS was performed on the third postoperative day. The left side was operated on through a thoracotomy to ensure the inclusion of the air leak in the area of resection. The right side was operated by means of video-assisted thoracoscopy. The apical segments of the lower lobes on both sides and the most destroyed parts of the upper lobe on the right side (anterior and apical segment) were resected with nonbuttressed endoscopic staples (TLC 45; Ethicon Endo-Surgery, Cincinnati, Ohio). Immediately after LVRS, ventilation became more effective. The tidal volume increased by 40%, and the inspired oxygen fraction could be reduced from 1.0 to 0.65.