Resp Care
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Editorial Comment
Central oxygen delivery systems: a disaster waiting to happen?
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Review Comparative Study
Long-term oxygen therapy vs long-term ventilatory assistance.
The use of positive-pressure nasal ventilation in combination with LTOT in stable COPD patients with hypercapnic respiratory failure controls hypoventilation and improves daytime ABGs, sleep, and quality of life. Nasal ventilation in COPD is unlikely to produce benefit unless used with supplemental oxygen therapy at night. The patients who show the greatest reduction in overnight PaCO2 with ventilation are the patients most likely to benefit from long-term ventilatory support. Although there is now evidence for short-term benefit from NPPV in hypercapnic COPD, large multicenter studies with survival, exacerbations, and hospital admissions as the primary end points are required to evaluate longer-term effects of this potentially important intervention.
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Home oxygen therapy represents a scientifically validated and universally accepted therapeutic regimen for the treatment of chronic hypoxemia secondary to COPD. The clinical benefits of home oxygen, including a decrease in morbidity and often a concomitant increase in the quality of life have been repeatedly confirmed through rigorous worldwide trials, studies, and investigations. However, since home oxygen is an expensive treatment modality, important questions continue to be raised about the overall cost-benefit of the intervention. ⋯ This would help ensure that those needing and using home oxygen would continue to receive the benefit. At the same time, patient-customers who, for one reason or another, stop using their oxygen equipment despite repeated encouragement, would have the equipment removed. The net result would be that reimbursement dollars currently wasted on home oxygen equipment that is not being used could be reallocated for those patient-customers willing and able to use the equipment as prescribed.
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NOD is a common event in patients with symptomatic COPD who are not hypoxemic while awake. Up to 45% of these patients may have significant oxyhemoglobin desaturation during sleep, and most have evidence of pulmonary arterial hypertension. ⋯ Medicare requirements for prescribing nocturnal oxygen are relatively liberal and there is the possibility of misuse, which would cause a substantial increase in the cost of home health care. A well designed multicenter study is needed to provide appropriate indications and guidelines for therapy in these patients.
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Lung disease affects exercise performance through a number of mechanisms, including hypoxemia, abnormal ventilatory mechanics, abnormal ventilatory muscles, abnormal ventilatory patterns, abnormal right heart function and subjective dyspnea. Supplemental oxygen improves hypoxemia and thus improves exercise impairment resulting from hypoxemia-related reductions in oxygen delivery. Supplemental oxygen also reduces exercise ventilation. ⋯ Finally, supplemental oxygen may reduce dyspnea caused by oxygen-related carotid body activity. Important questions remain. First, is long-term oxygen use of benefit in patients with only exercise hypoxemia? Second, is exercise conditioning possible in patients with exercise hypoxemia? Third, does supplemental oxygen enhance exercise conditioning efforts in those patients with CLD but without exercise hypoxemia? If the answer to this last question is yes, what selection criteria should be used to identify those who would benefit? The answers to all of these questions will have enormous impact on our approach to the optimal management of CLD patients.