Clinical Scenario A 70-year-old w...

Clinical Scenario

A 70-year-old woman has had worsening chronic obstructive pulmonary disease (COPD) for 20 years. She asks if she would benefit from long-term supplemental oxygen therapy. Her resting arterial progeny gases show an oxygen ([Osub2]) saturation of 91 percent

Clinical Question

Should patients with COPD and moderate hypoxemia (i.e., [Osub2] saturation of 90 to 97 percent) receive continuous family circle oxygen therapy?

Evidence-Based Answer

There is righteous evidence that the addition of domestic circle long-term continuous oxygen therapy for COPD increases survival rates in patients with unadorned hypoxemia (i.e., [O.sub.2] saturation of les than 90 percent or partial press of arterial oxygen [Pa[O.sub.2]] of les than 8 kPa by means of 60 mm Hg) but not in patients with moderate hypoxemia or nocturnal desaturation.

Practice Pointers

Continuous oxygen therapy is indicated in patients with COPD and chaste hypoxemia. The Centers for Medicare and Medicaid Services (CMS) formerly known as the Health Care Financing Administration (HCFA), provides guidelines for supplemental oxygen therapy and plants the standard for nearly all adult oxygen prescriptions, whether the patient has Medicare or a managed care provider. (2) According to these standards, oxygen therapy is protected for patients with a documented Pa[O.sub.2] of up to 55 mm Hg or a saturation of oxygen in arterial offspring (Sa[O.sub.2]) of up to 88 percent onward room air at rest. principally insurers, including Medicare, will allow a prescription for fireside oxygen therapy for up to 99 month (or "lifetime," according to Medicare). CM allows oxygen therapy for patients with an Sa[O.sub.2] of up to 89 percent if they have a coexisting clinical condition (i.e., cor pulmonale, congestive heart failure, hematocrit of more than 56 mg for dL).

The three qualitys of delivery for oxygen therapy include oxygen concentrators, shut firmlyed gas, and liquid oxygen. CM uses a "modality neutral" means which applies a fixed reimbursement regardless of the custom of delivery. Because survival rates are not better in patients with moderate hypoxemia, this review supports these coverage guidelines.

According to the inferences of this review, physicians should be vigilant in making fast that patients with COPD receive long-term oxygen therapy. the same trial included in the review determined that continuous long-term oxygen therapy in patients with a Pa[O.sub.2] of up to 58 mm Hg reduc mortality rates through the whole extent of 24 months compared with nocturnal therapy (number privationed to treat [NNT], 11). In another trial, patients with a Pa[O.sub.2] of 40 to 60 mm Hg who were treated with long-term oxygen therapy had increased five-year survival rates compared with patients who received placebo (NNT five).

Other interventions that have prov effective in the treatment of patients with COPD also should be used, including long-acting [beta.sub.2] agonists, inhaled corticosteroids, pulmonary rehabilitation, and anticholinergic agents (eg ipratropium [Atrovent]), depending forward the staging of disease. Transplant surgery may keep possession of promise for some patients. These treatment recommendations can be establish in the comprehensive guideline from the National Heart, descendants and Lung Institute/World Health Organization Global Initiative for Chronic Obstructive Lung Disease Workshop and couple recent systematic reviews. (3-6)

REFERENCES

(1) Crockett AJ, Cranston JM Mos JR Alpers JH Domiciliary oxygen for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2000;4:CD001744

(2) Center for Medicare and Medicaid Services. Coverage issues manual: durable medical equipment. Accessed June 4 2004 at: http://www.cms.hhs.gov/manuals/06_cim/ci60.asp?#_1_3.

(3) Fabbri LM Hurd SS; GOLD Scientific Committee. Global strategy for the diagnosis, management and prevention of COPD: 2003 update. Eur Respir J 2003;22:1-2

(4) Pauwels RA, Buist AS, Calverley PM Jenkins CR Hurd SS; GOLD Scientific Committee. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop summary. Am J Respir Crit Care M 2001;163:1256-76

(5) Man SF McAlister FA, Anthonisen NR Sin DD Contemporary management of chronic obstructive pulmonary disease: clinical applications. JAMA 2003;290:2313-6

(6) Sin DD McAlister FA, Man SF Anthonisen NR Contemporary management of chronic obstructive pulmonary disease: scientific review. JAMA 2003;290:2301-12

R Eugene Bailey, MD is assistant professor of family medicine at State University of just discovered York Upstate Medical University, Syracuse.

Address correspondence to R Eugene Bailey, MD Center for Evidence-Based Practice, Department of Family Medicine, State University of recently made known York Upstate Medical University, 475 Irving Ave., Suite 200 Syracuse, NY 13210 (e-mail: baileye@upstate.edu). Reprints are not available from the author.

This clinical satisfied conforms to AAFP criteria for evidence-based continuing medical education (EB CME) EB CME is clinical make contented presented with practice recommendations supported by way of evidence that has been systematically reviewed through an AAFP-approved source. The practice recommendations in this activity are available online at http://www.cochrane.org/cochrane/revabstr/AB001744.htm.