Long-term supplemental oxygen therapy
- Brian L Tiep, MD
Brian L Tiep, MD
- Director of Pulmonary Rehabilitation, City of Hope National Medical Center
- Associate Professor of Medicine, Western University of Health Sciences
- Rick Carter, PhD, MBA
Rick Carter, PhD, MBA
- Lamar University, Beaumont, TX
Long-term oxygen therapy (LTOT) increases survival and improves the quality of life of hypoxemic patients with chronic obstructive pulmonary disease (COPD) [1-14]. Each year, approximately one million patients receive LTOT through Medicare, at a cost exceeding two billion dollars per year . This cost is increasing at an annual rate of nearly 13 percent.
Because LTOT is a costly therapy, Medicare reimbursement for its prescription is tightly regulated. In this topic review, we describe the benefits of LTOT and indications for its use. In addition, we address practical issues including reimbursement, documenting the patient's need for LTOT, and the process of prescribing LTOT that is necessary for the patients to receive their oxygen. Continuous oxygen delivery systems, high-flow nasal cannula, portable oxygen delivery, and oxygen conserving devices are discussed separately. (See "Continuous oxygen delivery systems for infants, children, and adults" and "Portable oxygen delivery and oxygen conserving devices".)
Four randomized, controlled trials have evaluated the effect of long-term oxygen therapy (LTOT) on mortality in patients with COPD. Two of the trials, the Nocturnal Oxygen Therapy Trial (NOTT) and the Medical Research Council (MRC) trial, demonstrated improved survival among patients that received LTOT (figure 1 and figure 2), including correlation between survival and the average daily duration of oxygen use [1,2]. In contrast, two trials found no effect of LTOT on survival [4,15].
An important difference between these trials was the inclusion criteria . The trials that demonstrated a survival benefit included patients with more severe resting hypoxemia (arterial oxygen tension [PaO2] ≤60 mmHg [7.98 kPa]) than the trials that showed no benefit (PaO2 <69 mmHg [9.18 kPa]), indicating that individuals with less severe hypoxemia may not derive survival benefit from LTOT.
LTOT may improve outcome measures other than mortality, including quality of life, cardiovascular morbidity, depression, cognitive function, exercise capacity, and frequency of hospitalization [3,5-12,16,17]. Improved quality of life was demonstrated in a prospective study that measured health related quality of life (using the St. Georges Respiratory Questionnaire [SGRQ]) before and after six months of LTOT delivered via a concentrator . Prior to therapy, health related quality of life was worse among the patients with COPD who had hypoxemia (and had already been receiving LTOT for at least six months via a cylinder), compared to patients with COPD who were not hypoxemic. After six months of LTOT, health-related quality of life had improved and was similar in both groups. This suggests that LTOT improves quality of life and the improvement is related, at least in part, to the time spent using supplemental oxygen, which also relates to the delivery system(s) used. The effect of combining concentrators and portable devices to improve mobility and further enhance quality of life has yet to be determined. Prescribing oxygen during exertion with highly portable lightweight devices without the support of a pulmonary rehabilitation program may or may not lead to a more active lifestyle.
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- ADVERSE EFFECTS
- PRESCRIBING OXYGEN
- Determining need
- Oxygen flow rate
- Equipment selection
- Certification of Medical Necessity
- Ongoing assessment
- CLINICAL TRIALS APPROVED BY CMS AND SPONSORED BY THE NATIONAL HEART, LUNG, AND BLOOD INSITITUE (NHLBIH)
- ADDITIONAL CONSIDERATIONS
- Transtracheal oxygen
- Exercise training
- Nocturnal desaturation
- Air travel
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS