Maxine Hardinge

British Thoracic Society guidelines for home oxygen use in adults

The British Thoracic Society (BTS) Home Oxygen Guideline provides detailed evidence-based guidance for the use of home oxygen for patients out of hospital. Although the majority of evidence comes from the use of oxygen in patients with chronic obstructive pulmonary disease, the scope of the guidance includes patients with a variety of long-term respiratory illnesses and other groups in whom oxygen is currently ordered, such as those with cardiac failure, cancer and end-stage cardiorespiratory disease, terminal illness or cluster headache. It explores the evidence base for the use of different modalities of oxygen therapy and patient-related outcomes such as mortality, symptoms and quality of life. The guideline also makes recommendations for assessment and follow-up protocols, and risk assessments, particularly in the clinically challenging area of home oxygen users who smoke. The guideline development group is aware of the potential for confusion sometimes caused by the current nomenclature for different types of home oxygen, and rather than renaming them, has adopted the approach of clarifying those definitions, and in particular emphasising what is meant by long-term oxygen therapy and palliative oxygen therapy. The home oxygen guideline provides expert consensus opinion in areas where clinical evidence is lacking, and seeks to deliver improved prescribing practice, leading to improved compliance and improved patient outcomes, with consequent increased value to the health service.

Self-management support using an Internet-linked tablet computer (the EDGE platform)-based intervention in chronic obstructive pulmonary disease: protocol for the EDGE-COPD randomised controlled trial

Introduction The potential for telehealth-based interventions to provide remote support, education and improve self-management for long-term conditions is increasingly recognised. This trial aims to determine whether an intervention delivered through an easy-to-use tablet computer can improve the quality of life of patients with chronic obstructive pulmonary disease (COPD) by providing personalised self-management information and education. Methods and analysis The EDGE (sElf management anD support proGrammE) for COPD is a multicentre, randomised controlled trial designed to assess the efficacy of an Internet-linked tablet computer-based intervention (the EDGE platform) in improving quality of life in patients with moderate to very severe COPD compared with usual care. Eligible patients are randomly allocated to receive the tablet computer-based intervention or usual care in a 2:1 ratio using a web-based randomisation system. Participants are recruited from respiratory outpatient clinics and pulmonary rehabilitation courses as well as from those recently discharged from hospital with a COPD-related admission and from primary care clinics. Participants allocated to the tablet computer-based intervention complete a daily symptom diary and record clinical symptoms using a Bluetooth-linked pulse oximeter. Participants allocated to receive usual care are provided with all the information given to those allocated to the intervention but without the use of the tablet computer or the facility to monitor their symptoms or physiological variables. The primary outcome of quality of life is measured using the St Georges Respiratory Questionnaire for COPD patients (SGRQ-C) baseline, 6 and 12 months. Secondary outcome measures are recorded at these intervals in addition to 3 months. Ethics and dissemination The Research Ethics Committee for Berkshire—South Central has provided ethical approval for the conduct of the study in the recruiting regions. The results of the study will be disseminated through peer review publications and conference presentations. Trial registration Current controlled trials ISRCTN40367841.

Patients' experience of identifying and managing exacerbations in COPD: a qualitative study.

Background:Effective self-management in chronic obstructive pulmonary disease (COPD) is crucial to reduce hospital admissions and improve outcomes for patients. This includes early detection and treatment of exacerbations by patients themselves.Aims:To explore patients’ current understanding and experience of managing and identifying COPD exacerbations at home.Methods:A qualitative, interview-based study was carried out in patients’ homes. Interviews were audio-recorded, transcribed and analysed using a grounded theory approach. Forty-four patients (17 women, 27 men; age range 55–85 years), with moderate-to-very-severe COPD, were recruited to the interview study from primary and secondary care settings in Oxford, UK, during 2012–2013.Results:Patients identified exacerbations on the basis of measurable, ‘visible’ symptoms, such as cough and sputum and ‘invisible’ symptoms, such as chest sensations and bodily knowledge. Most patients seemed to use a combination of these approaches when identifying exacerbations, according to the symptoms that had the most impact on their well-being. Patients used additional self-management strategies during an exacerbation, such as self-medication (antibiotics and steroids) and monitored their recovery. Contact with health-care professionals usually occurred when patients felt no longer able to manage themselves.Conclusions:Patients use both assessment of objective biomarkers, which are aligned with medical knowledge, and subjective symptoms based on their experience, to identify and manage exacerbations of COPD. Health-care professionals and clinicians should acknowledge this ‘expert patient’ knowledge and integrate this into patients’ care plans to facilitate early recognition and treatment of exacerbations.

Guideline update: The British Thoracic Society Guidelines on home oxygen use in adults

The 2015 British Thoracic Society (BTS) Home Oxygen Guidelines provides detailed evidence-based guidance for the use of oxygen by patients in their own homes or other non-acute hospital settings.

Self-Management Support Using a Digital Health System Compared With Usual Care for Chronic Obstructive Pulmonary Disease: Randomized Controlled Trial

Background We conducted a randomized controlled trial of a digital health system supporting clinical care through monitoring and self-management support in community-based patients with moderate to very severe chronic obstructive pulmonary disease (COPD). Objective The aim of this study was to determine the efficacy of a fully automated Internet-linked, tablet computer-based system of monitoring and self-management support (EDGE‚ sElf-management anD support proGrammE) in improving quality of life and clinical outcomes. Methods We compared daily use of EDGE with usual care for 12 months. The primary outcome was COPD-specific health status measured with the St George’s Respiratory Questionnaire for COPD (SGRQ-C). Results A total of 166 patients were randomized (110 EDGE, 56 usual care). All patients were included in an intention to treat analysis. The estimated difference in SGRQ-C at 12 months (EDGE−usual care) was −1.7 with a 95% CI of −6.6 to 3.2 (P=.49). The relative risk of hospital admission for EDGE was 0.83 (0.56-1.24, P=.37) compared with usual care. Generic health status (EQ-5D, EuroQol 5-Dimension Questionnaire) between the groups differed significantly with better health status for the EDGE group (0.076, 95% CI 0.008-0.14, P=.03). The median number of visits to general practitioners for EDGE versus usual care were 4 versus 5.5 (P=.06) and to practice nurses were 1.5 versus 2.5 (P=.03), respectively. Conclusions The EDGE clinical trial does not provide evidence for an effect on COPD-specific health status in comparison with usual care, despite uptake of the intervention. However, there appears to be an overall benefit in generic health status; and the effect sizes for improved depression score, reductions in hospital admissions, and general practice visits warrants further evaluation and could make an important contribution to supporting people with COPD. Trial registration International Standard Randomized Controlled Trial Number (ISRCTN): 40367841; http://www.isrctn.com/ISRCTN40367841 (Archived by WebCite at http://www.webcitation.org/6pmfIJ9KK)

When should I be considering home oxygen for my patients

The ability to provide oxygen in a patient’s home can offer enormous benefits, including improvements in life expectancy when given in the appropriate setting. Confusingly, however, home oxygen is available in many forms, including long-term oxygen therapy (LTOT), ambulatory oxygen therapy (AOT), palliative oxygen therapy (POT) and short-burst oxygen therapy (SBOT)—each with varying degrees of supporting evidence. The British Thoracic Society (BTS) has recently published new guidance on home oxygen therapy, after collating the available evidence. This article aims to summarise those guidelines, focusing on who should and should not be considered for oxygen therapy. Although the BTS guidelines target a UK audience, many of the principles covered below are applicable internationally, even if the availability of certain oxygen modalities and supporting service arrangements may vary between different healthcare systems.

British Thoracic Society quality standards for home oxygen use in adults

Introduction The purpose of the quality standards document is to provide healthcare professionals, commissioners, service providers and patients with a guide to standards of care that should be met for home oxygen provision in the UK, together with measurable markers of good practice. Quality statements are based on the British Thoracic Society (BTS) Guideline for Home Oxygen Use in Adults. Methods Development of BTS Quality Standards follows the BTS process of quality standard production based on the National Institute for Health and Care Excellence process manual for the development of quality standards. Results 10 quality statements have been developed, each describing a key marker of high-quality, cost-effective care for home oxygen use, and each statement is supported by quality measures that aim to improve the structure, process and outcomes of healthcare. Discussion BTS Quality Standards for home oxygen use in adults form a key part of the range of supporting materials that the society produces to assist in the dissemination and implementation of a guideline’s recommendations.

P198 Managing Ventilatory Failure in patients on LTOT: A case series of outcomes using NIV

Background Long term Oxygen therapy (LTOT) has been shown to have survival benefits in patients with COPD when therapeutic levels are achieved (PO2 >8.0 kPa, saturations >92%). But for some patients, loss of hypoxic ventilatory drive, can lead to development of worsening ventilatory failure and symptomatic hypercapnia during oxygen titration. Current guidelines recommend use of nocturnal NIV in conjunction with LTOT in clinically stable patients who develop a respiratory acidosis and/or a rise in PaCO2 by >1 kPa (7.5 mmHg) during an LTOT assessment on two repeated occasions, but the evidence for this approach is lacking. We present a case series of patients on LTOT who were commenced on NIV for this indication, and look at arterial blood gas outcomes, survival time and hospital admissions. Methods Patients on both LTOT and NIV were identified using our local database and medical notes were reviewed. Results were analysed using a paired T-test and expressed as means with standard deviations. Results A case series of 15 patients with COPD on LTOT and NIV were identified. The mean (range) age was 68 (53–83) and mean FEV1% predicted was 29%. Mean (SD) pre-treatment pH on LTOT was 7.36 (± 0.67) and post treatment with NIV pH 7.41 (±0.38), p = 0.089. Mean LTOT pCO2 was 8.09 kPa (±1.25), and post LTOT/NIV treatment levels dropped to 7.03 kPa (±0.85), p = 0.001; with a significant improvement in PO2 from 7.26 kPa (±0.64) to 8.87 kPa (±1.15) p < 0.005. PaO2 increased to therapeutic range (≥ 8.0 kPa) in 80% of patients after commencing NIV with LTOT. Mean (SD) number of hospital admissions in the 12 months before and after the introduction of LTOT/NIV significantly reduced from 0.87 (±0.74) to 0.27 (±0.59), p = 0.023 (Figure 1). In patients with COPD, the mean survival time from starting NIV in addition to LTOT was 30 months.Abstract P198 Figure 1 Conclusion The addition of NIV to LTOT therapy can facilitate therapeutic oxygen delivery, whilst managing hypercapnia. Concurrent NIV and LTOT use can also reduce hospital admissions and increase survival times.

P41 The COPD Assessment Test (CAT) used to evaluate outcome in pulmonary rehabilitation

Introduction Outcomes in pulmonary rehabilitation (PR) can be evaluated using exercise performance tests and health status measures such as the St George′s Respiratory Questionnaire (SGRQ) and Hospital Anxiety and Depression Score (HADS). The SGRQ and HADS are timing consuming and difficult to analyse and may dissuade patients from attending. The COPD Assessment Test (CAT) is a shorter, simpler questionnaire for assessment and monitoring of health status in COPD. Scores range from 0 to 40. A high score indicates poor health status. CAT score correlates with SGRQ (r>0.8)1. Objective To determine if the CAT score could replace existing measures of health status in the evaluation of pulmonary rehabilitation. Method 70 patients underwent standard PR in community and hospital based programs. 45 were men and 25 were women. The mean age was 69. The vast majority of patients attending had COPD, confirmed by spirometry and clinical assessment. They had MRC score of 3 or more. All patients completed CAT, SGRQ questionnaires and did a modified shuttle walk test (MSWT) at the beginning and end of the program. Results After PR mean SGRQ score reduced by 5.54 (CI: 2.6 to 8.4, p <0.001). CAT score reduced by 2.08 (CI: 0.8 to 3.3, p=0.001). MSWT distance increased by 75.7 metres (CI: 55.7 to 95.8, p<0.001). Anxiety and depression scores reduced by 1.64 (CI: 0.6 to 2.6, p= 0.002) and 1.02 (CI: 0.17 to 1.88, p= 0.02) respectively. At baseline, the CAT score correlated moderately with SGRQ (r=0.48), shuttle walk (r=0.47), and HADS (r=0.43). The change in CAT before and after PR correlated weakly (r=0.38 p=0.001) with the change in SGRQ, and MSWT (r=0.45 p<0.001), and not significantly with change in HADS (r=0.28 p=0.059). Conclusion Jones et al. have evaluated the CAT in pulmonary rehabilitation.2 Their study reported an improvement in CAT of 2.2. At baseline, CAT correlated well with CRQ (Chronic Respiratory Questionnaire) domain scores. Change in CAT correlated with change in CRQ domain scores. Our study confirms CAT score can detect improvement in health status after PR. However, the lack of stong correlation with SGRQ & HADS suggests CAT should not be assumed to be equivalent in the evaluation of PR.