Zainab Ahmadi

End-of-life care in oxygen-dependent ILD compared with lung cancer: a national population-based study

Rationale Advanced fibrosing interstitial lung disease (ILD) is often progressive and associated with a high burden of symptoms and poor prognosis. Little is known about the symptom prevalence and access to palliative care services at end of life (EOL). Objectives Compare prevalence of symptoms and palliative treatments between patients dying with oxygen-dependent ILD and patients dying of lung cancer. Methods Nationwide registry-based cohort study of patients with oxygen-dependent ILD and patients with lung cancer who died between 1 January 2011 and 14 October 2013. Prevalence of symptoms and treatments during the last seven days of life were compared using data in Swedish Registry of Palliative Care. Measurements and main results 285 patients with ILD and 10 822 with lung cancer were included. In ILD, death was more likely to be ‘unexpected’ (15% vs 4%), less likely to occur in a palliative care setting (17% vs 40%) and EOL discussions with the patients (41% vs 59%) were less common than in lung cancer. Patients with ILD suffered more from breathlessness (75% vs 42%) while patients with lung cancer had more pain (51% vs 73%) (p<0.005 for all comparisons). Patients with ILD had more unrelieved breathlessness, pain and anxiety. The survival time from initiation of oxygen therapy in ILD was a median 8.4 months (IQR 3.4–19.2 months). Conclusions Patients with ILD receive poorer access to specialist EOL care services and experience more breathlessness than patients with lung cancer. This study highlights the need of better EOL care in oxygen-dependent ILD.

End-of-life care in oxygen-dependent COPD and cancer: a national population-based study.

Chronic obstructive pulmonary disease (COPD) is the third leading cause of mortality worldwide [1], and is associated with high morbidity and poor symptom control for long periods of time as the disease progresses [2]. At the end of life, COPD patients have a symptom burden comparable to, and often greater than, that associated with cancer [3]. Comparison between COPD and cancer is relevant because cancer patients have well-established palliative care programmes. Despite having extensive and similar end-of-life (EOL) needs to cancer patients, studies report unrelieved symptoms and low referral rates to palliative care in advanced COPD patients [4]. COPD patients have a high symptom burden but receive less palliative care than cancer patients at the end of life http://ow.ly/NchLv

Prescription of opioids for breathlessness in end-stage COPD: a national population-based study.

Background Low-dose opioids can relieve breathlessness but may be underused in late-stage COPD due to fear of complications, contributing to poor symptom control. Objectives We aimed to study the period prevalence and indications of opioids actually prescribed in people with end-stage COPD. Methods The study was a longitudinal, population-based study of patients starting long-term oxygen therapy (LTOT) for COPD between October 1, 2005 and June 30, 2009 in Sweden. A random sample (n=2,000) of their dispensed opioid prescriptions was obtained from the national Prescribed Drugs Register from 91 days before starting LTOT until the first of LTOT withdrawal, death, or study end (December 31, 2009). We analyzed medication type, dispensed quantity, date of dispensing, and indications categorized as pain, breathlessness, other, or unknown. Results In total, 2,249 COPD patients (59% women) were included. During a median follow-up of 1.1 (interquartile range 0.6–2.0) years, 1,034 patients (46%) were dispensed ≥1 opioid prescription (N=13,722 prescriptions). The most frequently prescribed opioids were tramadol (23%), oxycodone (23%), morphine (16%), and codeine (16%). Average dispensed quantity was 9.3 (interquartile range 3.7–16.7) defined daily doses per prescription. In the random sample, the most commonly stated indication was pain (97%), with only 2% for breathlessness and 1% for other reasons. Conclusion Despite evidence that supported the use of opioids for the relief of breathlessness predating this study, opioids are rarely prescribed to relieve breathlessness in oxygen-dependent COPD, potentially contributing to less-than-optimal symptom control. This study creates a baseline against which to compare future changes in morphine prescribing in this setting.

Long-Term Oxygen Therapy 24 vs 15 h/day and Mortality in Chronic Obstructive Pulmonary Disease

Long-term oxygen therapy (LTOT) ≥ 15 h/day improves survival in hypoxemic chronic obstructive pulmonary disease (COPD). LTOT 24 h/day is often recommended but may pose an unnecessary burden with no clear survival benefit compared with LTOT 15 h/day. The aim was to test the hypothesis that LTOT 24 h/day decreases all-cause, respiratory, and cardiovascular mortality compared to LTOT 15 h/day in hypoxemic COPD. This was a prospective, observational, population-based study of COPD patients starting LTOT between October 1, 2005 and June 30, 2009 in Sweden. Overall and cause-specific mortality was analyzed using Cox and Fine-Gray regression, controlling for age, sex, prescribed oxygen dose, PaO2 (air), PaCO2 (air), Forced Expiratory Volume in one second (FEV1), WHO performance status, body mass index, comorbidity, and oral glucocorticoids. A total of 2,249 included patients were included with a median follow-up of 1.1 years (interquartile range, 0.6–2.1). 1,129 (50%) patients died and no patient was lost to follow-up. Higher LTOT duration analyzed as a continuous variable was not associated with any change in mortality rate (hazard ratio [HR] 1.00; (95% confidence interval [CI], 0.98 to 1.02) per 1 h/day increase above 15 h/day. LTOT exactly 24 h/day was prescribed in 539 (24%) patients and LTOT 15–16 h/day in 1,231 (55%) patients. Mortality was similar between the groups for all-cause, respiratory and cardiovascular mortality. In hypoxemic COPD, LTOT 24 h/day was not associated with a survival benefit compared with treatment 15–16 h/day. A design for a registry-based randomized trial (R-RCT) is proposed.

A nationwide structure for valid Long-Term oxygen therapy : 29-Year prospective data in Sweden

Background Long-term oxygen therapy (LTOT) improves prognosis in COPD with severe hypoxemia. However, adherence to criteria for eligibility and quality of LTOT is often insufficient and varies between countries. The aim of this study was to evaluate a national structure for prescription and management of LTOT over three decades in Sweden. Methods The study was a prospective, population-based study of 23,909 patients on LTOT from 1987 to 2015 in the Swedish National Register of Respiratory Failure (Swedevox). We assessed the prevalence, incidence, and structure of LTOT; completeness of registration in Swedevox; and validity of prescription and management of LTOT in Sweden according to seven published quality indicators. Results LTOT was prescribed by 48 respiratory or medicine units and managed mainly by specialized oxygen nurses. Swedevox had a stable completeness of 85% of patients starting LTOT since 1987. The national incidence of LTOT increased from 3.9 to 14.7/100,000 inhabitants over the time period. In 2015, 2,596 patients had ongoing therapeutic LTOT in the registry, a national prevalence of 31.6/100,000. Adherence to prescription recommendations and fulfillment of quality criteria was stable or improved over time. Of patients starting LTOT in 2015, 88% had severe hypoxemia (partial pressure of arterial oxygen [PaO2] <7.4 kPa) and 97% had any degree of hypoxemia (PaO2 <8.0 kPa); 98% were prescribed oxygen ≥15 hours/day or more; 76% had both stationary and mobile oxygen equipment; 75% had a mean PaO2 >8.0 kPa breathing oxygen; and 98% were non-smokers. Conclusion We present a structure for prescription, management, and follow-up of LTOT. The national registry effectively monitored adherence to prescription recommendations and most likely contributed to improved quality of care.

Daily duration of long-term oxygen therapy and risk of hospitalization in oxygen-dependent COPD patients

Introduction Long-term oxygen therapy (LTOT) improves survival and may reduce hospital admissions in patients with chronic obstructive pulmonary disease (COPD) and severe hypoxemia, but the impact of daily duration of LTOT on hospitalization rate is unknown. We aimed to estimate the association between the daily duration of LTOT (24 vs 15 h/d) and hospital admissions in patients with LTOT due to COPD. Materials and methods A population-based, cohort study included patients who started LTOT due to COPD between October 1, 2005 and June 30, 2009 in the Swedish national register for respiratory failure (Swedevox). Time to first hospitalization from all causes and from respiratory or nonrespiratory disease, using the National Patient Registry, was analyzed using Fine–Gray regression, adjusting for potential confounders. Results A total of 2,249 patients with COPD (59% women) were included. LTOT 24 h/d was prescribed to 539 (24%) and LTOT 15–16 h/d to 1,231 (55%) patients. During a median follow-up of 1.1 years (interquartile range, 0.6–2.1 years), 1,702 (76%) patients were hospitalized. No patient was lost to follow-up. The adjusted rate of all-cause hospitalization was similar between LTOT 24 and 15–16 h/d (subdistribution hazard ratio [SHR] 0.96; [95% CI] 0.84–1.08), as was cause-specific hospitalizations analyzed for respiratory disease (SHR: 1.00; 95% CI: 0.86–1.17) and nonrespiratory disease (SHR: 0.92; 95% CI: 0.75–1.14). Conclusion LTOT prescribed for 24 h/d was not associated with decreased hospitalization rates compared with LTOT for 15–16 h/d in patients with oxygen-dependent COPD. The results should be validated in a randomized controlled trial.

Palliative oxygen for chronic breathlessness : What new evidence?

Purpose of review Supplemental oxygen improves survival in patients with chronic obstructive pulmonary disease (COPD) and severe hypoxaemia, but the effect of oxygen therapy in mild or moderate hypoxaemia to reduce symptomatic chronic breathlessness remains unclear. This review provides an overview of recent evidence about the role of oxygen therapy for the relief of chronic breathlessness in advanced illness. Recent findings In COPD, a recent Cochrane review strengthens earlier findings regarding the positive effect of supplemental oxygen compared with air during exercise test in the training setting. The novel analysis of effect of oxygen therapy on quality of life (QoL) showed no clear effect. Short-burst oxygen therapy given before exercise had no effect and should not be used. Summary Supplemental oxygen during exercise has been shown to reduce breathlessness in patients with COPD who have no or mild hypoxaemia, but it is not clear whether the reduction in breathlessness shown in the laboratory setting translates into a clinically important benefit. Further studies are needed to establish this.