CLINICAL COMPONENT FOR THE HOME OXYGEN SERVICE IN ENGLAND AND WALES

Transcription

1 CLINICAL COMPONENT FOR THE HOME OXYGEN SERVICE IN ENGLAND AND WALES This document has been prepared by members of the British Thoracic Society (BTS) Working Group on Home Oxygen Services, which is a Sub-Committee of the Standards of Care Committee of the BTS. January 2006

2 INTRODUCTION This document describes the clinical standard for the assessment and prescription of domiciliary oxygen therapy, based on the report prepared by the Royal College of Physicians on clinical guidelines for domiciliary oxygen therapy services (Domiciliary Oxygen Therapy Services. Clinical Guidelines and Advice for Prescribers. A report of the Royal College of Physicians. 1999). The document also discusses aspects of follow up requirements for optimal management of patients on long term oxygen therapy. The document is divided into two parts: Part A on the clinical standard for adults and a separate Part B on children as the issues involving oxygen therapy for children differ in many ways from those in adults. PART A ADULTS 1. LONG TERM OXYGEN THERAPY (LTOT) 1a Definition Long term oxygen therapy (LTOT) refers to the provision of oxygen therapy for continuous use at home for patients with chronic hypoxaemia (PaO 2 at or below 7.3 kpa, (55mHg)). The oxygen flow rate must be sufficient to raise the waking oxygen tension above 8 kpa, (60 mmhg). Once started, this therapy is likely to be life long. LTOT is usually given for at least 15 hours daily, to include night time, in view of the presence of worsening arterial hypoxaemia during sleep. 1b Indications A Chronic hypoxaemia Long term oxygen therapy is indicated for the following conditions with chronic hypoxaemia: Chronic obstructive pulmonary disease Severe chronic asthma Interstitial lung disease Cystic fibrosis Bronchiectasis Pulmonary vascular disease Primary pulmonary hypertension Pulmonary malignancy Chronic heart failure In patients with chronic hypoxaemia, LTOT should usually be prescribed after appropriate assessment, when the PaO 2 is consistently at or below 7.3 kpa (55 mmhg) (2,3), when breathing air during a period of clinical stability. Clinical stability is defined as the absence of exacerbation of chronic lung disease for the previous five weeks. The level of PaCO 2 (which may be normal or elevated) does not influence the need for LTOT prescription. In addition, LTOT can be prescribed in chronic hypoxaemia patients when the clinically stable PaO 2 is between 7.3 kpa and 8 kpa, together with the presence of one of the following: Secondary polycythaemia Clinical and or echocardiographic evidence of pulmonary hypertension. 2

3 LTOT should not be prescribed in patients with chronic hypoxaemia patients with a PaO2 value above 8kPa (4). B Nocturnal hypoventilation Obesity Neuromuscular/spinal/chest wall disease Obstructive sleep apnoea (with CPAP therapy) Assessment for LTOT requires referral to a physician with a specialist interest in these disorders. LTOT will normally be used as an adjunct to ventilatory support techniques (noninvasive ventilation (NIV) or continuous positive airway pressure (CPAP). C Palliative Use Domiciliary oxygen therapy can be prescribed for palliation of dyspnoea in pulmonary malignancy and other causes of disabling dyspnoea due to terminal disease (5). 1c Assessment for long term oxygen therapy - Adults Appropriate assessment for long term oxygen therapy requires consideration of three factors: A confident clinical diagnosis of the disorder associated with chronic hypoxaemia. There should have been optimum medical management of the particular condition and clinical stability for at least 5 weeks prior to assessment. Arterial blood gas tensions must be measured The patient will require referral to a service directed by a consultant physician with an interest in respiratory medicine for measurement of arterial blood gases and assessment for LTOT prescription. 1d Blood gases Arterial blood gas tensions must be measured on two occasions, not less than three weeks apart as blood gases can change over time and with changes in therapy (6). Either blood gases from a radial or femoral artery or arterialised ear lobe capillary blood gases can be used for assessments (7). Ear lobe gases may have an advantage as samples can be performed currently by various health care professionals. Blood gases must be measured, rather than SaO 2 with a pulse oximeter, as assessment of hypercapnia and its response to oxygen therapy is required for safe prescription of LTOT. Oximetry has also poor specificity in the crucial PaO 2 range for LTOT prescription and thus is unsuitable when used alone for primary assessment (8). However, it may prove valuable in selecting patients who require further blood gas analysis. Blood gases must be measured with the patient breathing air for at least 30 minutes after he/she last received any supplemental oxygen. If it is considered that LTOT would benefit the patient, arterial blood gases should also be measured with the patient breathing supplemental oxygen for at least 30 minutes to assess the change in the PaO 2 and PaCO 2. It is advised that measurements of blood gases should be taken, while patients are using the same equipment as will be provided in the home. It is usual to start with a supplemental oxygen flow rate of 2 l/minute via nasal cannulae, or from a 24% controlled oxygen face mask, and to aim for a PaO 2 value of at least 8 kpa. If oxygenation is 3

4 insufficient, the oxygen flow rate should be increased gradually. Some patients may require higher oxygen flow rates to correct hypoxaemia (greater than 4 l/minute) and thus may require an additional oxygen concentrator at home. There is no evidence of the benefit in increasing the oxygen flow rate routinely at night. Patients with neuromuscular disease or scoliosis who develop hypercapnic respiratory failure usually respond well to non-invasive ventilation (NIV). Use of LTOT alone in these patients will often lead to a further and potentially dangerous rise on PaCO 2. When chronic hypoxaemia persists on NIV, LTOT may be provided to be used with the ventilator. It is usual to start LTOT with a supplemental oxygen flow rate of 1 l/minute via nasal cannulae, or with a 24% controlled oxygen face mask In this group of patients, hypoxemia with a normal PaCO 2 is less common and hypercapnia often follows after a fairly short interval. Overnight SaO2 and PaCO 2 should be monitored before starting LTOT and at regularly intervals afterwards. 1e Assessment of nocturnal hypoxaemia There is a close relationship between the extent of daytime and nocturnal hypoxaemia and thus the routine monitoring of overnight SaO 2 and PaCO 2 is not required (9). However, this may be required under the following circumstances: Patients with COPD may report a history of morning headache, which could be due to overnight and early morning hypercapnia. When there is doubt about the adequacy of overnight correction of SaO 2, eg with the presence of persistent oedema or secondary polycythaemia. Patients with chest wall and neuromuscular conditions require measurement of overnight SaO 2 and PaCO 2 if they are to be prescribed LTOT. They will also require overnight assessment, if they intend to use LTOT in combination with noninvasive ventilatory support. Nocturnal SaO 2 should be measured if there is a suspicion of sleep apnoea and this will need to be combined with appropriate assessment of the severity of apnoea. Overnight SaO 2 may be measured with a pulse oximeter, either in hospital or at home. Measurement of overnight PtCO 2 is usually performed continuously with transcutaneous CO 2 measurements in hospital. Measurement of arterial blood gas tensions when the patient has woken in the morning can also provide some indication of the tendency to carbon dioxide retention. Patients not meeting criteria for LTOT prescription Patients with borderline blood gases for LTOT prescription should be reassessed in three months with repeat arterial blood gases, as a number of them will require LTOT subsequently. Smoking and home oxygen Smoking cessation techniques should be continued prior to any home oxygen assessment and prescription. Patients should be made aware of the dangers of continuing to smoke in the presence of home oxygen therapy. 4

5 2 AMBULATORY OXYGEN THERAPY 2a Definition: Ambulatory oxygen therapy refers to the provision of oxygen therapy during exercise and activities of daily living. Ambulatory oxygen therapy can be prescribed in patients on LTOT, who are mobile and need to or can leave the home on a regular basis. The type of portable device provided will depend on the patient's mobility and it has been shown that relatively few patients with COPD actually use ambulatory oxygen therapy for more than 4 hours daily in the first instance (10,11). The characteristics of longer-term concordance are unknown Ambulatory oxygen therapy is indicated for the following conditions (10,12): Chronic obstructive pulmonary disease Severe chronic asthma Interstitial lung disease Cystic fibrosis Pulmonary vascular disease Primary pulmonary hypertension Note Ambulatory oxygen therapy is not recommended in patients with chronic lung disease and mild hypoxaemia (not on LTOT) without exercise de-saturation. It is also not recommended for patients with chronic heart failure (13,14). 2b Patient grading for ambulatory oxygen prescription Ambulatory oxygen has been shown to be effective in increasing exercise capacity and reducing breathlessness in patients with exercise arterial oxygen desaturation, defined as a fall in SaO 2 of 4% to a value <90% (15,16). The purpose of ambulatory oxygen is to enable the patient to leave the home for a longer period of time, to improve daily activities and quality of life. Patients who are candidates for ambulatory oxygen prescription will be either already on LTOT or they will have a PaO 2 above the limit for LTOT prescription but show evidence of exercise de-saturation. Surveys have shown that many patients with ambulatory oxygen therapy spend relatively little time outside the home and do not use their equipment on a regular basis (13). Thus before prescription of ambulatory oxygen, it is important to determine the level of outside activity that the patient is likely to perform, so that the most effective and economical device is provided. However a significant proportion of patients on long term oxygen therapy are already housebound and unable to leave the home unaided (17,18). Not all patients in this group will require ambulatory oxygen. Portable oxygen use in this group will be required for short periods only and this low use will be reflected in the nature of the oxygen device that is provided. Grade 1 oxygen requirements - LTOT Low Activity Ambulatory oxygen therapy may also be indicated in patients with severe hypoxaemia who are on LTOT for up to 24 hours, and are mainly housebound. These patients will need ambulatory oxygen in order to leave the house, visit relatives etc. However, patients in this group may only require occasional ambulatory oxygen use and this will inform decisions or recommendations on the type of 5

6 device that is provided. The flow rate of the ambulatory system will generally be the same as used with the LTOT. The hours of use will be estimated during the assessment Grade 2 oxygen requirements - LTOT Active Group Ambulatory oxygen therapy is indicated in patients on LTOT, who are mobile and need to leave the home on a regular basis. The type of device that is provided will depend on the patient's mobility and use of ambulatory oxygen. The hours of use will be estimated during assessment, together with the oxygen flow rate. Grade 3 oxygen requirements - non LTOT patients Patients without chronic hypoxaemia and LTOT, should be considered for ambulatory oxygen therapy only if they show evidence of exercise oxygen desaturation, improvement in exercise capacity and/or less breathlessness with ambulatory oxygen therapy and the motivation to use the ambulatory oxygen outside the house. The hours of use will be estimated during assessment, together with the oxygen flow rate. 2c Assessment for ambulatory oxygen therapy Ambulatory oxygen therapy should only be prescribed after appropriate assessment by the hospital specialist. The purpose and nature of the assessment may vary according to the patient grading system and depend on the patient s activity and ability to leave the home. Assessments for ambulatory oxygen therapy are currently designed around the short-term response to supplemental oxygen therapy, when the patient is performing an exercise test, such as a six minute walking test, or a shuttle walk test (13.15). Endurance exercise tests may be more sensitive to benefit than tests of maximal capacity. In some cases the weight of the ambulatory device has been shown to negate the benefit of the therapy on the short term response. Also it may not always be possible to completely correct the exercise de-saturation even with higher flow rates. The assessment should be used as an opportunity to make an initial assessment, set a flow rate and introduce the patient to the device. The assessment should ideally be performed after pulmonary rehabilitation. The initial assessment should be followed by a review after two months when the true value of ambulatory oxygen can be judged by interview, diary card and oxygen usage. Ambulatory oxygen should be withdrawn if unhelpful. An example of a diary card is available as appendix 1 Grade 1 Oxygen Requirements - Low Activity Formal assessment is not practicable in this group of patients and the need for ambulatory oxygen will be intermittent and used mainly to travel outside the home to friends and relatives. In general, the same flow rate for portable oxygen should be used as for LTOT provision. Grade 2 Oxygen Requirements - Active Group 6

7 The main purpose of assessment is to evaluate the oxygen flow rate to correct exercise desaturation and to introduce the technology. The walking test assessments should be performed by an appropriately trained health care professional and may take the form of six minute walk test or shuttle walk tests. In view of learning effects with walking tests, the recommended practice walks are essential before the test walks are performed. A gap of 30 minutes for rest is recommended between the various walk tests. The walking test should ideally be performed on the oxygen equipment that will be provided by the contractor. The walking test may require repeating if higher oxygen flow rates are required. The following measurements should be obtained: (i) (ii) (iii) SpO 2 during the exercise test. (many oximeters can record the whole test) Supplemental oxygen flow rate that is required to maintain the SpO 2 above 90% where possible during exercise Walking distance and measurement of resting/end exercise dyspnoea using an instrument such as the Borg Score or a Visual Analogue Score. Grade 3 Requirements - Non- LTOT patients - Exercise Desaturators Patients with only moderate hypoxaemia (PaO 2 >7.3 kpa) and who are not on LTOT, may show exercise desaturation with a fall in SaO 2 of 4% to a value <90%. Assessment and education should be performed as above. Ambulatory oxygen should only be prescribed if there is evidence of exercise de-saturation that is corrected by the proposed device. The assessments described above are based on current recommended practice and it is likely that as further information is obtained from research studies, then these recommendations for assessment for ambulatory oxygen therapy will be amended. A flow chart for the provision of home oxygen is available as Appendix 2 3 SHORT BURST OXYGEN THERAPY Short burst oxygen therapy refers to the intermittent use of supplemental oxygen at home usually for periods of about 10 to 20 minutes at a time to relieve dyspnoea. It is important to differentiate short burst therapy from the provision of continuous oxygen with exercise and termed ambulatory oxygen therapy. 3a Use of short burst oxygen therapy Short burst oxygen therapy has traditionally been used for: pre-oxygenation before exercise breathlessness during recovery from exercise control of breathlessness at rest. used in palliative care used after an exacerbation of COPD to bridge the time to full LTOT assessment Despite extensive prescription of short burst therapy, there is no adequate evidence available for firm recommendations and further research is required (19,20). Short burst oxygen should be considered for episodic breathlessness, not relieved by other 7

8 treatments in patients with the following conditions: severe COPD interstitial lung disease heart failure palliative care. Short burst oxygen should only be prescribed if an improvement in breathlessness and/or exercise tolerance can be documented. Assessment for short burst oxygen therapy No specific methodology has been developed for assessment of short burst therapy. Other causes of breathlessness must be excluded and patients should be assessed for LTOT if appropriate 4 HOME OXYGEN ORDERS (PRESCRIPTIONS) 4a Home Oxygen Order Form (HOOF), consent and Home Oxygen Record (HOR) form Most orders (prescriptions) for home oxygen therapy will be initiated by a hospital specialist with an interest in respiratory disease. Patients who may require or benefit from provision of LTOT should be referred to a designated hospital specialist who is supported by a multidisciplinary team, trained in the assessment of home oxygen provision. General practitioners will continue to be able to prescribe home oxygen but it is expected that this will be mainly for palliative use. Prescription for all types of home oxygen therapy (adults and children) will be made on a specially designed "Home Oxygen Order Form (HOOF)" (Appendix 3). This form will then be sent by Fax to the contractor, who will organise delivery of oxygen to the home. All types of oxygen therapy (LTOT, ambulatory and short burst) will be prescribed on this single Order Form. Generally clinicians will not specify the type of equipment that is to be provided for provision of home oxygen, but they may discuss possible options with the service contractors. It will also be necessary to obtained consent from the patient to allow information provided on the HOOF to be shared. When the first order is placed the Home Oxygen Consent Form (HOCF) (Appendix 4) should be signed by the patient. The completed HOCF should be placed in the patient s medical file and a copy given to the patient. It is also recommended that all home oxygen prescribers also complete a "Home Oxygen Record Form (HORF) (Appendix 5). This form will also be used for recording assessment of these patients. The hospital specialist will complete the HORF for each patient as appropriate. It will have three separate parts for LTOT, ambulatory oxygen therapy and short burst oxygen therapy: Information on the HORF will include: Diagnosis for oxygen provision Arterial blood gas measurement on two occasions Oxygen flow rate that is suggested for therapy Results of ambulatory oxygen assessments Reason for short burst oxygen therapy Results of follow up assessments for LTOT and ambulatory oxygen therapy 8

9 The HORF should be included with the patient hospital records. A copy of the HORF should be sent to the general practitioner so that he is informed that the patient is receiving oxygen. 4b Provision in primary care Where LTOT or ambulatory oxygen is prescribed by the GP, this should be after a full assessment in hospital. When home oxygen is provided on a palliative basis a hospital assessments may not be necessary. It is recommended that The GP also completes the HORF to ensure that the blood gas data and other information is recorded on the HORF. Where a GP prescribes LTOT for example for palliative purposes - the appropriate information should be recorded on the HORF. 4c Provision after hospital admission and temporary oxygen supply Provision of long term oxygen therapy should be avoided on hospital discharge, when patients are recovering from an exacerbation. Patients should be reviewed 5 weeks later to assess blood gases when they are clinically stable. However some patients may have marked symptomatic hypoxaemia. For these patients, it is reasonable to provide a temporary source of supplemental oxygen (eg an F-size cylinder or temporary concentrator). Home oxygen equipment should be discontinued where arterial blood gases improve and where oxygen therapy is no longer required. The temporary oxygen supply is usually prescribed for up to a 6 week period. 4d Emergency/out of hours oxygen Provision of oxygen will be possible on an emergency basis if for example the GP feels that the patient is not ill enough to be admitted to hospital. Oxygen will be prescribed for a fixed period only. The GP should note the arterial oxygen saturation (SaO 2 ), if an oximeter is available. Patients usually receiving oxygen in this manner will later need formal assessment for LTOT etc. 4e Provision of oxygen outside the patient's home It will be possible to prescribe oxygen therapy when the patient travels outside their home in England/Wales. In these circumstances another oxygen order will be issued and this order will be sent to the contractor servicing the region to which the patient will travel. 5.ORGANISATION OF HOME OXYGEN SERVICES 5a Patient education Following a decision to provide LTOT and/or ambulatory oxygen therapy, it is recommended that the patient receives education and some written information about the reason for oxygen prescription and principles of oxygen therapy. This education can be supplied by a variety of people, including specialist nurse, either hospital based or affiliated with the oxygen contractor, physiotherapist, technologist/scientist or doctors. It is important that a spouse/family member or carer attends the education sessions with the patient and that the carer's needs are adequately addressed within the education programme. The following topics should be covered in the education programme: 9

10 1. Condition requiring LTOT and/or ambulatory oxygen and reason for prescription. 2. Explanation of requirements for taking LTOT for at least 15 hours daily and principles of low flow oxygen therapy. 3. Discussion of principles of ambulatory oxygen therapy, in relation to individual needs 4. Explanation of the principles of the oxygen concentrator and/or ambulatory oxygen equipment. 5. Assessment of requirements for a back up cylinder for the concentrator. 6. Demonstration of refilling and maintenance of portable equipment. 7. Explanation of home servicing arrangements and electricity reimbursement. 8. Discussion of the advantages of nasal cannulae for oxygen delivery. Some patients may require masks. 9. Assessment of requirement for humidifier. 10. Warning about the dangers of cigarette smoking in the presence of oxygen equipment. 11. Enquiry about the domestic situation with respect to installation of oxygen equipment or storage. 12. Contact telephone number for a nurse specialist or physiotherapist or technician should be available if possible. The oxygen concentrator company will provide the patient with a contact telephone number for emergency breakdowns and problems. 13. Advice on travel with oxygen therapy. Further education, relating specifically to the oxygen equipment will be provided by the field engineer at oxygen delivery and installation. 5b Education for health care professionals Changes are being introduced to the home oxygen service and the new guidelines for assessment and provision of home oxygen therapy must be communicated to respiratory physicians, other hospital physicians and primary care. The British Thoracic Society, Royal College of Paediatrics, Royal College of Nursing and other professional societies (eg ARTP, ACPRC) will need to play a part in dissemination of the new regulations. The subject of home oxygen therapy will require priority in continuing medical education programmes, organised by the relevant professional Colleges. Respiratory physicians should also organise local teaching sessions for their staff and general practitioners on new aspects of oxygen therapy. The new guidelines should be also incorporated into the curriculum for specialist respiratory registrar training, into undergraduate courses and training for other professional health care groups. 5c Patient follow up Formal arrangements are required for the follow - up of patients using home oxygen therapy to ensure that LTOT adequately corrects hypoxaemia, that there is good compliance with LTOT and ambulatory oxygen therapy, to detect clinical deterioration and to ensure continuing requirement for domiciliary oxygen (17). Adequate resources will have to be identified for a follow - up programme. Long term oxygen therapy 1. Specialist follow-up All patients should be reviewed by an appropriate specialist three months after initial LTOT prescription, with arterial blood gas measurements on air and with supplemental oxygen at the 10

11 prescribed flow rate, using the same equipment as provided in the home. This is required to ensure continuing LTOT requirement and adequate correction with LTOT. It is recommended that all patients on LTOT have arterial blood gases checked at least yearly. Patients should be referred for reassessment to the hospital specialist when there is clinical deterioration, under-correction of the SaO 2 with LTOT or symptoms of worsening hypercapnia eg morning headache. Measurement of SaO 2 is a guide as to whether further assessment is required with blood gas measurement. 2. Home follow-up All patients on LTOT should be visited at home within 4 weeks of LTOT prescription by a respiratory nurse specialist, physiotherapist, technologist or scientist (depending on local arrangements), and who are experienced in the provision of domiciliary oxygen therapy. The aim of this visit is to provide further education and support for the patient and carer and to record the SaO 2 with oximetry on air and on the prescribed oxygen flow rate. For satisfactory correction of hypoxaemia, the SaO 2 should be at 92% or above with oxygen therapy. Results of the home oximetry should be sent to the hospital specialist and general practitioner. During this visit attention should be paid to the following: Concentrator location Nasal cannulae/masks Requirement for back-up cylinder. Check oxygen usage with patients and understanding of importance of adequate compliance. Reinforce that no smoking is essential. Assess use of ambulatory device if provided. Provide with contact telephone numbers for oxygen supplier and respiratory nurse/physiotherapist/technologist/scientist. All LTOT patients should be followed up six monthly at home with measurement of SaO 2 at home on air and on LTOT and communication with hospital and primary care. In patients, where the SaO 2 is under-corrected, the patient will need to have repeat blood gas assessment on oxygen therapy to adjust the LTOT. Although the oxygen flow rate can be adjusted using oximetry at home, there is a risk of worsening hypercapnia with increasing supplemental oxygen flow rate. Where the SaO 2 is noted to be at a level of 92% or above on air, the patients should be visited again in 4 weeks for repeat oximetry. If the SaO 2 level is still at 92% or above, then the patient should be referred for review by the hospital specialist to assess the requirement for LTOT. 3. Oxygen concentrator removal It may be required to remove the oxygen concentrator under the following circumstances: (a) Death of the patient (b) No further requirement due to improvement in PaO 2. This will apply to patients where LTOT may be prescribed for a limited time following an episode of respiratory failure, such as patients with sleep apnoea on CPAP therapy or patients using home ventilatory support for chest wall disease. (c) LTOT patients may be found on follow - up to have arterial blood gas tensions above the requirement for LTOT prescription. Following careful review by the respiratory physician, 11

12 LTOT may be withdrawn. There must be no other criteria for LTOT prescription in these patients eg palliative use. All patients where LTOT has been discontinued must have blood gases checked three months later and yearly if appropriate. Follow up of patients on ambulatory oxygen therapy Most patients on ambulatory oxygen therapy will be also using LTOT and the use and requirement for ambulatory equipment can be reviewed at the LTOT follow up visits. Review of ambulatory oxygen use and activity outside the house must also be made on follow - up assessment. Patients on ambulatory oxygen, who are not on LTOT, should have arterial blood gases checked at least once per year, as oxygenation may deteriorate in this patient group. In the event of symptomatic deterioration, then repeat assessment with exercise tests may be required. Short burst oxygen therapy All patients on short burst oxygen therapy should be seen at least once per year by the general practitioner or hospital specialist to review the continuing need for the short burst oxygen. In the event of clinical deterioration, then repeat assessment of arterial blood gases will have to be made. REFERENCES 1. Domiciliary Oxygen Therapy Services. Clinical Guidelines and Advice for Prescribers. A report of the Royal College of Physicians Medical Research Council Working Party Long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema. Lancet 1981; i: Nocturnal Oxygen Therapy Trial Group. Continuous or nocturnal oxygen therapy in hypoxaemic chronic obstructive lung disease. Ann Intern Med 1980; 93: Gorecka D, Gorzelak K, Sliwinski P, Tobiasz M, Zielinski J. Effect of long term oxygen therapy on survival in chronic obstructive pulmonary disease with moderate hypoxaemia. Thorax 1997: 52: Bruera E, de Stoutz N, Valsco - Leiva A, Schoeller T, Hanson J. Effects of oxygen on dyspnoea in hypoxaemic terminal-cancer patients. Lancet 1993; 342: Levi-Valensi P, Aubry P, Rida Z. Nocturnal hypoxaemia and long term oxygen therapy in chronic obstructive pulmonary disease patients with a daytime PaO2 of mmhg. Lung 1990; 168(S):

13 7. Pitkin AD, Roberts CM, Wedzicha JA. Arterialised ear lobe blood gas analysis: an underused technique. Thorax 1994; 49: Roberts CM, Bugler JR, Melchor R, Hetzel MR, Spiro SG. Value of pulse oximetry in screening for long-term oxygen requirement. Eur Respir J 1993; 6: Stradling JR, Lane DJ, Nocturnal hypoxaemia in chronic obstructive pulmonary disease. Clin Sci 1983; 64: Lock AH, Paul EA, Rudd RM, Wedzicha JA Portable oxygen therapy: assessment and usage. Respiratory Medicine 1991; 85: Lock S, Prynne M, Blower G, Wedzicha J.A. Comparison of liquid and gaseous oxygen for portable domiciliary use. Thorax 1992; 47: Marcus CL, Bader D, Stabile MW, Wand CI, Osher AB, Keens TG. Supplemental oxygen and exercise performance in patients with cystic fibrosis with severe pulmonary disease.chest 1992; 101; McDonald CF, Blyth CM, Lazarus MD, Marschner I, Barter CE. Exertional oxygen of limited benefit in patients with chronic obstructive pulmonary disease and mild hypoxaemia. Am J Respir Crit Care Med 1995; 152: Restrick LJ, Davies SW, Noone L, Wedzicha JA. Ambulatory oxygen in chronic heart failure. Lancet 1992; 340: Leach RM, Davidson AC, Chinn S, Twort CHC, Cameron IR, Bateman NT. Portable liquid oxygen and exercise ability in severe respiratory disability. Thorax 1992; 47: Eaton T, Garrett JE, Young P et al. Ambulatory oxygen improves quality of life of COPD patients: a randomised controlled study. Eur Resp J 2002: 20: Restrick LJ, Paul EA, Braid GM, Cullinan P, Moore-Gillon J, Wedzicha JA. Assessment and follow-up of patients prescribed long term oxygen treatment. Thorax 1993; 48: Wedzicha JA, Bestall J, Garnham R, Garrod R, Paul EA, Jones PW. Randomised controlled trial of pulmonary rehabilitation in patients with severe chronic obstructive pulmonary disease stratified for disability. Eur Resp J 1998; 12: Smith AA, Crawford A, MacRae KD, Garrod R, Seed WA, Roberts CM. Oxygen supplementation before or after submaximal exercise in patients with chronic obstructive pulmonary disease. Thorax 2003; 58:

14 20. N J Stevenson and M A Calverley Effect of oxygen on recovery from maximal exercise in patients with chronic obstructive pulmonary disease. Thorax 2004; 59:

15 AMBULATORY OXYGEN TRIAL DIARY CARD APPENDIX 1 Name: Flow rate (L/ min): Hospital / NHS No. Start date: Week Nos. Monday How many times did you use your ambulatory oxygen today? How long did you use the ambulatory oxygen cylinder to leave the house today? (hours & minutes) How long did you use the ambulatory oxygen cylinder around the house today? (hours & minutes) Did the ambulatory oxygen help you with activities? (Yes / No) Did the ambulatory oxygen help control your breathlessness? (Yes / No) Comments (e.g. reason for using ambulatory oxygen, reason for leaving house or any problems encountered with ambulatory oxygen) Tuesday Wednesday Thursday Friday Saturday Sunday Monday Tuesday Wednesday Thursday Friday Saturday Sunday 15

16 HOME OXYGEN FLOW CHART APPENDIX 2 Has patient chronic hypoxaemia (Pa O 2 <7.3kPa) Yes No Assess & prescribe LTOT & follow-up patient Does patient have oxygen desaturation on exercise (SaO 2 <90%) Consider if patient requires ambulatory oxygen based on walking test (i.e. 6 minute or shuttle) (Grade 3 ambulatory O 2 requirements) Does patient need & want ambulatory oxygen Yes No Does not require ambulatory No O 2 at present time Yes Does not require ambulatory O 2 How active is the patient? at present time Low activity Active (Grade 1 ambulatory (Grade 2 ambulatory) O 2 requirements) O 2 requirements) Prescribe patient Patient requires assessment ambulatory O 2 at same to determine flow rate to correct flow rate as LTOT hypoxaemia on exercise (SaO 2 >90%) 2 month trial period to determine usage Diary card to be completed 16

17 APPENDIX 3 17

18 18

19 APPENDIX 4 19

20 20

21 APPENDIX 5 ADULT HOME OXYGEN RECORD FORM Patient name.date of birth. Address Hospital No Tel No. Post code GP Surgery name and address and telephone number Mobile. PCT.. (PCT for patient s GP s main surgery, not the patient s address) Post Code Hospital Consultant.. Hospital.. Primary diagnosis: Chronic obstructive pulmonary disease Cystic fibrosis Interstitial lung disease Pulmonary hypertension Neuromuscular / chest wall disease Palliative/ disabling dyspnoea Heart failure Obesity hypoventilation syndrome Other (specify) Respiratory Support: Non-invasive ventilation CPAP Neither LONG TERM OXYGEN THERAPY (LTOT) ASSESSMENT: Date O 2 (l/min) FEV 1 FVC PaO 2 PaCO 2 SaO 2 Initial assessment (On air) 2 nd assessment (On air) 2 nd assessment (On oxygen) AMBULATORY OXYGEN THERAPY ASSESSMENT: Type of exercise test: 6 minute walk Shuttle test Other (state) Assessment on air (grade 3 only) Assessment on oxygen Date O 2 (l/min or %) to correct > 90% SaO 2 at rest Lowest SaO 2 during test Walking distance Borg / VAS pre Borg / VAS post Usage Hours / day Ambulatory O 2 Grade SHORT BURST OXYGEN: Reason for short burst : 21

22 LONG TERM OXYGEN THERAPY FOLLOW UP: Date O 2 (l/min) Oxygen device Hours / day SaO 2 on air SaO 2 PaO 2 PaCO 2 Comments / change to LTOT on O 2 4 weeks 3 months 6 months 12 months 18 months 24 months 30 months 36 months AMBULATORY OXYGEN THERAPY FOLLOW-UP: 2 months Date O 2 (l/min or %) to correct > 90% Oxygen delivery (e.g. Cylinder, Conserver, Liquid) Hours / day averaged out over a week No. days/ week leaving home Symptomatic relief Yes / No Comments / change to ambulatory oxygen 6 months 12 months 18 months 24 months 30 months 36 months This information is for clinical purposes and for confidentiality reasons should not be sent to the oxygen company. APPENDIX 6 22

23 Costings for assessment and follow-up for adult home oxygen service The changes to the home oxygen service in England and Wales have identified the need for secondary care to undertake oxygen assessments for patients being considered for LTOT and ambulatory oxygen therapy. In addition the clinical component of the home oxygen service clearly identifies the need to provide follow-up for patients prescribed home oxygen therapy. The main cost of assessment and followup is on manpower. LTOT assessment and follow-up Initial assessment 4 week follow-up 3 month follow-up 6 month follow-up 12 month follow-up Spirometry, ABG s, CXR Consultation - Dr. / respiratory nurse specialist (includes clinical examination, education, completion of oxygen order form & liaison with oxygen company) Home visit respiratory nurse specialist (includes clinical assessment, risk assessment & education) Hospital outpatient review Lung function, ABG s Consultation - Dr. / respiratory nurse specialist Home visit respiratory nurse specialist (includes clinical assessment, risk assessment & education) Hospital review Lung function, ABG s Consultation - Dr. / respiratory nurse specialist Hours Total 7.5 Ambulatory oxygen assessment and follow-up Initial Consultation (includes completion of order from & liaison with oxygen assessment company) Walking test (explanation, 2-3 walks with rest periods) 2 month Follow-up Patient education (equipment use, diary card completion) Home / outpatient visit - review of diary card & education (changes to order from & liaison with oxygen company may be required) Total 4.5 NB Follow-up of patients on ambulatory oxygen needs to occur at least 6 monthly following initial 2 month assessment period. For patients on LTOT the ambulatory oxygen review can take place at same time as LTOT follow-up. Many of the patients on LTOT will also be eligible for ambulatory oxygen and therefore it is anticipated that at least 50% of this group would require assessment. In addition patients who have exercise oxygen desaturation but not on LTOT need to be considered. Therefore for each LTOT patient 12 hours of manpower time should be allocated per year. This does not address shortburst oxygen and therefore consideration for this is required once the number of these patients have been identified locally. 1 WTE based on 40 weeks per year to take account of annual leave and study leave will provide 1500 hours of staff time per year. In addition to the clinical aspects of the home oxygen service a day per week needs to be allocated for administration, research / audit activity and in-service staff teaching. This will result in 1200 hours being available for oxygen assessment and follow-up. Therefore 1 WTE is required for 100 LTOT patients. A practitioner with advanced clinical skills, such as a respiratory nurse specialist, would be an appropriate person to undertake this role. Consideration of how best to incorporate this role within services so that patients receive comprehensive care for their long term respiratory condition needs to be determined locally to prevent fragmentation of care. 23