New perspectives in pulmonology
Long-term oxygen therapy (LTOT) revisited: In defense of traditional LTOT systems
Oxigenoterapia de longa duração (OLD) revista: Em defesa dos sistemas tradicionais de OLD
M.J. Kampelmacher
Center for Home Mechanical Ventilation, University Medical Center Utrecht, Utrecht, The Netherlands
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Dunne" "autores" => array:1 [ 0 => array:2 [ "nombre" => "P.J." "apellidos" => "Dunne" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S217351151200067X" "doi" => "10.1016/j.rppnen.2012.02.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217351151200067X?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0873215912000359?idApp=UINPBA00004E" "url" => "/08732159/0000001800000004/v2_201509041425/S0873215912000359/v2_201509041425/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">New perspectives in pulmonology</span>" "titulo" => "Long-term oxygen therapy (LTOT) revisited: In defense of traditional LTOT systems" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "158" "paginaFinal" => "159" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "M.J. Kampelmacher" "autores" => array:1 [ 0 => array:3 [ "nombre" => "M.J." "apellidos" => "Kampelmacher" "email" => array:1 [ 0 => "M.J.Kampelmacher@umcutrecht.nl" ] ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Center for Home Mechanical Ventilation, University Medical Center Utrecht, Utrecht, The Netherlands" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Oxigenoterapia de longa duração (OLD) revista: Em defesa dos sistemas tradicionais de OLD" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In the last two decennia the stationary oxygen concentrator has been the most cost effective oxygen source for most patients using long-term oxygen therapy (LTOT).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In most countries the oxygen concentrator has, therefore, largely replaced stationary oxygen cylinders with a volume of 10 litres or more.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The oxygen concentrator is very convenient and safe for home use. However, for patients needing an oxygen flow rate of ><span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>L/min the oxygen concentration delivered may be insufficient to meet the patient's oxygenation needs.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">At present, stationary oxygen cylinders are only being used as a back up for the oxygen concentrator in case of power failure or in the rare circumstance that there is no electrical power. Small oxygen cylinders for ambulatory use are, however, still being used to a great extent. They are made of aluminium, composite or steel. Their capacity is determined by their volume and pressurization, which may go up to 200<span class="elsevierStyleHsp" style=""></span>bars in steel cylinders. Their capacity remains, nonetheless, small and decreases even further with less weight. To increase their capacity they may be supplied with a demand oxygen delivery system (DODS), but the clinical performance of these devices is highly variable and may contribute to limitations in exercise tolerance.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">For patients who are still active the liquid oxygen system may be a better alternative. This system is not only reliable and very convenient for both home and ambulatory use but it also provides high oxygen purity, irrespective of the oxygen flow rate used.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> With a continuous flow rate of 1<span class="elsevierStyleHsp" style=""></span>L/min patients may stay away from home for a whole day. Even patients with a continuous flow rate of 3<span class="elsevierStyleHsp" style=""></span>L/min may stay away from the stationary canister for as long as 10<span class="elsevierStyleHsp" style=""></span>h if they use two portable canisters. If combined with an oxygen conserving device, such as a transtracheal catheter or a DODS, this may even double. In order to reduce the full weight of the portable canister (2.2–6.0<span class="elsevierStyleHsp" style=""></span>kg for a volume of 1.0–2.0<span class="elsevierStyleHsp" style=""></span>L of liquid oxygen) smaller canisters with an integrated DODS have been developed. As with small oxygen cylinders and a DODS it is, however, questionable if the maximum setting on the portable containers is able to meet the patient's oxygenation needs. A major disadvantage of all liquid oxygen systems is the requirement for pressure relief venting. The effect is that oxygen is consumed even if the patient does not use it. Another drawback is that the different systems are incompatible with each other. For out-of-town travel, this factor takes on a particular significance. Finally, the high costs of the liquid oxygen system in comparison to an oxygen concentrator may explain why at present this convenient oxygen source is provided less often than 10 years ago.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">By far the majority of patients using LTOT suffer from COPD, and most of them spend most of their time in and around their house. They are generally at rest but occasionally they may perform some light activities. These patients usually can be oxygenated effectively most of the day by an oxygen concentrator. For patients who cannot be oxygenated sufficiently with an oxygen concentrator, a liquid oxygen system seems justified. Only patients who are still active, and who desire and are able to leave their home would need a portable oxygen source. For most of them an oxygen cylinder with a capacity of 3–6<span class="elsevierStyleHsp" style=""></span>h at a continuous flow rate of 1.0–2.0<span class="elsevierStyleHsp" style=""></span>L/min would suffice to visit a friend or to do some shopping, at least in Europe where travelling time is usually not very long. The patient needing an oxygen flow rate ><span class="elsevierStyleHsp" style=""></span>2.0<span class="elsevierStyleHsp" style=""></span>L/min and who wants to leave her/his house several times per week for more than 3<span class="elsevierStyleHsp" style=""></span>h could be enabled to use oxygen nearly all the time by means of a liquid oxygen system, particularly if combined with an oxygen conserving device.</p><p id="par0025" class="elsevierStylePara elsevierViewall">With the development of non-delivery LTOT technology patients were given unlimited access to portable oxygen.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> First, special concentrators were developed that are able to safely refill reusable gaseous cylinders or liquid oxygen canisters in several hours at home. However, as patients still remained dependent on their home stationary unit, two types of portable oxygen concentrators (POCs) were created. One type can deliver oxygen only in the pulse-dose-mode, while the other is capable of delivering oxygen in either the continuous-flow (0.5–3.0<span class="elsevierStyleHsp" style=""></span>L/min) or pulse-dose mode. The latter type weighs, however, 7.7<span class="elsevierStyleHsp" style=""></span>kg and, unlike pulse-dose-mode only types (2.7–4.5<span class="elsevierStyleHsp" style=""></span>kg), cannot be carried in a shoulder bag. This new technology gives LTOT patients more freedom than ever, since they are no longer dependent on oxygen providers for frequent deliveries to refill or replace depleted oxygen sources.</p><p id="par0030" class="elsevierStylePara elsevierViewall">While the new non-delivery technology may certainly have its benefits, there are several drawbacks, which may hamper the widespread use of this technology, particularly in Europe. First, due to the low weight of the POCs the oxygen production capacity is limited to no more than 1.0<span class="elsevierStyleHsp" style=""></span>L/min. Higher flow rates can only be achieved in the pulse-dose mode. However, while usually preserving adequate oxygenation at rest, POCs like DODS may not always be able to prevent serious desaturation if the respiratory rate increases, as may occur during increased activity, during an exacerbation or in an aeroplane.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,8,9</span></a> This may be caused by the decrease of the ratio of oxygen from the POC to entrained air, thus decreasing the relative inspiratory oxygen fraction. Second, although the pulse-mode may be acceptable during exercise, several patients do not like it at rest or during sleep. Besides the risk of non-compliance this also raises important questions about the effectiveness of providing oxygen continuously. Third, the batteries are quite heavy, the battery life (1–8<span class="elsevierStyleHsp" style=""></span>h) may still prevent a wide range of action, especially at higher flow settings, and in case of malfunctioning or power failure there is no back-up. Fourth, there is a lack of standardization and the settings on the control panel of each POC do not specifically reflect the actual bolus size in mL. It is, however, the volume of the pulse dose and not the pulse dose setting that determines the actual delivered oxygen dose to the patient (in L/min or mL per breath). This underlines the importance of a titration study, and not only whenever a patient is set up on a POC. Subsequent reassessments, also during and following acute exacerbations, remain necessary to ensure that the selected pulse-dose settings remain effective.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> In many European countries, however, oxygen is still not regarded as a medicine needing a proper dose. Oxygen titration is neither reimbursed nor performed much, and usually only at rest. The potential for serious under-treatment is thus real. Indeed, the benefits reported from the use of LTOT are observed only with the effective and prolonged correction of hypoxemia.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Finally, unlike the US with its long distances and desire for mobility, for most patients in Europe this technology seems unnecessary. Likewise, OCDs have never become popular in Europe. Without any incentive for the prescribing physician, without clear overall cost effectiveness for most patients and with the low and flat price oxygen providers receive nowadays, many if not most LTOT patients in Europe will probably keep their traditional LTOT systems.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In conclusion, although non-delivery LTOT technology seems to offer more freedom than the traditional LTOT systems there is a serious risk of insufficient oxygenation, which may reduce or even annul the goal of LTOT itself: to improve survival and the quality of life by assuring adequate oxygenation at all times. Only if there were proof that this technology is able to meet this goal of LTOT, in the home setting under conditions of real life, could it be prescribed for selected patients. Until then, further research is needed to demonstrate that the same endpoints can be attained using pulse-dose-only delivery devices, like OCDs, as with the traditional LTOT systems.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">DOI of refers to article: <span class="elsevierStyleInterRef" href="doi:10.1016/j.rppneu.2012.02.011">http://dx.doi.org/10.1016/j.rppneu.2012.02.011</span>.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Andersson A, Ström K, Brodin H, et al. Domiciliary liquid oxygen versus concentrator treatment in chronic hypoxaemia: a cost–utility analysis. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 6 | 14 |
| 2024 October | 46 | 42 | 88 |
| 2024 September | 50 | 31 | 81 |
| 2024 August | 52 | 47 | 99 |
| 2024 July | 47 | 28 | 75 |
| 2024 June | 36 | 29 | 65 |
| 2024 May | 54 | 34 | 88 |
| 2024 April | 46 | 33 | 79 |
| 2024 March | 43 | 28 | 71 |
| 2024 February | 35 | 24 | 59 |
| 2024 January | 29 | 22 | 51 |
| 2023 December | 35 | 34 | 69 |
| 2023 November | 27 | 39 | 66 |
| 2023 October | 25 | 43 | 68 |
| 2023 September | 30 | 32 | 62 |
| 2023 August | 21 | 25 | 46 |
| 2023 July | 19 | 30 | 49 |
| 2023 June | 39 | 24 | 63 |
| 2023 May | 35 | 24 | 59 |
| 2023 April | 32 | 15 | 47 |
| 2023 March | 84 | 30 | 114 |
| 2023 February | 28 | 19 | 47 |
| 2023 January | 34 | 24 | 58 |
| 2022 December | 56 | 29 | 85 |
| 2022 November | 89 | 31 | 120 |
| 2022 October | 88 | 28 | 116 |
| 2022 September | 54 | 26 | 80 |
| 2022 August | 71 | 35 | 106 |
| 2022 July | 56 | 40 | 96 |
| 2022 June | 37 | 25 | 62 |
| 2022 May | 59 | 37 | 96 |
| 2022 April | 53 | 36 | 89 |
| 2022 March | 49 | 38 | 87 |
| 2022 February | 43 | 33 | 76 |
| 2022 January | 38 | 30 | 68 |
| 2021 December | 21 | 31 | 52 |
| 2021 November | 36 | 37 | 73 |
| 2021 October | 38 | 38 | 76 |
| 2021 September | 25 | 27 | 52 |
| 2021 August | 30 | 27 | 57 |
| 2021 July | 37 | 15 | 52 |
| 2021 June | 32 | 26 | 58 |
| 2021 May | 67 | 40 | 107 |
| 2021 April | 59 | 81 | 140 |
| 2021 March | 75 | 11 | 86 |
| 2021 February | 65 | 11 | 76 |
| 2021 January | 31 | 11 | 42 |
| 2020 December | 35 | 9 | 44 |
| 2020 November | 45 | 24 | 69 |
| 2020 October | 30 | 14 | 44 |
| 2020 September | 60 | 18 | 78 |
| 2020 August | 65 | 24 | 89 |
| 2020 July | 100 | 22 | 122 |
| 2020 June | 88 | 24 | 112 |
| 2020 May | 89 | 19 | 108 |
| 2020 April | 96 | 11 | 107 |
| 2020 March | 68 | 5 | 73 |
| 2020 February | 61 | 16 | 77 |
| 2020 January | 91 | 21 | 112 |
| 2019 December | 72 | 20 | 92 |
| 2019 November | 104 | 16 | 120 |
| 2019 October | 105 | 27 | 132 |
| 2019 September | 62 | 14 | 76 |
| 2019 August | 114 | 13 | 127 |
| 2019 July | 118 | 20 | 138 |
| 2019 June | 100 | 8 | 108 |
| 2019 May | 89 | 21 | 110 |
| 2019 April | 110 | 18 | 128 |
| 2019 March | 119 | 11 | 130 |
| 2019 February | 110 | 7 | 117 |
| 2019 January | 126 | 19 | 145 |
| 2018 December | 84 | 3 | 87 |
| 2018 November | 32 | 2 | 34 |
| 2018 October | 62 | 9 | 71 |
| 2018 September | 19 | 5 | 24 |
| 2018 August | 44 | 27 | 71 |
| 2018 July | 55 | 14 | 69 |
| 2018 June | 64 | 17 | 81 |
| 2018 May | 91 | 12 | 103 |
| 2018 April | 123 | 18 | 141 |
| 2018 March | 137 | 14 | 151 |
| 2018 February | 48 | 11 | 59 |
| 2018 January | 121 | 10 | 131 |
| 2017 December | 102 | 22 | 124 |
| 2017 November | 39 | 19 | 58 |
| 2017 October | 39 | 18 | 57 |
| 2017 September | 34 | 17 | 51 |
| 2017 August | 32 | 20 | 52 |
| 2017 July | 52 | 13 | 65 |
| 2017 June | 44 | 17 | 61 |
| 2017 May | 53 | 22 | 75 |
| 2017 April | 25 | 4 | 29 |
| 2017 March | 22 | 30 | 52 |
| 2017 February | 15 | 6 | 21 |
| 2017 January | 19 | 5 | 24 |
| 2016 December | 17 | 8 | 25 |
| 2016 November | 34 | 7 | 41 |
| 2016 October | 29 | 8 | 37 |
| 2016 September | 13 | 10 | 23 |
| 2016 August | 15 | 2 | 17 |
| 2016 July | 7 | 7 | 14 |
| 2016 June | 0 | 10 | 10 |
| 2016 May | 0 | 5 | 5 |
| 2016 April | 24 | 2 | 26 |
| 2016 March | 62 | 19 | 81 |
| 2016 February | 63 | 17 | 80 |
| 2016 January | 41 | 22 | 63 |
| 2015 December | 42 | 12 | 54 |
| 2015 November | 40 | 10 | 50 |
| 2015 October | 54 | 11 | 65 |
| 2015 September | 42 | 11 | 53 |
| 2015 August | 37 | 11 | 48 |
| 2015 July | 35 | 12 | 47 |
| 2015 June | 31 | 3 | 34 |
| 2015 May | 77 | 18 | 95 |
| 2015 April | 81 | 12 | 93 |
| 2015 March | 61 | 5 | 66 |
| 2015 February | 65 | 9 | 74 |
| 2015 January | 52 | 12 | 64 |
| 2014 December | 50 | 14 | 64 |
| 2014 November | 53 | 8 | 61 |
| 2014 October | 121 | 17 | 138 |
| 2014 September | 47 | 15 | 62 |
| 2014 August | 45 | 7 | 52 |
| 2014 July | 64 | 9 | 73 |
| 2014 June | 50 | 7 | 57 |
| 2014 May | 50 | 12 | 62 |
| 2014 April | 51 | 9 | 60 |
| 2014 March | 58 | 13 | 71 |
| 2014 February | 61 | 9 | 70 |
| 2014 January | 53 | 7 | 60 |
| 2013 December | 46 | 13 | 59 |
| 2013 November | 44 | 19 | 63 |
| 2013 October | 50 | 17 | 67 |
| 2013 September | 45 | 13 | 58 |
| 2013 August | 51 | 28 | 79 |
| 2013 July | 73 | 18 | 91 |
| 2013 June | 66 | 20 | 86 |
| 2013 May | 50 | 18 | 68 |
| 2013 April | 53 | 29 | 82 |
| 2013 March | 59 | 22 | 81 |
| 2013 February | 57 | 25 | 82 |
| 2013 January | 62 | 32 | 94 |
| 2012 December | 38 | 21 | 59 |
| 2012 November | 43 | 26 | 69 |
| 2012 October | 59 | 17 | 76 |
| 2012 September | 31 | 12 | 43 |
| 2012 January | 79 | 0 | 79 |
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