The effect of home oxygen therapy on hospitalization in moderate hypoxaemic COPD.

BACKGROUND: The aim of the study was to determine whether home oxygen therapy (HOT) reduces hospitalization in moderate hypoxaemic COPD patients. METHODS: We studied 170 consecutive moderate hypoxaemic COPD patients (PaO2 on room air and rest: 7.3-9.5 kPa), who were treated with HOT for at least one month. The patients were acting as their own control. Admission rates, days spent in hospital and number of patients with at least one hospitalization were compared in two periods of 10 months before and after initiation of HOT. RESULTS: The admission rates, number of days spent in hospital and number of patients with at least one hospitalization was not reduced (preoxygen period versus postoxygen period): 1.55 (2.00) versus 1.67 (2.26), 14.3 (19.9) versus 14.8 (23.7), and 60.6% versus 61.2%--P-level > 0.05 for all three parameters. CONCLUSIONS: Our results do not support the hypothesis that home oxygen therapy reduces hospitalization in patients with COPD without severe hypoxaemia. However, as this is not a randomized study, we cannot exclude that oxygen therapy has prevented progression of the disease, and that without this therapy, the hospitalization could have been even higher.

Transesophageal endoscopic ultrasound/fine-needle aspiration diagnosis of a malignant adrenal gland in a patient with non-small cell lung cancer and a negative CT scan.

Adrenal metastasis is only seen on CT scan is less than 5% of patients with otherwise resectable NSCLS, but this diagnosis has a major impact on treatment and prognosis. We present a case of a patient with NSCLC and an adrenal metastasis, which was diagnosed by EUS/FNA of an enlarged adrenal gland, who had false-negative CT scan for adrenal metastasis. PET was not performed. Prospective studies are needed to assess the incremental yield of EUS/FNA over upper abdominal CT scan and PET for detecting left adrenal metastasis in patients with suspected or proven otherwise respectable NSCLC.

BMI and oral glucocorticoids as predictors of prognosis in COPD patients on long-term oxygen therapy.

AIMS: The objectives of the study were to determine whether body mass index (BMI), and oral corticosteroid use predict survival and hospitalization in hypoxaemic chronic obstructive pulmonary disease (COPD) patients. METHODS: The study was a prospective cohort study with analysis of a nationwide database (Danish Oxygen Register). We studied survival and hospitalization in 221 hypoxaemic COPD patients who were on long-term oxygen therapy (LTOT). RESULTS: Low BMI was strongly associated with high mortality (P < 0.001). Maintenance treatment with steroids was only associated with higher mortality in overweight patients (BMI > or = 25 kg/m2), RR = 3.8 (1.4-10.5), P = 0.011. Whereas BMI had no influence on risk of any hospitalization in patients using oral steroids, high BMI was independently associated with reduced risk of any hospitalization in patients without oral steroids [the RR of any hospitalization for each 1 kg/m2 increase in BMI was 0.94 (CI: 0.90-0.99), P = 0.009]. Overall, the use of oral steroids was associated with increased risk of any hospitalization, RR = 1.7 (1.2-2.4), P = 0.002. This increase was especially pronounced in the group with BMI above 25 kg/m2, where steroid treatment increased the risk of any hospitalization with RR = 3.6 (1.5-8.7), P = 0.005. CONCLUSIONS: In hypoxaemic patients on LTOT, low BMI is an independent risk factor of death and any hospitalization. Maintenance treatment with oral corticosteroids is associated with increased mortality and hospitalization in COPD patients with high BMI. Our findings suggest that loss of body weight should be avoided, and that oral corticosteroids should be used cautiously in patients on LTOT--especially those with high BMI. Further research on the role of changes in body composition as a prognostic factor is needed.

Does long-term oxygen therapy reduce hospitalisation in hypoxaemic chronic obstructive pulmonary disease?

The aim of this study was to determine whether long-term oxygen therapy (LTOT) reduces hospitalisation in hypoxaemic patients with chronic obstructive pulmonary disease (COPD). The circumstances of initiation of LTOT (start during hospitalisation versus start as an outpatient) and compliance with oxygen were also investigated (continuous oxygen therapy (COT) > or = 15 h daily versus noncontinuous oxygen therapy (NCOT) <15 h daily). A total 246 COPD patients were studied, with each patient acting as their own control. Patients were divided into four groups: 125 patients on COT who started LTOT in conjunction with hospitalisation, 37 patients on COT who started LTOT as outpatients, 58 patients on NCOT who started LTOT in conjunction with hospitalisation and 26 patients on NCOT who started LTOT as outpatients. Admission rates, days spent in hospital and number of patients with at least one hospitalisation (ever hospitalised) were compared in two periods of 10 months before and after initiation of LTOT. Overall during the LTOT period, in comparison with the preoxygen period, the admission rates, hospital days and "ever hospitalised" were reduced by 23.8%, 43.5% and 31.2%, respectively. Among patients who started LTOT as outpatients, a tendency towards a higher effect in the compliant group was observed. This study shows that in hypoxaemic chronic obstructive pulmonary disease patients, long-term oxygen therapy is associated with a reduction in hospitalisation.

Are patients on long-term oxygen therapy followed up properly? Data from the Danish Oxygen Register.

OBJECTIVES: The aim of the study was to assess the extent and quality of follow-up of patients on LTOT. SETTING: The Danish Oxygen Register. SUBJECTS: A total of 890 chronic obstructive pulmonary disease (COPD) patients who were on long-term oxygen therapy (LTOT) during the period from 1 November 1994 to 31 August 1995. MAIN OUTCOME MEASURES: The extent and quality of follow-up. RESULTS: Only 38.5% of the patients were followed up in the study period, and only 17.5% had a 'sufficient follow-up' defined as at least one follow-up visit within 10 months which included measurement of arterial blood gases or pulsoximetry with oxygen supply, verification that the patient used oxygen > or =15 h day-1 and was nonsmoker. Female gender, LTOT initiated 3-12 months ago, LTOT started by a chest physician at pulmonary department and LTOT prescribed > or =15 h day-1 were found to be significant predictors of 'sufficient follow-up' (odds ratio (OR): 1.7, 2.0, 3.7 and 1.9, respectively). CONCLUSIONS: The extent and the quality of follow-up of patients on LTOT were poor, especially if a nonpulmonary physician initiated LTOT. We recommend that more attention should be paid on proper monitoring of LTOT, and that only chest physicians should be able to prescribe and re-evaluate LTOT.

Geographic variation in long-term oxygen therapy in Denmark : factors related to adherence to guidelines for long-term oxygen therapy.

STUDY OBJECTIVES: To evaluate regional differences in adherence to guidelines for long-term oxygen therapy (LTOT) in Denmark and to determine factors related to compliance with these guidelines. DESIGN: Cross-sectional study and analysis of a nationwide database (Danish Oxygen Register). SETTING: Denmark. PATIENTS: In November 1994, 1,354 COPD patients were receiving LTOT in Denmark. MEASUREMENTS AND RESULTS: Among 16 counties, the prevalence of LTOT for COPD varied from 14 to 53 per 100,000. The prevalence was highest in counties where general practitioners (GPs) were prescribing LTOT. Adherence to national guidelines for LTOT was found in 34.4% of the patients for the whole of Denmark and varied regionally from 14 to 63%. Mean compliance with guidelines was 5.3 (range, 2.9 to 9.1) times as likely if the oxygen was prescribed by a pulmonary department compared to LTOT initiated by a GP. CONCLUSIONS: Marked geographic variations in compliance with LTOT guidelines are present even in a small country as Denmark. In general, the adherence to the guidelines is poor, especially when non-chest physicians prescribe LTOT. We therefore recommend that local and national thoracic societies together with health organizations responsible for treatment should play a more forceful role in implementing the guidelines. This could be done by enhanced educational efforts, by monitoring of adherence, or even by centralizing the prescription right to departments with pulmonary physicians.

Non-continuous home oxygen therapy: utilization, symptomatic effect and prognosis, data from a national register on home oxygen therapy.

About half of all patients on home oxygen therapy receive non-continuous oxygen therapy (less than 15 h daily) (NCOT). The goal of NCOT is to improve well-being during daily activities and to improve sleep quality. The aim of this study was to evaluate the effect of NCOT on pulmonary symptoms and sleep quality, and to determine whether patients with a subjective beneficial effect differed from those without effect in terms of patients' characteristics, utilization of oxygen, hospitalization and survival. Furthermore, the relationship between the reported beneficial effect of NCOT on dyspnoea and physical activity during domestic activities was examined. During the period November 1994 to July 1995, 254 Danish patients were prescribed oxygen less than 12 h daily or 'on demand'. Of these patients, 142 (55.9%) answered a questionnaire on hours spent with oxygen and symptomatic effect of oxygen treatment. While on oxygen, 76.3% of the patients reported improved dyspnoea score (0-10) more than 0.5 points, 78.3% had improved quality of life, 59.5% improved sleep, 48.5% increased physical activity, 49.3% felt less tired and 40.0% reported improved thinking. Fifty-seven (43.2%) patients reported both improved dyspnoea and physical activity whereas seven (5.3%) patients reported that oxygen had no effect on dyspnoea but a beneficial effect on physical activity Only 11 (7.7%) patients reported no subjective improvement on oxygen. The subjective effect of NCOT was not significantly associated to hours spent with oxygen. the underlying disease, gender, hospitalization or survival. During daily activity and regardless of daily number of hours spent with oxygen, NCOT improved well-being in nearly all patients. The most pronounced improvement was reported on dyspnoea, sleep and quality of life. Very few patients sensed improved physical activity without relief in breathlessness.

[Rehabilitation of patients with chronic obstructive lung disease. Are two exercise sessions per week sufficient?]. / Rehabilitering af patienter med kronisk obstruktiv lungesygdom. Er troening to gange ugentlig tilstroekkeligt?

Several studies of patients with chronic obstructive pulmonary disease (COPD) have shown that pulmonary rehabilitation three to seven times a week improves exercise performance and well being. This study investigates feasibility, effect and economic aspects of a programme consisting of two sessions a week. Twenty-four patients were randomized to rehabilitation and twenty-one to placebo. In an outpatient setting patients were assigned to an eight-week programme of exercise plus education twice a week (Exercise group) or conventional community cares (Placebo group). Seven patients did not complete the rehabilitation. The characteristics of the thirty-eight COPD patients at baseline (mean +/- SD): forced expiratory volume in one second (FEV-1) 1.1 +/- 0.4 L, six-minute walk distance (6MWD) 413 +/- 75 m. Rehabilitation resulted in an insignificant improvement in well being and the 6MWD (29 m ¿95% confidence interval: -8-66 m¿. Rehabilitation session twice a week for eight weeks had no effect in patients with moderate COPD.

Rehabilitation of patients with chronic obstructive pulmonary disease. Exercise twice a week is not sufficient!

Several studies of chronic obstructive pulmonary disease (COPD) have shown that pulmonary rehabilitation, consisting of at least three training sessions a week, improves exercise performance and health status. This study investigates feasibility, effect and economic aspects of a rehabilitation programme consisting of two sessions a week for 8 weeks. Twenty-four patients with moderate COPD were randomized to rehabilitation and 21 to placebo. Patients were assigned to an 8-week programme of exercise plus education (Exercise group) or conventional community care (Placebo group). The rehabilitation program was carried out in a hospital outpatient setting and consisted of 16 h exercise and 13.5 h of education. The exercise group received physiotherapy and education twice a week. Seven patients did not complete the programme. The characteristics of the 38 COPD-patients at baseline were the following: (mean +/- SD) forced expiratory volume in 1 sec (FEV1) 1.1+/-0.4 1 (47% of predicted), 6-min walking distance (6MWD) 413+/-75 m, score of St. George's Respiratory Questionnaire (SGRQ) 44+/-21. Health-status, assessed by SGRQ and The Psychological General Well-being (PGWB) Index, did not improve. Rehabilitation resulted in an insignificant improvement in the 6MWD [29 m (95% confidence interval: -8 -66 m)]. We conclude that a rehabilitation program consisting of exercise and education twice a week for 8 weeks had no effect on exercise performance and well being in patients with moderate COPD.

[Diagnostic procedure in patients with suspected lung cancer. Results of combined evaluation by thoracic surgery and pulmonary medicine specialists]. / Den diagnostiske proces hos patienter mistaenkt for lungekraeft. Resultaterne af foelles thoraxkirurgisk-lungemedicinsk visitation.

During the last 50 years, the 5-year survival of lung cancer patients has been unchanged at 5%. As the prognosis for patients with operable nonsmall cell lung cancer (NSCLC) is much better, the diagnostic examination of tumour suspicious lesions with secondary judgement of operability in NSCLC is an important subject. This study focuses on the diagnostic process. During the years 1991-1993, 467 consecutive patients with pulmonary tumour suspicious lesions were prospectively followed at the Department of Pulmonary Medicine and the Department of Thoracic Surgery, Bispebjerg Hospital. In 40% of the patients, the diagnostic delay was longer than 30 days. Fiberbronchoscopy and fine needle biopsy were the most important diagnostic tests with an accuracy of approx. 90% for both central and peripheral lesions. Benign lesions comprised 19% of all, while the prevalence of squamous cell carcinoma, adenocarcinoma, small-cell carcinoma and large-cell carcinoma was respectively 21%, 26%, 15% and 18% of the malignant infiltrates. Histological diagnosis was not achieved in 104 patients. Histological diagnosis was achieved in most patients, but the diagnostic process was slow. A faster diagnostic process is to be aimed for and can, hopefully, be achieved by accomplishing diagnostic standards as just proposed by the Danish Lung Cancer Group.

[Therapeutic and prognostic course in patients with suspected lung cancer. Results of combined thoracic surgery-pulmonary medicine evaluation]. / Det terapeutiske og prognostiske forløb hos patienter mistaenkt for lungekraeft. Resultaterne af foelles thoraxkirurgisk-lungemedicinsk visitation.

Survival of patients with lung cancer is poor in Denmark and worse than in the other Nordic countries. The study focuses on the treatment, the selection for operation, prognostic factors and the prognosis in lung cancer. During the years 1991-1993, 467 consecutive patients with pulmonary tumour suspicious lesions were prospectively followed at the Departments of Pulmonary Medicine and Thoracic Surgery, Bispebjerg Hospital, Copenhagen. Operation was performed in 83 (33%) of 252 patients with non-small-cell lung cancer. More than 70% of the 169 non-operated patients were judged inoperable on the basis of a clinical examination and a chest x-ray. The initial estimation of operability, done by the chest physician, was able to predict 91% of the inoperable patients. Therapeutic delay (diagnosis-operation) was on average 26 days and 95% were operated within 60 days. Three-year survival for all the operated patients was 36%, while 62% were alive when they were judged radically operated. For stage I tumours, 51% were alive after three years, while all with stage IV tumours were dead. In the operated patients, lung function was positively related to survival (p = 0.013). Females had a better survival than males (p = 0.01 for operated, p = 0.02 for non-operated). Among 43 with small-cell lung cancer, 32 were treated with chemotherapy, and half of these were alive after one year. Preoperative histology in peripheral lesions is of value in preventing unnecessary operations without significant losses. Mediastinoscopy should be performed before operation. Registration of TNM stage and lung function should become standard in order to make comparison from country to country more valid.

[Salmeterol improves the control of disease in patients with moderate asthma. A comparative study of inhaled salmeterol 50 mg and salbutamol depot tablets 8 mg, both administered twice daily]. / Salmeterol forbedrer sygdomskontrollen hos patienter med moderat astma. En sammenlignende undersøgelse af inhaleret salmeterol 50 mg og salbutamol depottabletter 8 mg, begge doseret to gange daglig.

In a randomized, double-blind, double-dummy, cross-over study the efficacy and safety of inhaled salmeterol 50 mcg (b.i.d.) was compared with oral salbutamol controlled release 8 mg (b.i.d.). Fifty-nine patients with moderate asthma were randomized to two four-week periods of treatment with a two-week washout period. During the study period the patients were allowed to use inhaled Salbutamol on a prn. basis. Inhaled steroids, if any, were continued. On diary cards patients recorded peak expiratory flow rate (PEFR) morning and evening before medication, asthma symptom score, and use of inhaled salbutamol. Salmeterol was more effective than salbutamol CR in decreasing daily symptoms (p = 0.001) and increasing morning-PEFR (p = 0.004). Salmeterol resulted in significantly more days without symptoms (p = 0.0004) and days and nights without need for rescue medication (p = 0.01 and p = 0.01). Salmeterol was better tolerated than salbutamol CR.

[Reversibility test in obstructive lung disease. Use and limitations]. / Reversibilitetstest ved obstruktiv lungesygdom. Anvendelsesmuligheder og begroensninger.

Spirometry is often repeated after administration of bronchodilators or corticosteroids as a reversibility test. This review focuses on the performance, the utility and limitations of these tests. The response to bronchodilators and corticosteroids is regarded as statistically significant if the increase in FEV1 respectively exceeds 0.2 l and 0.35 l, but a higher improvement is probably necessary for clinical benefit. Response to corticosteroids is a characteristic feature of asthma, and most asthmatics will normalise their lung function or increase FEV1 by more than 0.5 l. A similar response to bronchodilators can be obtained in some asthmatics. Both tests are necessary for the patient with obstructive airway disease to determine the optimal lung function, and further therapy should be adjusted to reach this goal.