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A Person-Centered Approach to Supplemental Oxygen Therapy in the Outpatient Setting: A Review

Author/s: 
Angela O Suen, Susan S Jacobs, Mary R Kitlowski, Richard D Branson, Anand S Iyer

Importance: Approximately 1.5 million adults in the US use supplemental oxygen annually in the outpatient setting. However, many do not receive delivery systems that adequately meet their needs, and few receive education about devices or how to maintain independence. This Review summarizes guidelines and evidence on outpatient supplemental oxygen across several cardiopulmonary conditions, highlights evidence gaps where benefits are unclear, and discusses outcomes that inform a person-centered framework for supplemental oxygen therapy.

Observations: Most studies of supplemental oxygen have been conducted in chronic obstructive pulmonary disease, with limited high-quality data in other cardiopulmonary conditions. Data strongly support supplemental oxygen therapy in people with severe resting desaturation (oxygen saturation [SpO2] of 88% or less), with demonstrated improvement in mortality. Whether supplemental oxygen improves symptoms or function in patients with isolated severe exertional desaturation remains inconclusive, prompting an individualized approach and exertional oxygen testing if a patient is mobile and reporting exertional symptoms. Apart from cor pulmonale, evidence does not support supplemental oxygen therapy in patients with moderate resting or exertional desaturation (SpO2 of 89% to 93%). Supplemental oxygen's broad impact on patient-centered outcomes; the supplemental oxygen landscape of devices, testing, prescription, and delivery; and how to weigh the potential harms vs benefits with patients are summarized. These data inform a person-centered supplemental oxygen framework to help patients minimize loss of independence and improve quality of life across the following domains: (1) health care values and preferences; (2) functional status, mobility, and frailty; (3) cognition and supplemental oxygen education; (4) physical symptoms; (5) psychological and social impact; and (6) caregiver support. Guidance on deimplementation and future directions are also summarized.

Conclusions and relevance: Supplemental oxygen therapy should follow a person-centered approach that empowers patients and caregivers; helps patients improve independence and quality of life by optimizing function, mobility, and social well-being; weighs benefits and burdens; and engages in shared decision-making when the evidence is unclear.

Keywords 
oxygen Caregivers heart disease Chronic Disease

Long-Term Oxygen Therapy for 24 or 15 Hours per Day in Severe Hypoxemia

Author/s: 
Magnus Ekström, Anders Andersson, Savvas Papadopoulos, Taivo Kipper, Bo Pedersen, Ozren Kricka

Background: Long-term oxygen supplementation for at least 15 hours per day prolongs survival among patients with severe hypoxemia. On the basis of a nonrandomized comparison, long-term oxygen therapy has been recommended to be used for 24 hours per day, a more burdensome regimen.

Methods: To test the hypothesis that long-term oxygen therapy used for 24 hours per day does not result in a lower risk of hospitalization or death at 1 year than therapy for 15 hours per day, we conducted a multicenter, registry-based, randomized, controlled trial involving patients who were starting oxygen therapy for chronic, severe hypoxemia at rest. The patients were randomly assigned to receive long-term oxygen therapy for 24 or 15 hours per day. The primary outcome, assessed in a time-to-event analysis, was a composite of hospitalization or death from any cause within 1 year. Secondary outcomes included the individual components of the primary outcome assessed at 3 and 12 months.

Results: Between May 18, 2018, and April 4, 2022, a total of 241 patients were randomly assigned to receive long-term oxygen therapy for 24 hours per day (117 patients) or 15 hours per day (124 patients). No patient was lost to follow-up. At 12 months, the median patient-reported daily duration of oxygen therapy was 24.0 hours (interquartile range, 21.0 to 24.0) in the 24-hour group and 15.0 hours (interquartile range, 15.0 to 16.0) in the 15-hour group. The risk of hospitalization or death within 1 year in the 24-hour group was not lower than that in the 15-hour group (mean rate, 124.7 and 124.5 events per 100 person-years, respectively; hazard ratio, 0.99; 95% confidence interval [CI], 0.72 to 1.36; 90% CI, 0.76 to 1.29; P = 0.007 for nonsuperiority). The groups did not differ substantially in the incidence of hospitalization for any cause, death from any cause, or adverse events.

Conclusions: Among patients with severe hypoxemia, long-term oxygen therapy used for 24 hours per day did not result in a lower risk of hospitalization or death within 1 year than therapy for 15 hours per day. (Funded by the Crafoord Foundation and others; REDOX ClinicalTrials.gov number, NCT03441204.).

Keywords 
oxygen oxygen therapy hypoxia
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