Recomendaciones sobre el uso de oxigenoterapia en situaciones especiales

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Abstract

La hipoxemia crónica severa se define por la presencia de una presión parcial de oxígeno arterial inferior a 60 mmHg. La oxigenoterapia, es decir el uso terapéutico del oxígeno, consiste en su administración a concentraciones mayores de las que se encuentran en el aire ambiente, con la intención de tratar o prevenir las manifestaciones de la hipoxia. Cuando se prescribe y se usa correctamente, ha demostrado que mejora la sobrevida en pacientes con EPOC e hipoxemia. Ha sido establecido que la oxigenoterapia a largo plazo representa el único tratamiento que mejora la evolución de pacientes con EPOC en etapa avanzada. En particular, dos estudios clave, el NOTT (Nocturnal Oxygen Therapy Trial) y el MRC (British Medical Research Council) hace más de 30 años han demostrado que la oxigenoterapia usada más de 15 horas por día, mejora la sobrevida de pacientes con EPOC severo más hipoxemia en reposo. A pesar de que este concepto se ha extendido por analogía a la insuficiencia respiratoria crónica originada por otras enfermedades respiratorias y no respiratorias, la eficacia de la oxigenoterapia continua no está demostrada claramente en otras entidades. Considerando que el 25% de las prescripciones de oxigenoterapia en nuestro medio no corresponden a pacientes con EPOC e hipoxemia, la Asociación Argentina de Medicina Respiratoria encomendó a un grupo de médicos neumonólogos argentinos la elaboración de la presente normativa, redactada a modo de guía sencilla, sobre el uso de la oxigeno-terapia en “situaciones especiales”, basada en nivel de evidencia por el sistema Grade.

Translated abstract

The severe chronic hypoxemia is defined as an arterial partial oxygen pressure measuring less than 60 mmHg. Oxygen therapy is defined as the therapeutic use of oxygen; it consists in oxygen administration at higher concentrations than room air concentrations, to prevent or treat hypoxia. The right use of oxygen therapy has clearly shown to improve survival in hypoxemic chronic obstructive pulmonary disease (COPD) patients. It is well known that long-term oxygen therapy (LTOT) is the only treatment that has been proved to improve the late course of chronic obstructive pulmonary disease. Specially, two landmark studies, the Nocturnal Oxygen Therapy Trial (NOTT) and the British Medical Research Council (MRC) study conducted in the late 1970s have clearly demonstrated that LTOT (when used for more than 15hours/day) improves survival rates in patients with severe COPD associated with hypoxemia at rest. Although this concept has been extended by analogy to chronic respiratory failure caused by respiratory and non-respiratory diseases, continuous oxygen therapy has not been shown to be equally effective in other disorders. Because of 25% of patients who receive oxygen therapy do not have COPD with hypoxemia, the Argentine Association of Respiratory Medicine established a task force of pneumonologists to recommend guidelines about oxygen therapy in “special situations”, based on the level of evidence of the Grades System.

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Most cited references 56

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Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: a double-blind, randomised controlled trial.

David Currow, Glen Wheeler, Katherine Clark … (2010)

Palliative oxygen therapy is widely used for treatment of dyspnoea in individuals with life-limiting illness who are ineligible for long-term oxygen therapy. We assessed the effectiveness of oxygen compared with room air delivered by nasal cannula for relief of breathlessness in this population of patients. Adults from outpatient clinics at nine sites in Australia, the USA, and the UK were eligible for enrolment in this double-blind, randomised controlled trial if they had life-limiting illness, refractory dyspnoea, and partial pressure of oxygen in arterial blood (PaO(2)) more than 7.3 kPa. Participants were randomly assigned in a 1:1 ratio by a central computer-generated system to receive oxygen or room air via a concentrator through a nasal cannula at 2 L per min for 7 days. Participants were instructed to use the concentrator for at least 15 h per day. The randomisation sequence was stratified by baseline PaO(2) with balanced blocks of four patients. The primary outcome measure was breathlessness (0-10 numerical rating scale [NRS]), measured twice a day (morning and evening). All randomised patients who completed an assessment were included in the primary analysis for that data point (no data were imputed). This study is registered, numbers NCT00327873 and ISRCTN67448752. 239 participants were randomly assigned to treatment (oxygen, n=120; room air, n=119). 112 (93%) patients assigned to receive oxygen and 99 (83%) assigned to receive room air completed all 7 days of assessments. From baseline to day 6, mean morning breathlessness changed by -0.9 points (95% CI -1.3 to -0.5) in patients assigned to receive oxygen and by -0.7 points (-1.2 to -0.2) in patients assigned to receive room air (p=0.504). Mean evening breathlessness changed by -0.3 points (-0.7 to 0.1) in the oxygen group and by -0.5 (-0.9 to -0.1) in the room air group (p=0.554). The frequency of side-effects did not differ between groups. Extreme drowsiness was reported by 12 (10%) of 116 patients assigned to receive oxygen compared with 14 (13%) of 108 patients assigned to receive room air. Two (2%) patients in the oxygen group reported extreme symptoms of nasal irritation compared with seven (6%) in the room air group. One patient reported an extremely troublesome nose bleed (oxygen group). Since oxygen delivered by a nasal cannula provides no additional symptomatic benefit for relief of refractory dyspnoea in patients with life-limiting illness compared with room air, less burdensome strategies should be considered after brief assessment of the effect of oxygen therapy on the individual patient. US National Institutes of Health, Australian National Health and Medical Research Council, Duke Institute for Care at the End of Life, and Doris Duke Charitable Foundation. Copyright 2010 Elsevier Ltd. All rights reserved.

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A randomized trial of nocturnal oxygen therapy in chronic obstructive pulmonary disease patients.

R Schott, M Enrhart, C Charpentier … (1999)

The beneficial effects of nocturnal oxygen therapy (NOT) in chronic obstructive pulmonary disease (COPD) patients with mild-to-moderate daytime hypoxaemia (arterial oxygen tension (Pa,O2) in the range 7.4-9.2 kPa (56-69 mmHg)) and exhibiting sleep-related oxygen desaturation remains controversial. The effectiveness of NOT in that category of COPD patients was studied. The end points included pulmonary haemodynamic effects after 2 yrs of follow-up, survival and requirement for long-term oxygen therapy (LTOT). Seventy-six patients could be randomized, 41 were allocated to NOT and 35 to no NOT (control). The goal of NOT was to achieve an arterial oxygen saturation of >90% throughout the night. All these patients underwent polysomnography to exclude an associated obstructive sleep apnoea syndrome. The two groups exhibited an identical meansD daytime Pa,O2 of 8.4+/-0.4 kPa (63+/-3 mmHg) at baseline. Twenty-two patients (12 in the NOT group and 10 in the control group, p=0.98) required LTOT during the whole follow-up (35+/-14 months). Sixteen patients died, nine in the NOT group and seven in the control group (p=0.84). Forty-six patients were able to undergo pulmonary haemodynamic re-evaluation after 2 yrs, 24 in the NOT and 22 in the control group. In the control group, mean resting pulmonary artery pressure increased from 19.8+/-5.6 to 20.5+6.5 mmHg, which was not different from the change in mean pulmonary artery pressure in the NOT group, from 18.3+/-4.7 to 19.5+/-5.3 mmHg (p= 0.79). Nocturnal oxygen therapy did not modify the evolution of pulmonary haemodynamics and did not allow delay in the prescription of long-term oxygen therapy. No effect of NOT on survival was observed, but the small number of deaths precluded any firm conclusion. These results suggest that the prescription of nocturnal oxygen therapy in isolation is probably not justified in chronic obstructive pulmonary disease patients.

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Oxygen therapy for patients with COPD: current evidence and the long-term oxygen treatment trial.

Philip D Doherty, Samuel Krachman, Ralph Panos … (2010)

Long-term use of supplemental oxygen improves survival in patients with COPD and severe resting hypoxemia. However, the role of oxygen in symptomatic patients with COPD and more moderate hypoxemia at rest and desaturation with activity is unclear. The few long-term reports of supplemental oxygen in this group have been of small size and insufficient to demonstrate a survival benefit. Short-term trials have suggested beneficial effects other than survival in patients with COPD and moderate hypoxemia at rest. In addition, supplemental oxygen appeared to improve exercise performance in small short-term investigations of patients with COPD and moderate hypoxemia at rest and desaturation with exercise, but long-term trials evaluating patient-reported outcomes are lacking. This article reviews the evidence for long-term use of supplemental oxygen therapy and provides a rationale for the National Heart, Lung, and Blood Institute Long-term Oxygen Treatment Trial. The trial plans to enroll subjects with COPD with moderate hypoxemia at rest or desaturation with exercise and compare tailored oxygen therapy to no oxygen therapy.