Home Oxygen Therapy Guidelines for ILD
In this podcast, Anne Holland, PT, PhD, talks about the American Thoracic Society's new home oxygen therapy guidelines as they pertain to patients with interstitial lung diseases, as well as the research that is needed to fill the knowledge gaps.
- Jacobs SS, Krishnan JA, Lederer DJ, et al; American Thoracic Society Assembly on Nursing. Home oxygen therapy for adults with chronic lung disease. an official American Thoracic Society clinical practice guideline. Am J Respir Crit. 2020;202(10):121-141. doi:10.1164/rccm.202009-3608ST
Anne Holland, PT, PhD, is a professor of physiotherapy at Monash University and Alfred Health Melbourne in Australia. She is also a cochair of the writing committee for the American Thoracic Society’s Guidelines on Home Oxygen Therapy.
Amanda Balbi: Hello everyone, and welcome to another installment of Podcasts360—your go-to resource for medical news and clinical updates. I’m your moderator, Amanda Balbi with Consultant360 Specialty Network.
The American Thoracic Society has released new guidelines on home oxygen therapy for patients with chronic obstructive pulmonary disease (or COPD) and interstitial lung diseases (or ILD). Today I’ll be speaking with the cochair of the guideline writing committee, Dr Anne Holland, who is a professor of physiotherapy at Monash University and Alfred Health Melbourne in Australia, about the ILD-specific recommendations.
Thank you for joining me today, Dr Holland. So, the summary of recommendations is separated into a few sections, one of which is ILD. Can you talk about the recommendations specifically for patients with ILD?
Anne Holland: Certainly. For patients with ILD, they often have quite profound hypoxemia, either at rest or in exertion. And the guidelines deal with 2 specific areas. They look at the prescription of long-term oxygen therapy (or LTOT), and they look at the prescription of ambulatory oxygen therapy.
LTOT for patients who have resting hypoxemia is a really about patients who have relatively advanced disease, and they have hypoxemia at rest. And these are patients who often have quite severe resting hypoxemia as their disease advances, and oxygen has long been thought of as an important treatment.
Despite that, there's actually no randomized controlled trials specifically in ILD. When we looked at making a recommendation in this space, we had to draw on indirect evidence that came from patients with COPD, where we do have some randomized trials that show mortality benefit.
In light of that and given the real burden of resting hypoxemia for these patients, the panel placed a really high value on those trials, which were indirect evidence. The recommendation for long-term oxygen therapy for patients with ILD with resting hypoxemia was to have these prescribed for 15 hours a day at least. And that was a strong recommendation.
For ambulatory oxygen therapy, this is prescribed for patients who have only exertional desaturation. In this area, we did have one trial that we could draw on, which showed an improvement in quality of life, which we consider a very important outcome for these patients.
In this area, there were no long-term trials. The only trial we had a short term over about 2 weeks. We couldn't say anything really about long-term benefits of this therapy. We're also aware, for this particular treatment, that there are burdens for patients. They described difficulties using the equipment, loss of independence, and more caregiver burden—needing to manage cylinders, to manage the equipment, and also stigma associated with using oxygen in the community.
In this area, there was more of a tradeoff between the benefits and the burdens, particularly given there was not a lot of evidence. For ambulatory oxygen, the panel actually made a conditional recommendation in favor of prescribing this therapy for patients who had exertional desaturation.
I think one of the nice things about the guidelines is that it has a best practice recommendation around education and support for users of oxygen therapy.
We know from many of the qualitative studies that this is an area where patients and caregivers often feel like they don't have enough information about their devices and about how to use them. It's possibly an area that hasn't appeared very much in oxygen guidelines before.
The guidelines suggest that we should pay attention to making sure that our patients and caregivers understand the safety requirements around oxygen—that's including managing falls risk with things like oxygen tubing at home but also managing fire risk, of course, as well. Keeping away from open flames and making sure that nobody is smoking around oxygen devices.
And then of course there's the making sure that the patients and caregivers feel confident in the use of their devices—how to manage their cylinders, how to turn their equipment on and off, how to change the cylinders when needed, how to interact with their oxygen providers—and really feel confident to use these devices in a way that they can get the most out of them.
I think that's a really positive development to have that articulated in the guideline alongside the clinical recommendations.
Amanda Balbi: What can these recommendations mean for prescribing oxygen to your patients with ILD?
Anne Holland: For patients who have resting hypoxemia, these guidelines support the existing practice, which is the prescription of long-term oxygen therapy for these patients. And this has been something that's been prescribed for many years. It's considered a really important part of treatment. And the strong recommendation continues to support that practice of prescribing long-term oxygen therapy.
I think with ambulatory oxygen therapy, what the guidelines do is place this therapy more squarely in the space of shared decision-making. The guidelines articulate that there are really quite considerable benefits for some patients, but for other patients, they may choose not to use this therapy. There may be some patients for whom actually the burdens outweigh the benefits.
So, for ambulatory oxygen therapy, this becomes much more of a shared decision-making process between clinicians and individual patients. It was nice to see that really articulated in the guidelines in a way that I think will help people to have those discussions with their patients about whether this is the right therapy for them at the right time. For some patients that will absolutely be “yes,” and for other patients it’s possible that some will choose “no” at this time.
Amanda Balbi: And you mentioned before that there is a lack of evidence or lack of research. So what research is either currently in the works or do you hope will be conducted that will help improve these guidelines in the future?
Anne Holland: It's a good question. There was certainly a number of research gaps that were identified as we went through the process of making the guidelines. In terms of long-term oxygen therapy, because this is such an established part of treatment for patients who have quite advanced disease, it's really difficult to imagine a situation where you might have a randomized controlled trial where you randomized some of these patients to not receiving the therapy.
Many clinicians would feel that there was a lack of equipoise in that space, particularly given these are people toward the end of their life, and the potential benefits in terms of the mortality benefit are quite substantial. Although there were really no randomized controlled trials for long-term oxygen therapy in ILD, the traditional model of trials is still going to be very difficult to run.
In this situation, the panel actually suggested that this might be a space where investigators might choose to do innovative trial designs—using things like quasi-randomized controlled trials or some of the more adaptive models, which include choice in the design. I think what we're looking for here is really, in the future, some advanced trial designs to answer the question of the benefits of long-term oxygen therapy.
In terms of ambulatory oxygen therapy, there are certainly some trials underway in ILD to look at long-term benefits of this therapy. We currently have one underway here in Australia and at sites in Sweden, looking at the benefits in patients with fibrotic ILD and comparing that to a sham device delivering air and with a period of about 6 months. We would hope that will provide some more answers about the benefits of his treatment, particularly for patient-centered outcomes such as physical activity in daily life and quality of life and symptoms.
The other area that I think the panel identified as a gap which we’d like to see filled in the future is around having better oxygen devices for patients with ILD. These are patients who often have quite profound hypoxemia, either at rest or during exertion. Many of the current devices we have available are not able to correct that. They're not able to deliver high enough levels of oxygen, particularly in a portable enough form for patients who need to be ambulatory and need the device to move around.
We really like to see is some good partnerships between device developers and researchers to develop better devices that can better meet the needs of patients with ILD for oxygen therapy.
Amanda Balbi: What is the overall key take-home message for providers who care for patients with ILDs?
Anne Holland: The key take-home message for people caring for patients with ILD is that these are patients who have really quite significant exertional desaturation or resting hypoxemia. It's very important to evaluate patients for those things and identify when hypoxemia is present.
Long-term oxygen therapy has a really critical role for patients who have resting hypoxemia, particularly those patients with advanced disease toward the end of their life. Patients should certainly be referred for assessment for that.
For patients who have needs for ambulatory oxygen therapy, that's often a bit more of a complex discussion where we need to evaluate the benefits vs the burdens for the individual patients at that particular point in time.
Amanda Balbi: Thank you so much for joining me today and answering my questions about this guideline.
Anne Holland: Thank you very much for the opportunity to talk about this guideline, which I hope will contribute to the care of patients with lung disease into the future. I’d particularly like to thank the American Thoracic Society for supporting the work on the guideline and the many ways in which they helped the guideline come to a publication and fruition. So, thank you.