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The Clinical Impact of New LTOT Technology

The Clinical Impact of New LTOT Technology. Patrick J. Dunne, MEd, RRT, FAARC HealthCare Productions, Inc. Fullerton, CA pjdunne@sbcglobal.net. Disclosure. This presentation is sponsored by SeQual Technologies, Inc. GOLD Guidelines. IV: Very Severe. III: Severe. FEV 1 /FVC < 0.70

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The Clinical Impact of New LTOT Technology

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  1. The Clinical Impact of New LTOT Technology Patrick J. Dunne, MEd, RRT, FAARC HealthCare Productions, Inc. Fullerton, CA pjdunne@sbcglobal.net

  2. Disclosure This presentation is sponsored by SeQual Technologies, Inc.

  3. GOLD Guidelines IV: Very Severe III: Severe • FEV1/FVC < 0.70 • FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure II: Moderate I: Mild • FEV1/FVC < 0.70 • 30% ≤ FEV1 < 50% predicted • FEV1/FVC < 0.70 • 50% ≤ FEV1 < 80% predicted • FEV1/FVC < 0.70 • FEV1 ≥ 80% predicted Active reduction of risk factor(s); smoking cessation, flu vaccination Add short-acting bronchodilator (as needed) Add regular treatment with long-acting bronchodilators; BeginPulmonary Rehabilitation Add inhaled glucocorticosteroids if repeated acute exacerbations Add LTOT for chronic hypoxemia. Consider surgical options Global Initiative for Chronic Obstructive Lung Disease (GOLD): Global Strategy for Diagnosis, Management and Prevention of Chronic Obstructive Lung Disease. November 2006.

  4. Role of Pulmonary Rehabilitation in COPD Management

  5. Pulmonary Rehabilitation Finnerty JP, Keeping I, et al. Chest, 2001 “Pulmonary rehabilitation resulted in clinically significant improvement in dyspnea and fatigue” Puhan MA, Scharplatz M, et. al. Respir Res, 2005 “Six RCTs, in patients with baseline FEV1≤ 40% predicted, showed a reduction in hospitalizations and clinically significant improvement in health status and exercise capacity”

  6. Pulmonary Rehabilitation Porszasz J, Emtner M, et. al. Chest, 2005 “Exercise training in patients with severe COPD dramatically improves submaximal exercise endurance” Joint ACCP-AACVPR Evidence-Based CPGs for Pulmonary Rehabilitation. Chest, 2007 “Based on a growing body of scientific evidence, pulmonary rehabilitation has emerged as a recommended standard of care for patients with chronic lung disease”

  7. Pulmonary Rehabilitation: Summary • Pulmonary rehabilitation can help improve • Exercise tolerance • Dyspnea • Health-relatedquality of life • Pulmonary rehabilitation can help decrease • Hospital re-admissions • Length of hospital stay • Health care utilization

  8. New LTOT Technology for COPD Management

  9. The Evidence Base for LTOT Levine BE, Biglow DB, et al. Ann Intern Med, 1967 “Oxygen improved exercise tolerance in patients with COPD” Report of British Medical Research Council, Lancet, 1981 “Over a 5 year period, patients receiving nocturnal oxygen lived longer than did those receiving no oxygen at all” Nocturnal Oxygen Therapy Trial (NOTT), Ann Intern Med, 1980 “Over a 3 year period, patients receiving continuous oxygen (≥ 17 hrs/day) lived longer than those receiving only nocturnal oxygen”

  10. The Evidence Base for LTOT Heaton RK, Grant I, et al. Ann Intern Med, 1983 “Over a 12 month period, patients receiving continuous oxygen scored higher on measures of performance IQ and brain age quotient than did those receiving only nocturnal oxygen” Petty TL, Bliss P. Respir Care, 2000 “Over a 3 year period, patients in the NOTT Study receiving continuous oxygen and reporting high daily walking lived longer than did those reporting low walking activity”

  11. Scientific Basis for LTOT: Summary • LTOT prolongs life •  pulmonary hypertension •  cardiac output • More LTOT better than less •  systemic oxygen delivery •  exercise tolerance • LTOT with walking exercise the best!

  12. The LTOT Continuum RestingActivitiesSleepAltitude Ambulatory use Scheduled walking Structured exercise Nocturnal desaturation OSA Air travel Travel to Stationary use Domiciliary ADLs

  13. Traditional LTOT Systems • Prior century technology • 2 continuous flow (CF) delivery systems • Stationary(liquid oxygen dewer, oxygen concentrator) • Ambulatory(liquid portable, small aluminum cylinders) • Oxygen conserving technology( Introduced mid-1980s) • Pulse dose (PD) v/s CF • Goal - extend time away from stationary system • Major issue  re-supplying depleted contents

  14. Traditional Stationary LTOT Equipment

  15. Traditional Ambulatory LTOT Equipment

  16. Trends in LTOT • Patients more demanding - becoming more knowledgeable about their options • OGPE systems are often preferred over older less portable devices • Freedom and ability to ambulate a top priority • Improved quality of life; reduces depression and other problems associated with traditional LTOT

  17. 21st Century Technology • Self sustaining oxygen delivery systems • “Delivery-less technology” • Oxygen generating portable equipment(OGPE) • Provides stationary & ambulatory oxygen • Patient is relatively self-sufficient • Repeat home deliveries no longer needed • Different engineering platforms • Different performance characteristics

  18. Delivery-less Platform - A • Concentrators that re-fill cylinders • Standard PSA concentrator for CF stationary needs • Re-fills small, PD-only cylinder for ambulation • Return home for unlimited re-fills • Standard PSA concentrator with liquifier • Standard concentrator for CF stationary needs • Concentrator feeds liquifier; re-fills small PD-only liquid canister (SmartDose technology) • Return home for unlimited re-fills

  19. Concentrators that Transfill iFill Home Fill VIAspire

  20. Delivery-less Platform - B • Portable Oxygen Concentrator (POC) • Scaled version of standard PSA concentrator • ≤ 10 pounds; easily transportable • Standard AC, DC and rechargeable battery • Marketed to provide stationary & ambulatory oxygen • Small size limits oxygen production • 480 – 1050 mls/minute of therapeutic oxygen (≥ 90%) • Can only operate in PD mode! • Primary objective – prolong battery life!

  21. Portable Oxygen Concentrators Evergo XPO2 Inogen One Lifestyle Freestyle

  22. POCs: Technical Specifications COMPANYPRODUCTWEIGHTMAX O2 PRODUCTION AirSep FreeStyle 6 lbs 480 mls/min Invacare XPO2 7 lbs 900 mls/min AirSep LifeStyle 10 lbs 750 mls/min Inogen Inogen One 10 lbs 750 mls/min Respironics EverGo 10 lbs 1050 mls/min

  23. POCs: Technical Specifications PRODUCT PULSE SETTINGS MAX BOLUS SIZE Freestyle 1 - 3 26 mls Lifestyle 1 - 5 41 mls Inogen One 1 - 5 26 mls XPO2 1 - 5 42 mls Evergo 1 - 6 36 mls Any pulse dose delivery device must be capable of providing the same degree of protection from desaturation as does the continuous flowprescription!

  24. Delivery-less Platform – C • Personal Ambulatory Oxygen System • Scaled version of proprietary ATF concentrator •  17 pounds; easily transportable • Standard AC, DC and rechargeable battery • Able to provide both stationary & ambulatory oxygen • 3,000 mls/minute of therapeutic oxygen • Both continuous flow and pulse dose mode • Known Increase in dose setting in both CF and PD mode • CF: 0.5 – 3 LPM; PD: 16 mls (setting 1) up to 96 mls (setting 6) • AutoSat feature in PD mode

  25. Personal Ambulatory Oxygen System Eclipse 2

  26. Delivery-less LTOT Technologies • A: Concentrators that transfill • B: Pulse-only portable concentrators • C: Personal Ambulatory Oxygen System

  27. The LTOT Continuum: How Does New Technology Measure-up? RestingActivitiesSleepAltitude Platform A:Yes Maybe Yes No Platform B: Maybe Maybe Maybe Maybe Platform C: Yes Yes Yes Yes Be sure any delivery-less technology delivers enough oxygen to meet each patient’s needs - regardless of location or activity!

  28. Effects of a Walking Aide in COPD Patients Receiving Oxygen Therapy* Will a simple walking aide improve physical performance in COPD patients who usually carry their own heavy oxygen canister? * Crisafulli E, Costi S, et al. Chest; April 2007.

  29. Effects of a Walking Aide in COPD Patients Receiving Oxygen Therapy* • Randomized, cross-over design • 60 stable COPD patients in 3 rehab centers • Mean age: 70.6 yrs; Mean FEV1 44% predicted • 3 lpm CF via nasal cannula • 7.2 lb canister (1) carried or (2) pulled on cart • Primary outcomes: • Distance walked on 6MWT (threshold 300 m) • Peak effort dyspnea • Leg fatigue * Crisafulli E, Costi S, et. al. Chest, April 2007

  30. Effects of a Walking Aid in COPD Patients Receiving Oxygen Therapy* OutcomesNo-AidAid Distance walked 262 m 291 m Peak effort dyspnea 5.8 3.9 Leg fatigue 5.1 3.6 “Our results show that use of a wheeled cart to carry the oxygen canister enabled LTOT users to significantly increase the distance walked with less dyspnea and leg fatigue,which is a practical objective to be reached in the everyday life of these individuals”. * Crisafulli E, Costi S, et. al. Chest, April 2007

  31. Emerging Issues in LTOT • Target SPO2 94-95% (v/s 90%) • Titrate to saturate (v/s O2 @ 2 L/min) • Use of RT directed protocols • Efficacy of pulse-dose delivery • During exercise, sleep & air travel • Predictiveness of exercise dose • Need for evidence-based research

  32. September 2008

  33. End Notes • New advances in COPD treatment offer patients options that can improve outcomes • Newer drugs and LTOT technology can improve patient adherence with prescribed controller medications • Exercise and overall ambulation enriches the quality of life for COPD patients • Titration protocols must ensure patients receive the right oxygen dose to minimize hypoxic events

  34. The Clinical Impact of New LTOT Technology Patrick J. Dunne, MEd, RRT, FAARC HealthCare Productions, Inc. Fullerton, CA pjdunne@sbcglobal.net

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