An 85-year-old man comes to the emergency department due to acute-onset shortness of breath associated with coughing spells for 24 hours. He has no chest pain, fevers, or chills. He has had no recent upper respiratory infection symptoms. The patient has a medical history significant for chronic obstructive pulmonary disease (COPD) and has had previous hospitalizations for COPD exacerbation. His other medical problems include persistent atrial fibrillation, hypothyroidism, rheumatoid arthritis, and hypertension. He is an ex-smoker with a 40-pack-year history. Temperature is 36.9 C (98.4 F), blood pressure is 140/90 mm Hg, pulse is 110/min and irregular, and respirations are 22/min. Physical examination shows bilateral decrease in breath sounds with prolonged expiration and wheezing in both lung fields. There is no jugular venous distension or peripheral edema. X-ray of the chest reveals hyperinflation of both lungs. The patient is admitted to the hospital and treated with bronchodilators and systemic corticosteroids. After 3 days of hospitalization, he is ready for discharge and is being considered for home oxygen therapy. Which of the following is an indication for initiating long-term home oxygen therapy in such patients?

Question

An 85-year-old man comes to the emergency department due to acute-onset shortness of breath associated with coughing spells for 24 hours.  He has no chest pain, fevers, or chills.  He has had no recent upper respiratory infection symptoms.  The patient has a medical history significant for chronic obstructive pulmonary disease (COPD) and has had previous hospitalizations for COPD exacerbation.  His other medical problems include persistent atrial fibrillation, hypothyroidism, rheumatoid arthritis, and hypertension.  He is an ex-smoker with a 40-pack-year history.  Temperature is 36.9 C (98.4 F), blood pressure is 140/90 mm Hg, pulse is 110/min and irregular, and respirations are 22/min.  Physical examination shows bilateral decrease in breath sounds with prolonged expiration and wheezing in both lung fields.  There is no jugular venous distension or peripheral edema.  X-ray of the chest reveals hyperinflation of both lungs.  The patient is admitted to the hospital and treated with bronchodilators and systemic corticosteroids.  After 3 days of hospitalization, he is ready for discharge and is being considered for home oxygen therapy.  Which of the following is an indication for initiating long-term home oxygen therapy in such patients?

Quizplus · Accepted Answer

Progressive hypoxemia is common in patients with advanced chronic obstructive pulmonary disease (COPD), and studies have shown survival benefit of long-term home oxygen therapy (LTOT) in those with significant chronic hypoxemia. The criteria for initiating LTOT in patients with COPD include: Resting arterial oxygen tension (PaO₂) ≤55 mm Hg or pulse oxygen saturation (SaO₂) ≤88% on room airPaO₂ ≤59 mm Hg or SaO₂ ≤89% in patients with cor pulmonale, evidence of right heart failure, or hematocrit >55% Resting arterial oxygen tension (PaO₂) ≤55 mm Hg or pulse oxygen saturation (SaO₂) ≤88% on room air PaO₂ ≤59 mm Hg or SaO₂ ≤89% in patients with cor pulmonale, evidence of right heart failure, or hematocrit >55% The dose of supplemental oxygen should be titrated so that SaO₂ is maintained at >90% during sleep, normal walking, and at rest. Survival benefits of home oxygen therapy are significant when it is used for ≥15 hours a day. (Choice A) FEV1 <30% of predicted is consistent with very severe COPD. A high percentage of patients with very severe COPD will have significant chronic hypoxemia, but FEV1 is not a factor in determining indication for LTOT. (Choice B) Left ventricular ejection fraction ≤40% is consistent with left-sided systolic heart failure. LTOT is indicated in patients with significant hypoxemia and evidence of right-sided heart failure, but left-sided heart failure is not an indication. (Choices C and E) In the absence of cor pulmonale, right heart failure, and polycythemia, LTOT is indicated for PaO₂ ≤55 mm Hg (not ≤65 mm Hg) or SaO₂ ≤88% (not ≤90%); there is no survival benefit at less severe levels of hypoxemia. Educational objective: Patients with chronic obstructive pulmonary disease who have resting arterial oxygen tension (PaO₂) ≤55 mm Hg or pulse oxygen saturation (SaO₂) ≤88% are candidates for long-term home oxygen treatment. Those with signs of right heart failure or hematocrit >55% should be started on home oxygen if PaO₂ ≤59 mm Hg or SaO₂ ≤89%.

An 85-Year-Old Man Comes to the Emergency Department Due to Acute-Onset