Supplemental Oxygen

 

 

Don't Statement

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Don’t administer supplemental oxygen to relieve dyspnea in patients with cancer who do not have hypoxia.

Rationale

Dyspnea is the sensation of inability to catch one’s breath or subjective breathing discomfort. Dyspnea is one of the most distressing and frightening experiences for patients (Thomas & vonGunten, 2003). More than 50% of advanced cancer patients have reported dyspnea at some point throughout their illness (Bruera, Schmitz, Pither, Neumann, & Hanson, 2000; Solano, Gomes, & Higginson, 2006). Reports of the prevalence of dyspnea range from 21 to 90% overall, and the prevalence and severity of dyspnea increase in the last 6 months of life, regardless of cancer diagnosis (Currow et al., 2010).

Supplemental oxygen therapy is commonly prescribed to relieve dyspnea in people with advanced illness despite arterial oxygen levels within normal limits, and has been seen as standard care (Abernathy et al., 2010; Kvale, Selecky, & Prakash, 2007; Simoff et al., 2013). Abernathy cited evidence that over 70% of physicians reported prescribing palliative oxygen, and that, in Canada, compassionate use of oxygen in non-hypoxemic patients accounts for about 1/3 of the total oxygen therapy budget.  A DHHS report from the office of the inspector general  in 2006 noted that the average purchase price for an oxygen concentrator was $587 (Levinson, 2006) and a home oxygen cost analysis showed that supplemental oxygen use costs $ 201.20 per patient per month (Morrison Informatics, 2006).  In the past it was estimated that about 800,000 patients in the United States receive home oxygen therapy and total cost likely exceeds $1.1 billion (O’Donohue & Plummer, 1995). The proportion of use for palliation in non-hypoxic individuals in the United States is not clear; however, if practice is similar to that seen in other countries, the cost is substantial.

Supplemental oxygen is costly and is not a benign intervention. There are multiple safety risks associated with use of oxygen equipment. People also experience functional restriction and may have some distress from being attached to a device.

Palliative oxygen(administration in nonhypoxic patients) has consistently been shown not to improve dyspnea in individual studies and systematic reviews. Rather than use of a costly and ineffective intervention for dyspnea, care should be focused on those interventions which have demonstrated efficacy.

Background

In situations where individuals are experiencing breathlessness, the automatic tendency has been to administer oxygen. Patients and their families expect that oxygen will be available, and clinicians likewise respond by providing home oxygen irrespective of the measured partial pressure of oxygen (PaO2).  In palliative care, despite evidence that breathlessness may not be due to hypoxemia, oxygen is still provided by ambulance personnel, emergency department, and hospital staff (Nonoyama, Brooks,  Guyatt, & Goldstein, 2007; Uronis, Currow, MCCrory, Samsa, & Abernaethy, 2008; Wiese, Barrels, Graf,  & Hanekop, 2009).  Oxygen is widely used for palliation of breathlessness in cancer patients (Thomas, Bausewein, Higginson, & Booth, 2011).

Supplemental oxygen is frequently requested by patients and implemented by practitioners to relieve dyspnea (Kamal, Maguire, Wheeler, Currow, & Abernethy, 2012). Uronis and Abernathy (2008) pointed out that surveys of physicians in Australia showed that palliative medicine and respiratory physicians surveyed believed that palliative oxygen is beneficial and that dyspnea was the most common reason for prescription. 

Palliative oxygen continues to be recommended in some consensus guidelines.  Multiple consensus guidelines state the aim of oxygen therapy as provision of symptomatic relief of breathlessness and recommend use of palliative oxygen for symptom relief.  Supplemental oxygen is often given out of compassion in end-of-life care or because of patient or family request.  It has been suggested that the medical symbolism of supplemental oxygen may create a placebo effect (Berger, Shuster, & von Roenn, 2013).  

Evidence

  • While there is evidence to support the use of oxygen to prolong survival in hypoxemic people with COPD and symptom relief in hypoxemic patients with cancer, evidence regarding the use of oxygen to relieve the sensation of dyspnea in non-hypoxemic individuals with cancer does not support its use.  In early systematic reviews of interventions to improve palliation at the end of life, it was concluded that evidence regarding effects of palliative oxygen was equivocal (Cranston, Crockett, & Currow, 2009; Qaseem et al., 2008). 
  • Clemens, Quednau, and Klaschik (2009) compared effects of oxygen and opioid treatment on ventilation and dyspnea in 46 hypoxic and nonhypoxic palliative care patients and found no correlation between severity of dyspnea and oxygen saturation and that use of opioids for dyspnea was more effective than oxygen administration, even in those patients who were hypoxic (Clemens et al., 2009). 
  • Currow, Agar, Smith, and Abernathy (2009) reviewed findings of 230 patients who were prescribed home oxygen for symptoms of breathlessness. They found no significant improvement in symptoms after 1 and 2 weeks of home oxygen.
  • Several small, randomized, prospective studies showed no difference in dyspnea severity between patients who were given supplemental oxygen versus air (Booth, Kelly, Cox, Adams, & Guz, 1996; Bruera, de Stoutz, Velasco-Leiva, Schoeller, & Hanson, 1993; Bruera et al., 2003; Campbell, Yarandi, & Dove-Medows, 2013; Philip et al., 2006) or heliox (Ahmedzai,  Laude, Robertson, Troy, & Vora, 2004).
  • In 2010 a large, multicenter, double blind, randomized trial among patients who did not meet eligibility guidelines for long term oxygen therapy, patients showed no difference in breathlessness, functional status, or quality of life between patients with various diagnoses who received oxygen versus medical air (Abernathy et al., 2010).  
  • In a systematic review of various interventions to relieve dyspnea, the conclusion from 8 studies of oxygen use was that oxygen was no better than medical air in relieving dyspnea, except for patients with hypoxia (Ben-Aharon, Gafter-Gvili, Paul, Leibovici, & Stemmer, 2008).  A later meta-analysis showed lack of benefit from oxygen administration (SMD =-0.3, 95% CI =1.06, 0.47).  (Ben-Aharon, Gafter-Gvili, Leibovici, & Stemmer, 2012). 
  • Uronis et al.  (2008) also concluded that oxygen therapy in mildly or non-hypoxemic patients with cancer was not effective for relief of dyspnea.  The 2012 update of the American Thoracic Society systematic review of evidence and consensus statement on dyspnea from any etiology concluded there was limited evidence to support the use of oxygen therapy for patients who are not hypoxic (Parshall et al., 2012).

References

Abernethy, A. P., McDonald, C. F., Frith, P. A., Clark, K., Herndon, J. E., Marcello, J., . . . Currow, D. C.  (2010). Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: A double-blind, randomised controlled trial. Lancet, 376, 784–793. doi:10.1016/S0140-6736(10)61115-4

Ahmedzai, S. H., Laude, E., Robertson, A., Troy, G., & Vora, V. (2004). A double-blind, randomized, controlled phase II trial of Heliox28 gas mixture in lung cancer patients with dyspnoea on exertion. British Journal of Cancer, 90, 366–371. doi:10.1038/sj.bjc.6601527

Ben-Aharon, I., Gafter-Gvili, A., Leibovici, L., & Stemmer, S. M. (2012). Interventions for alleviating cancer-related dyspnea: A systematic review and meta-analysis. Acta Oncologica, 51, 996–1008. doi:10.3109/0284186X.2012.709638

Ben-Aharon, I., Gafter-Gvili, A., Paul, M., Leibovici, L., & Stemmer, S. M. (2008). Interventions for alleviating cancer-related dyspnea: A systematic review. Journal of Clinical Oncology, 26, 2396–2404. doi:10.1200/JCO.2007.15.5796

Berger, A. M., Shuster, J. L., & Von Roenn, A. H. (2013).  Principles and practice of palliative care and supportive oncology. Philadelphia, PA: Lippincott, Williams and Wilkins.

Booth, S., Kelly, M. J., Cox, N. P., Adams, L., & Guz, A. (1996). Does oxygen help dyspnea in patients with cancer? American Journal of Respiratory and Critical Care Medicine, 153, 1515–1518. doi:10.1164/ajrccm.153.5.8630595

Bruera, E., de Stoutz, N., Velasco-Leiva, A., Schoeller, T., & Hanson, J. (1993). Effects of oxygen on dyspnoea in hypoxaemic terminal-cancer patients. Lancet, 342, 13–14. doi:10.1016/0140-6736(93)91880-U

Bruera, E., Schmitz, B., Pither, J., Neumann, C., & Hanson, J. (2000). The frequency and correlates of dyspnea in patients with advanced cancer. Journal of Pain and Symptom Management, 19, 357–362. doi:10.1016/S0885-3924(00)00126-3

Bruera, E., Sweeney, C., Willey, J., Palmer, J. L., Strasser, F., Morice, R. C., & Pisters, K. (2003). Randomized controlled trial of supplemental oxygen versus air in cancer patients with dyspnea. Palliative Medicine, 17, 659–663. doi:10.1191/0269216303pm826oa

Campbell, M. L., Yarandi, H., & Dove-Medows, E. (2013). Oxygen is nonbeneficial for most patients who are near death. Journal of Pain and Symptom Management, 45, 517–523. doi:10.1016/j.jpainsymman.2012.02.012

Clemens, K. E., Quednau, I., & Klaschik, E. (2009). Use of oxygen and opioids in the palliation of dyspnoea in hypoxic and non-hypoxic palliative care patients: A prospective study. Supportive Care in Cancer, 17, 367–377. doi:10.1007/s00520-008-0479-0

Cranston, J. M., Crockett, A., & Currow, D. (2008). Oxygen therapy for dyspnoea in adults. Cochrane Database of Systematic Reviews, 2008(3). doi:10.1002/14651858.CD004769.pub2

Currow, D. C., Agar, M., Smith, J., & Abernethy, A. P. (2009). Does palliative home oxygen improve dyspnoea? A consecutive cohort study. Palliative Medicine, 23, 309–316. doi:10.1177/0269216309104058

Currow, D. C., Smith, J., Davidson, P. M., Newton, P. J., Agar, M., & Abernathy, A. P. (2010). Do the trajectories of dyspnea differ in prevalence and intensity by diagnosis at the end of life? A consecutive cohort study. Journal of Pain and Symptom Management, 39, 680–690. doi:10.1016/j.jpainsymman.2009.09.017

Kamal, A. H., Maguire, J. M., Wheeler, J. L., Currow, D. C., & Abernethy, A. P. (2012). Dyspnea review for the palliative care professional: Treatment goals and therapeutic options. Journal of Palliative Medicine, 15, 106-114. doi:10.1089/jpm.2011.0110

Kvale, P. A., Selecky, P. A., & Prakash, U. B. S. (2007).  Palliative care in lung cancer: ACCP evidence-based clinical practice guidelines (2nd Edition). Chest, 132 (Suppl. 3), 368s-403s. doi:10.1378/chest.07-1391

Levinson, D. R. (2006, September). Medicare home oxygen equipment: Cost and servicing (OEI-09-04-00420). Washington, D.C.: U.S. Department of Health and Human Services, Office of Inspector General. Retrieved from http://oig.hhs.gov/oei/reports/oei-09-04-00420.pdf

Morrison Informatics, Inc. (2006, June 27). A comprehensive cost analysis of Medicare home oxygen therapy: A study for the American Association for Homecare. Retrieved from http://www.bipac.net/cqrc_test/MorrisonResearch.pdf

Nonoyama, M. L., Brooks, D., Guyatt, G. H., & Goldstein, R. S. (2007). Effect of oxygen on health quality of life in patients with chronic obstructive pulmonary disease with transient exertional hypoxemia. American Journal of Respiratory and Critical Care Medicine176, 343-349. doi:10.1164/rccm.200702-308OC

O'Donohue, W. J., & Plummer, A. L. (1995). Magnitude of usage and cost of home oxygen therapy in the United States. CHEST Journal107, 301-302. doi:10.1378/chest.107.2.301

Parshall, M. B., Schwartzstein, R. M., Adams, L., Banzett, R. B., Manning, H. L., Bourbeau, J., . . . O’Donnell, D. E. (2012). An official American Thoracic Society statement: Update on the mechanisms, assessment, and management of dyspnea. American Journal of Respiratory and Critical Care Medicine, 185, 435–452. doi:10.1164/rccm.201111-2042ST

Philip, J., Gold, M., Milner, A., Di Iulio, J., Miller, B., & Spruyt, O. (2006). A randomized, double-blind, crossover trial of the effect of oxygen on dyspnea in patients with advanced cancer. Journal of Pain and Symptom Management, 32, 541–550. doi:10.1016/j.jpainsymman.2006.06.009

Qaseem, A., Snow, V., Shekelle, P., Casey, D. E., Jr., Cross, J. T., Jr., & Owens, D. K. (2008). Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 148, 141–146. doi:10.7326/0003-4819-148-2-200801150-00009

Simoff, M. J., Lally, B., Slade, M.G., Goldberg, W. G., Lee, P., Michaud, G. C., . . . Chawla, M. (2013). Symptom management in patients with lung cancer: Diagnosis and management of lung cancer, 3rd Edition: American College of Chest Physicians evidence-based clinical practice guidelines. Chest, 143(5 Suppl.), e455S-e497S. doi:10.1378/chest.12-2366

Solano, J., Gomes, B., & Higginson, I. (2006). A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. Journal of Pain and Symptom Management, 31, 58–69. doi:10.1016/j.jpainsymman.2005.06.007

Thomas, J. R., & von Gunten, C. F. (2003). Management of dyspnea. Journal of Supportive Oncology, 1, 23-32. Retrieved from http://www.oncologypractice.com/jso/journal/articles/0101023.pdf

Thomas, S., Bausewein, C., Higginson, I., & Booth, S. (2011). Breathlessness in cancer patients—Implications, management and challenges. European Journal of Oncology Nursing, 15, 459-469. doi:10.1016/j.ejon.2010.11.013

Uronis, H. E., & Abernethy, A. P. (2008). Oxygen for relief of dyspnea: What is the evidence? Current Opinion in Supportive and Palliative Care, 2, 89–94. doi:10.1097/SPC.0b013e3282ff0f5d

Uronis, H. E., Currow, D. C., McCrory, D. C., Samsa, G. P., & Abernethy, A. P. (2008). Oxygen for relief of dyspnoea in mildly- or non-hypoxaemic patients with cancer: A systematic review and meta-analysis. British Journal of Cancer, 98, 294–299. doi:10.1038/sj.bjc.6604161

Wiese, C. H., Barrels, U. E., Graf, B. M., & Hanekop, G. G. (2009). Out-of-hospital opioid therapy of palliative care patients with “acute dyspnoea”: A retrospective multicenter investigation. Journal of Opioid Management, 5, 115–122. Retrieved from www.opioidmanagement.com