Using titrated oxygen instead of high flow oxygen during an acute exacerbation of chronic obstructive pulmonary disease (COPD) saves lives.

In patients with a suspected acute exacerbation of COPD, does titrated oxygen in the pre-hospital setting change mortality, length of hospital stay and blood gas measurements? Cluster randomised controlled trial in which paramedics were allocated to deliver titrated or high flow oxygen. Randomisation sequence was concealed prior to allocation. Ambulance service and emergency department in Hobart, Australia. People who were: transported by ambulance to the emergency department, aged ≥35 years, breathless, and were thought to have COPD based on their acute symptoms, a patient-stated history of COPD, or a smoking history of > 10 pack-years. Randomisation of 64 paramedics allocated 32 to the titrated oxygen group and 30 to the high flow oxygen group. Over the study duration, 179 and 226 patients were allocated to the titrated and high flow oxygen groups, respectively. Patients in both groups received basic support, nebulised bronchodilators, intravenous dexamethasone and, if necessary, intravenous or intramuscular salbutamol. In addition, the intervention group received titrated oxygen via nasal prongs, with the aim of maintaining arterial oxygen saturation, measured via a pulse oximeter (SpO(2)) between 88% and 92%. Nebulised therapy was delivered by compressed air. The control group received high flow oxygen (8 to 10 L/min) via a non-rebreather face mask. Nebulised therapy was delivered by compressed oxygen at 6 to 8 L/min. The primary outcome was pre-and in-hospital mortality. Secondary outcomes were length of hospital stay and blood gas measurements. The primary outcome was captured for all enrolled patients. According to the intention to treat (ITT) analysis, mortality in the intervention and control groups was 4% (n = 7) and 9% (n = 21), respectively. The relative risk was 0.42 (95% CI 0.20 to 0.89). Similar results were demonstrated when only those patients who had a physician-confirmed diagnosis of COPD were included in the analyses (mortality of 2%, n = 2, vs 9%, n = 11, and relative risk of 0.22, 95% CI 0.05 to 0.9]). The ITT analysis did not demonstrate between-group differences in the secondary outcomes. In patients with a suspected acute exacerbation of COPD, using titrated oxygen to maintain SpO(2) between 88% and 92% reduced the risk of mortality by 58%. Physiotherapists working in acute care should strive to ensure that these patients are not treated with high-flow oxygen.

Ntoumenopoulos G 《-》

Action plans and case manager support may hasten recovery of symptoms following an acute exacerbation in patients with chronic obstructive pulmonary disease (COPD).

In patients with COPD, does an action plan (AP) with support from a case manager lead to earlier contact with healthcare professionals and faster recovery from an exacerbation? Randomised, controlled trial with concealed allocation. Patients were unaware of the study aims. 8 regional hospitals and 5 general practices in Europe. Adults with COPD, aged > 40 years, with a substantial smoking history, and using bronchodilators were eligible. Exclusion criteria were a primary diagnosis of asthma or cardiac disease, or presence of disease that would affect mortality or participation (eg, confusion). Randomisation of 233 patients allocated 111 to the intervention group and 122 to the control group. Both groups received usual care and brief nurse-led education about management of their disease. In addition, the intervention group received an individualised written AP, encouragement to contact the nurse for more information if needed, and two standardised telephone reinforcement sessions at 1 and 4 months following randomisation. The nurse, in consultation with physician, was able to provide a course of corticosteroids and antibiotics. Patients recorded their symptoms daily and completed the 24-hour Clinical COPD Questionnaire (CCQ) every 3 days, for 6 months. The primary outcome was time to recovery of health status following an exacerbation, defined as a return to pre-exacerbation CCQ scores. Secondary outcomes included the time delay between exacerbation onset and exacerbation-related healthcare contact and exacerbationrelated self-efficacy. CCQ data were available for 216 patients. The mean symptom recovery time was shorter in the AP group by 3.68 days (95% CI 0.04 to 7.32). Patients in the AP group with an exacerbation sought treatment 2.9 days earlier (95% CI 2.4 to 3.5) than patients in the control group. The change in self-efficacy was higher in favour of the AP group. There were no differences in the number of exacerbations or healthcare contact between the groups. An AP with case manager support enhanced early detection of exacerbations and expedited recovery from symptoms following these events.

Effing T 《-》

Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial.

Austin MA ，Wills KE ，Blizzard L ，Walters EH ，Wood-Baker R ... -  《-》

Standard vs. targeted oxygen therapy prehospitally for chronic obstructive pulmonary disease (STOP-COPD): study protocol for a randomised controlled trial.

A high concentration of inspired supplemental oxygen may possibly cause hypercapnia and acidosis and increase mortality in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Even so, patients with AECOPD are being treated with high oxygen flow rates when receiving inhalation drugs in the prehospital setting. A cluster-randomised controlled trial found that reduced oxygen delivery by titrated treatment reduced mortality-a result supported by observational studies-but the results have never been reproduced. In the STOP-COPD trial, we investigate the effect of titrated oxygen delivery compared with usual care consisting of high flow oxygen delivery in patients with AECOPD in the prehospital setting. In this randomised controlled trial, patients will be blinded to allocation. Patients with suspected AECOPD (n = 1888) attended by the emergency medical service (EMS) and aged > 40 years will be allocated randomly to either standard treatment or titrated oxygen, targeting a blood oxygen saturation of 88-92% during inhalation therapy. The trial will be conducted in the Central Denmark Region and include all ambulance units. The power to detect a 3% 30-day mortality risk difference is 80%. The trial is approved as an emergency trial. Hence, EMS providers will include patients without prior consent. The results will provide evidence on whether titrated oxygen delivery outperforms standard high flow oxygen when used to nebulise inhaled bronchodilators in AECOPD treatment. The trial is designed to ensure unselected inclusion of patients with AECOPD needing nebulised bronchodilators-a group of patients that receives high oxygen fractions when treated in the prehospital setting where the only compressed gas is generally pure oxygen. Conducting this trial, we aim to improve treatment for people with AECOPD while reducing their 30-day mortality. European Union Clinical Trials (EUCT) number: 2022-502003-30-00 (authorised 06/12/2022), ClinicalTrials.gov number: NCT05703919 (released 02/02/2023), Universal trial number: U1111-1278-2162.

Jensen ASR ，Valentin JB ，Mulvad MG ，Hagenau V ，Skaarup SH ，Johnsen SP ，Væggemose U ，Gude MF ... -  《-》

Neuromuscular electrical stimulation appears to be useful in people with severe chronic obstructive pulmonary disease.

In patients with chronic obstructive pulmonary disease (COPD), what effect does neuromuscular electrical stimulation (NMES) have on muscle function and walking endurance? Randomised, controlled trial in which the patients and those who collected outcome measures were blinded to group allocation. Home-based intervention with outcomes collected at a hospital in Quebec City, Canada. Patients who were clinically stable, sedentary and able to travel to the hospital with: (a) a smoking history >20 pack-years, (b) severe airflow obstruction, and (c) a 6-minute walk distance <400m. Exclusion criteria comprised any co-morbid condition associated with muscle wasting. Randomisation of 22 patients allocated 13 to the intervention group and 9 to the control group. Both groups received electrical stimulation 5 times a week for 6 weeks. Each session comprised 35min of bilateral stimulation for the quadriceps and 25min of bilateral stimulation for the calf. Stimulation was applied with the patient in sitting. They were encouraged to increase the intensity to the maximum they could tolerate. Patients were visited weekly at home by a research nurse to monitor progress. Parameters used by the intervention group were 50Hz frequency, 400μs pulse duration, and 6sec/16sec duty cycle. Parameters used by the control/sham group were 5Hz frequency, 100μs pulse duration, applied continuously. The primary outcome was quadriceps strength. The secondary outcomes included quadriceps endurance and performance during the endurance shuttle walk test. Data were available on 12 and 8 patients in the intervention and control groups, respectively. Current intensity increased over the training period in the intervention group from 20±4mA to 31±10mA (p <0.001). Compared with the control group, the intervention group conferred greater gains in quadriceps force (difference in mean percent change from baseline 14%, 95% CI 1% to 26%) and endurance (42%, 95% CI 4% to 80%), but not walking endurance. In patients with severe COPD, NMES delivered at home enhanced muscle function but not walking endurance.

Gerovasili V 《-》