Since the introduction of the domiciliary oxygen concentrator service in 1985, thereby facilitating the prescription of long-term oxygen therapy (LTOT), the number of patients treated with oxygen at home has steadily increased.
Several studies, however, have highlighted problems, including variability in prescribing, poor adherence to present guidelines, and lack of any organised follow-up and monitoring.1,2
In response, the DoH requested that the RCP lead a multidisciplinary Working Party to devise new guidance for the use of domiciliary oxygen, not only in adults with chronic respiratory disease but also in paediatrics, cardiology and palliative medicine. The specific terms of reference were to:
- Review current arrangements for the provision of domiciliary oxygen
- Provide guidelines for whom, and in what circumstances, domiciliary oxygen should be prescribed.
The Report,3 published in July 1999, highlights the indications for LTOT in adults under three main categories:
- Diseases where there is chronic hypoxaemia, of which COPD is numerically the most important and the area about which there is most information
- Diseases associated with nocturnal hypoventilation, where oxygen therapy may be used in conjunction with ventilatory support
- Palliative use in patients with pulmonary malignancy or who are terminally ill with other conditions.
Requirements for domiciliary oxygen in infants and children are addressed, highlighting bronchopulmonary dysplasia (chronic lung disease of infancy) as the main indication.
Although the importance of blood gas analysis in assessment of adults for LTOT is emphasised, the use of saturation measurements with a pulse oximeter in both adults and children is identified as valuable in selecting those who require further evaluation: an arterial oxygen saturation of >92% excludes patients who are not significantly hypoxaemic.
There is also guidance on ambulatory oxygen therapy, i.e. the provision of oxygen with portable equipment for use during exercise and the activities of daily living. This area of oxygen provision is frequently identified by patient surveys as highly unsatisfactory.
However, improvements in the availability of ambulatory oxygen will have financial implications and the Working Party recommends that appropriate ambulatory equipment should be made available on the Drug Tariff.
There are sections on the technology for provision of home oxygen therapy and on the organisation of home oxygen services, with for the first time recommendations for follow-up and long-term monitoring.
These sections contain practical advicedabout safety issues and emphasise the key role of education for patients, carers and healthcare professionals. Domiciliary Oxygen Record forms are proposed as a novel way of combining the assessment and prescription of domiciliary oxygen, and as a means of resolving the current conflict between the need for home oxygen in England and Wales to be prescribed by a GP while the assessments are undertaken by hospital physicians.
This report has followed the standard criteria for developing evidence-based recommendations, but the lack of good quality evidence in many areas has predictably highlighted the need for further research. Despite this, these guidelines should provide a firm basis on which to improve domiciliary oxygen services to meet the needs of those who depend on them.
- The report Domiciliary Oxygen Therapy Services is available from the Publications Dept of the RCP (020 7935 1174, ext 358) and costs £10.50 (incl. p&p).
- Baudouin SV, Waterhouse JC, Tahtamouni T et al. Thorax l990; 45: 195-8.
- Restrick LJ, Paul EA, Braid GM et al. Thorax 1993; 48: 708-13.
- Report of the Royal College of Physicians. Domiciliary Oxygen Services: Clinical Guidelines and Advice for Prescribers. London: The Royal College of Physicians of London, 1999.