Smoking and home oxygen therapy: a review and consensus statement from a multidisciplinary Swedish taskforce.

BACKGROUND: Home oxygen therapy (HOT) improves survival in patients with hypoxaemic chronic respiratory disease. Most patients evaluated for HOT are former or active smokers. Oxygen accelerates combustion and smoking may increase the risk of burn injuries and fire hazards; therefore, it is considered a contraindication for HOT in many countries. However, there is variability in the practices and policies regarding this matter. This multidisciplinary Swedish taskforce aimed to review the potential benefits and risks of smoking in relation to HOT, including medical, practical, legal and ethical considerations. METHODS: The taskforce of the Swedish Respiratory Society comprises 15 members across respiratory medicine, nursing, medical law and ethics. HOT effectiveness and adverse risks related to smoking, as well as practical, legal and ethical considerations, were reviewed, resulting in five general questions and four PICO (population-intervention-comparator-outcome) questions. The strength of each recommendation was rated according to the GRADE (grading of recommendation assessment, development and evaluation) methodology. RESULTS: General questions about the practical, legal and ethical aspects of HOT were discussed and summarised in the document. The PICO questions resulted in recommendations about assessment, management and follow-up of smoking when considering HOT, if HOT should be offered to people that meet the eligibility criteria but who continue to smoke, if a specific length of time of smoking cessation should be considered before assessing eligibility for HOT, and identification of areas for further research. CONCLUSIONS: Multiple factors need to be considered in the benefit/risk evaluation of HOT in active smokers. A systematic approach is suggested to guide healthcare professionals in evaluating HOT in relation to smoking.

Burn injury during long-term oxygen therapy in Denmark and Sweden: the potential role of smoking.

BACKGROUND: Long-term oxygen therapy (LTOT) increases life expectancy in patients with COPD and severe hypoxemia. Smoking is the main cause of burn injury during LTOT. Policy regarding smoking while on LTOT varies between countries. In this study, we compare the incidence of burn injury that required contact with a health care specialist, between Sweden (a country with a strict policy regarding smoking while on LTOT) and Denmark (a country with less strict smoking policy). METHODS: This was a population-based, cohort study of patients initiating LTOT due to any cause in Sweden and Denmark. Data on diagnoses, external causes, and procedures were obtained from the Swedish and Danish National Patient Registers for inpatient and outpatient care. Patients were followed from January 1, 2000, until the first of the following: LTOT withdrawal, death, or study end (December 31, 2009). The primary end point was burn injury during LTOT. RESULTS: A total of 23,741 patients received LTOT in Denmark and 7,754 patients in Sweden. Most patients started LTOT due to COPD, both in Sweden (74%) and in Denmark (62%). The rate of burn injury while on LTOT was higher in Denmark than in Sweden; 170 (95% confidence interval [CI], 126-225) vs 85 (95% CI, 44-148) per 100,000 person-years; rate ratio 2.0 (95% CI, 1.0-4.1). The risk remained higher after adjustment for gender, age, and diagnosis in multivariate Cox regression, hazard ratio 1.8 (95% CI, 1.0-3.5). Thirty-day mortality after burn injury was 8% in both countries. CONCLUSION: Compared to Sweden, the rate of burn injury was twice as high in Denmark where smoking is not a contraindication for prescribing LTOT.

Real-life effectiveness of smoking-cessation treatments in general practice clinics in Denmark. The Escape Smoke project.

BACKGROUND: The smoking prevalence has not decreased in the last years in Denmark. General practice (GP) offers smoking cessation (SC) treatment. Studies of real-life effectiveness of daily practice SC-activities from the GP-setting opposed to efficacy results from randomized clinical trials are few. The study aim was to evaluate the real-life effectiveness of SC-treatments for daily smokers among Danish GP-clinics. METHODS: In a multi-centre-based observational study design Danish GP-clinics with prior SC-activity recruited daily smokers motivated for quitting. As per usual clinical practice SC-medicine could be nicotine replacement therapy (NRT), prescription-based SC-medicine (varenicline or bupropion) or no medicine. The primary endpoint was percentage of patients remaining abstinent 6 months after the quit date (ITT, self-reported continuous abstinence). RESULTS: Forty GP-clinics recruited 515 (273 females, 20% COPD) daily smokers being moderately nicotine dependent and heavy smoking (19 cigarettes/day). Receiving intensive advice, 74% did use SC-medicine paid out-of-pocket (1/3 NRT and 2/3 prescription-based). After 6 months, 187 participants had remained abstinent (36%). Adjusted for potential confounding the use of prescription-based SC-medicine plus counseling was associated with significantly doubling the chance of staying abstinent after 6 months as compared to no SC-medicine (OR: 1.97). This association could not be found for NRT. Being male and using prescription-based SC-medicine were independent significant predictors for long-term abstinence. CONCLUSIONS: Smoking cessation in Danish GP-clinics with some prior SC-activity can result in rather high long-term quit rates, especially when combining counseling and prescription-based SC-medicine. The effectiveness of prescription-based SC-medications versus NRT in the general population merits further investigation.

[Smoking water pipe is injurious to lungs].

This review describes the pulmonary consequences of water pipe smoking. Smoking water pipe affects the lung function negatively, is significantly associated with chronic obstructive pulmonary disease and increases the risk of lung infections. Case reports suggest that regular smokers of water pipe have a higher risk of developing malignancies, particularly lung cancer than cigarette smokers.

Management of pneumothorax differs across Denmark.

INTRODUCTION: Pneumothorax is a common problem in Denmark. Guidelines recommend insertion of small-bore (≤ 14 Fr) chest tubes or simple needle aspiration in spontaneous pneumothorax. Our objective was to investigate the management of pneumothorax in Danish hospitals. MATERIAL AND METHODS: We undertook a questionnaire survey at all Danish acute hospitals enquiring about current practice in the management of pneumothorax. A questionnaire was sent to 35 hospitals in May 2013. After follow-up in September 2013, a total of 32 completed questionnaires were assessed. RESULTS: We found that three hospitals (10.7%) used simple needle aspiration in primary spontaneous pneumothorax. The majority of the hospitals treated all types of pneumothorax by inserting chest tubes with a traditional small thoracotomy (75%), and most hospitals used large-bore (> 14 Fr) chest tubes (85.7%). There were no regional differences in the management of pneumothorax among the five regions in Denmark (p > 0.05), but we found a trend towards use of less invasive techniques in hospitals with departments of either Respiratory Medicine or Thoracic Surgery. CONCLUSION: Management of pneumothorax in Denmark is mainly based on insertion of a large-bore (> 14 Fr) chest tube by a traditional small thoracotomy. Only a few hospitals in Denmark use minimally invasive techniques in the management of spontaneous pneumothorax. We speculate that implementation of these techniques may reduce hospital admission time for patients with spontaneous pneumothorax in Denmark. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Association between vitamin D status and COPD phenotypes.

BACKGROUND: It has been suggested that identifying phenotypes in chronic obstructive pulmonary disease (COPD) might improve treatment outcome and the accuracy of prediction of prognosis. In observational studies vitamin D deficiency has been associated with decreased pulmonary function, presence of emphysema and osteoporosis, upper respiratory tract infections, and systemic inflammation. This could indicate a relationship between vitamin D status and COPD phenotypes. The aim of this study was to assess the association between vitamin D levels and COPD phenotypes. In addition, seasonality of vitamin D levels was examined. METHODS: A total of 91 patients from a Danish subpopulation of the "Evaluation of COPD Longitudinally to Identify Predictive Surrogate End-points" cohort took part in a biomarker substudy. Vitamin D concentration was measured from blood samples taken at two visits, approximately 6 months apart. The participants were 40-75-year-old patients with COPD and had a smoking history of >10 pack-years. RESULTS: Fifty-six patients had 25-hydroxyvitamin D measured from blood samples from both visits. In the final model of the multivariate analyses, the factors that were associated with vitamin D deficiency at the first visit were age (OR: 0.89, p = 0.02) and summer season (OR: 3.3, p = 0.03). Factors associated with vitamin D level also at the first visit were age (B: 0.9, p = 0.02) and 6 min walking distance (B: 0.05, p = 0.01). CONCLUSION: Vitamin D was not associated with COPD phenotypes and season did not seem to be a determinant of vitamin D levels in patients with moderate to severe COPD.

[Rehabilitation and palliative care of patients with severe COPD must be integrated]. / Rehabilitering og palliation af patienter med svær KOL bør integreres.

Treatment elements of rehabilitation and palliative care are described in relation to the main clinical manifestations of severe and very severe chronic obstructive pulmonary disease (COPD). With increasing loss of function the need for multidisciplinary effort increases. Physiotherapy, occupational therapy and medical treatment are adjusted to the improvement of the current quality of life with new treatment goals and decision on cessation of treatment including oxygen without subjective effect. Palliation with end-of-life discussion must be integrated in COPD rehabilitation programmes especially for patients with frequent exacerbations.

Shuttle walking test as predictor of survival in chronic obstructive pulmonary disease patients enrolled in a rehabilitation program.

BACKGROUND: The Incremental Shuttle Walking Test (ISWT) is used to assess exercise capacity in chronic obstructive pulmonary disease (COPD) and is employed as an outcome measure for pulmonary rehabilitation. We studied the value of this test in predicting survival in COPD patients enrolled in a rehabilitation program. METHODS: A total of 416 patients performed an ISWT before entering a 7-week outpatient pulmonary rehabilitation program. Their survival was observed over a mean period of 4.5 years (range = 1.2-7.2 years). RESULTS: During the observation period, 169 (40.6%) patients died. Univariate analyses showed that the ISWT as well as age, gender, present and previous tobacco smoking, forced expiratory volume in 1 second, body mass index, oxygen saturation at rest, long-term oxygen therapy, Medical Research Council dyspnea score, and treatment with oral corticosteroids were significantly associated with survival. Multivariate analysis, including relevant confounders, revealed that low ISWT was independently associated with poor survival (P = .001). The association was not linear and the risk of dying increased markedly when ISWT was lower than 170 m (RR = 2.84, 95% CI: 2.05-3.93). CONCLUSION: This study shows that the ISWT is a strong and independent predictor of survival in patients with COPD enrolled in a rehabilitation program.

The impact of the Danish Oxygen Register on adherence to guidelines for long-term oxygen therapy in COPD patients.

OBJECTIVES: To evaluate the impact of The Danish Oxygen Register on COPD patients' treatment modalities, survival, and adherence to guidelines for long-term oxygen therapy (LTOT). DESIGN: The Danish Oxygen Register. SUBJECTS: 8487 COPD patients who received LTOT in the study period from November 1, 1994, to December 31, 2000. MAIN OUTCOME MEASURES: Follow-up, smoking status, correct prescription of LTOT (15-24h/day), and survival. RESULTS: During the study period an increasing number of patients were prescribed LTOT in connection with discharge after hospitalisation for an exacerbation (1995 vs. 2000: 74.4% vs. 82.2%, P<0.001), were prescribed oxygen 15-24h/day (66.2% vs. 85.5%, P<0.001), had delivered oxygen concentrator or liquid oxygen (77.8% vs. 96.9%, P<0.001), and had mobile oxygen (29.9% vs. 42.8%, P<0.001). Only 65.8% of the patients were followed-up in an outpatient clinic with the possibility of re-evaluation of the criteria for LTOT and adjustment for oxygen flow, with no change during the study period (P=0.43). In a representative subsample, 77.1% had smoking habits or measurement of CO-level registered in 1995 compared to 79.6% in year 2000 (P=0.65), and 25.1% vs. 21.2% (P=0.34) were considered current smokers. The median survival increased from 1.07 to 1.40 years (P=0.032). CONCLUSIONS: Adherence to guidelines for LTOT has improved concerning administration of oxygen, but has remained poor concerning follow-up of the patients and smoking cessation. Survival of COPD patients on LTOT has improved during the observation period.