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Editorials: Point and Counterpoint |

Rebuttal From Drs Christopher and Repine FREE TO VIEW

Kent L. Christopher, MD, RRT, FCCP; John E. Repine, MD
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following: K. L. C. has licensed patents to Transtracheal Systems, Inc. and might receive financial gain in the future. None declared (J. E. R.).

CORRESPONDENCE TO: Kent L. Christopher, MD, RRT, FCCP, 9086 East Colorado Circle, Denver, CO 80231


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;149(2):309-310. doi:10.1016/j.chest.2015.10.075
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Published online

We agree with our counterparts’ assertion that “…no ‘gold standard’ trials prove or disprove [their] position.”

In contrast, there is gold standard evidence—that patients with COPD using long-term domiciliary oxygen therapy (LDOT) live longer,—that unequivocally supports our position that LDOT does not expose patients with COPD to more radiation-like risks than patients without COPD. Because patients with COPD and who are receiving LDOT live longer, there is no meaningful risk or consequence of LDOT in COPD.

Irrespective of “biopsychosocial” issues, multisociety guidelines endorse LDOT for qualifying patients with COPD. Oxygen reimbursement constraints by the Centers for Medicare and Medicaid Services (Part D) and other payors, reduced education and care issues, and challenging socioeconomics already threaten access to life-saving LDOT. Our counterparts’ position of limiting LDOT for COPD, based only on theoretical “radiation-like risks,” simply adds another barrier to LDOT-improved pulmonary hemodynamics, and survival,, in COPD.

Landmark randomized controlled studies,, and evidence-based guidelines for both long-term LDOT and LDOT use in the acutely ill, confirm that “low as reasonably achievable” guidelines for LDOT in COPD have been “reasonably” established. For example, when maximal medical therapy was administered in a stable medical state, 21% of patients with COPD no longer qualified for LDOT. This is a more prudent approach than unproven antioxidant pretreatment to avoid speculative LDOT risk. Criteria for appropriately correcting hypoxemia by LDOT are established in COPD., An LDOT “Choosing Wisely” campaign should be based on evidence-based guidelines.

Tallying COPD and non-COPD publications fails to document more “problematic exposures” in patients with COPD. The paucity of results and absent relevance of our counterparts’ “problematic” methodology are not surprising. The British Thoracic Society home oxygen guidelines document both scientific evidence and clinical recommendations for using LDOT in COPD. The relevant guideline reference to absence of oxygen toxicity was based on outcomes in the Medical Research Council study. Of note, despite insufficient evidence in patients without COPD, recommendations for using LDOT in COPD were adopted since the large COPD population and scientific evidence support widespread LDOT use without implicating any speculative risk of “problematic” injurious exposure.

While LDOT is justified for COPD,,,, no evidence exists that LDOT is risky in COPD. Irradiation and chemically generated reactive oxygen and nitrogen species (RONS) can damage various molecules in vitro and in vivounless antioxidants are added or other protective mechanisms are induced. If RONS increase in patients with COPD receiving LDOT, an adaptive response (our counterparts’ suggestion) could explain why RONS are not toxic and why patients with COPD who are undergoing LDOT live longer. LDOT may also enhance phagocyte RONS production and bactericidal activity and thereby reduce bronchitis episodes that worsen COPD. COPD and lung cancer may share an RONS pathology, but no evidence exists that LDOT causes lung cancer.

The possibility that LDOT reduces antioxidant defenses could be important, but treatment with N-acetylcysteine (also a mucolytic agent) and melatonin (also a sleep improvement and antibacterial agent) to correct blood antioxidant and oxidative biomarkers in patients with COPD must be an insignificant epiphenomenon in light of the increased longevity with LDOT in COPD.

The overriding positive impact—the “bottom line” if you will, or “big picture”—of the increased longevity of patients with COPD using LDOT convincingly eliminates any theoretical risks.

References

Kopp V.J. .Stavas J.M. . Does low-dose oxygen expose patients with COPD to more radiation-like risks than patients without COPD? Yes. Chest. 2016;149:303-306 [PubMed]journal
 
Medical Research Council Working Party Long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema: report of the Medical Research Council Working Party. Lancet. 1981;1:681-686 [PubMed]journal. [PubMed]
 
Hardinge M. .Annandale J. .Bourne S. . British Thoracic Societyet al BTS guidelines for home oxygen use in adults. Thorax. 2015;70:i1-i43 [PubMed]journal. [CrossRef] [PubMed]
 
Nocturnal Oxygen Therapy Trial Group Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical trial. Ann Intern Med. 1980;93:391-398 [PubMed]journal. [CrossRef] [PubMed]
 
O’Driscoll B.R. .Howard L.S. .Davison A.G. . British Thoracic Societyet al BTS guideline for emergency oxygen use in adult patients. Thorax. 2008;63:vi1-vi68 [PubMed]journal. [PubMed]
 
Koch S. .Della-Morte D. .Dave K.R. .et al Biomarkers for ischemic preconditioning: finding the responders. J Cereb Blood Flow Metab. 2014;34:933-941 [PubMed]journal. [CrossRef] [PubMed]
 
Goldberg J.J. .Pankey J.W. .Politis I. .et al Effect of oxygen tension on killing of Escherichia coli by bovine polymorphonuclear leucocytes in vitro. J Dairy Res. 1995;62:331-338 [PubMed]journal. [PubMed]
 

Figures

Tables

References

Kopp V.J. .Stavas J.M. . Does low-dose oxygen expose patients with COPD to more radiation-like risks than patients without COPD? Yes. Chest. 2016;149:303-306 [PubMed]journal
 
Medical Research Council Working Party Long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema: report of the Medical Research Council Working Party. Lancet. 1981;1:681-686 [PubMed]journal. [PubMed]
 
Hardinge M. .Annandale J. .Bourne S. . British Thoracic Societyet al BTS guidelines for home oxygen use in adults. Thorax. 2015;70:i1-i43 [PubMed]journal. [CrossRef] [PubMed]
 
Nocturnal Oxygen Therapy Trial Group Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical trial. Ann Intern Med. 1980;93:391-398 [PubMed]journal. [CrossRef] [PubMed]
 
O’Driscoll B.R. .Howard L.S. .Davison A.G. . British Thoracic Societyet al BTS guideline for emergency oxygen use in adult patients. Thorax. 2008;63:vi1-vi68 [PubMed]journal. [PubMed]
 
Koch S. .Della-Morte D. .Dave K.R. .et al Biomarkers for ischemic preconditioning: finding the responders. J Cereb Blood Flow Metab. 2014;34:933-941 [PubMed]journal. [CrossRef] [PubMed]
 
Goldberg J.J. .Pankey J.W. .Politis I. .et al Effect of oxygen tension on killing of Escherichia coli by bovine polymorphonuclear leucocytes in vitro. J Dairy Res. 1995;62:331-338 [PubMed]journal. [PubMed]
 
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