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Home oxygen therapy for children: New guidelines combine limited evidence, expert experience

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More research sorely needed

It is unfortunate that over the course of a decade, the evidence base supporting home oxygen therapy in children has not substantially changed, according to Ian Balfour-Lynn, MD, a member of the American Thoracic Society (ATS) committee that developed the clinical practice guideline.

The ATS clinical practice guideline on home oxygen therapy for children echoes conclusions reached in a 2009 guideline published by the British Thoracic Society (BTS), he wrote in The Lancet Respiratory Medicine.

Dr. Balfour-Lynn, who chaired the BTS guideline committee, said new research is sorely needed, particularly in the prevention of preterm births, which he said constitute the commonest cause of home oxygen need among children, according to the Lancet report.

In addition, a large prospective trial is needed to evaluate strategies for weaning or discontinuing oxygen, he said, noting that the ATS recommendations on weaning were almost entirely based on the expert panel’s combined clinical experience.

Dr. Balfour-Lynn is a consultant in pediatric respiratory medicine at Royal Brompton Hospital, London. This summary of his opinions is based on his comments in a report that appeared March 8 in The Lancet Respiratory Medicine . He reported no relationships with commercial interests relevant to his work on the ATS clinical practice guideline.



Based on the very limited evidence available, an expert panel convened by the American Thoracic Society has devised a clinical practice guideline specific to children who require home oxygen therapy.

A tank of oxygen for medical use. Photodisc/ThinkStock

The guideline authors not only addressed specific indications for chronic lung and pulmonary vascular diseases, but also defined hypoxemia in children – noting that Medicare and Medicaid coverage determinations for home oxygen therapy in children are based on decades-old studies that lacked pediatric patients – and offer expert advice on how to wean and discontinue oxygen, when warranted.

The disease-specific recommendations on whether or not to prescribe home oxygen therapy are characterized either as strong, meaning that it’s the right course of action for at least 95% of patients; or conditional, meaning it might not be right for a “sizable minority” of patients, authors explained in the guideline.

Home oxygen therapy gets a strong recommendation, for example, in patients with cystic fibrosis complicated by severe chronic hypoxemia, but gets a conditional recommendation for sickle cell disease with severe chronic hypoxemia, according to the guideline, published in the American Journal of Respiratory and Critical Care Medicine.

Regardless of strong or conditional, the recommendations were largely based on “very low-quality evidence,” according to ad hoc subcommittee of the ATS Assembly on Pediatrics, cochaired by Don Hayes Jr., MD, of Nationwide Children’s Hospital, Columbus, Ohio, and Robin R. Deterding, MD, of Children’s Hospital Colorado, Denver.

“Despite widespread use of home oxygen therapy for various lung and pulmonary vascular diseases, there is a striking paucity of data regarding its implementation, efficacy, monitoring, and discontinuation,” Dr. Hayes, Dr. Deterding, and 20 additional committee members wrote in their report.

Accordingly, the panel sought to add expert opinion and experience to the limited evidence, in the hope that it would aid clinicians in the management of complex pediatric patients, they said.

One new tool they provide, toward that end, is a definition of hypoxemia in children based on oxygen saturation as quantified by pulse oximetry (SpO2).

Based on a review of 31 selected studies measuring oxygenation in healthy children, the expert panel defined hypoxemia (at or near sea level) as SpO2 of 90% or lower for 5% of the recording time in children under 1 year old, and an SpO2 of 93% or lower in older children; or alternately, as three independent measurements of SpO2 less than or equal to 90% in the younger children and 93% in the older children.

By contrast, an SpO2 of less than 88% is one of the indications for funding home oxygen therapy as determined by the Centers for Medicare & Medicaid Services for both pediatric and adult patients, according to the committee.

The CMS indications derived from “seminal studies” showing that continuous oxygen therapy reduced mortality in adults with chronic obstructive pulmonary disease, they said in the guideline document.

“Despite the lack of pediatric patients in these historic studies performed over 35 years ago, the CMS coverage determination for [home oxygen therapy] is the same for pediatric patients of all ages compared with adult patients,” they wrote in the report.

The committee unanimously agreed that 2 weeks of low SpO2 was “sufficient evidence” to indicate chronic hypoxemia, their report says.

Dr. Hayes reported no relationships with relevant commercial interests, while Dr. Deterding provided disclosures related to Boehringer Ingelheim, Novartis, and Elsevier Publishing, among others. Fellow committee members provided disclosures related to Shire Pharmaceuticals, United Therapeutics, and others as listed in the clinical practice guideline document.

SOURCE: Hayes D Jr. et al. J Respir Crit Care Med. 2019 Feb 1;199(3):e5-e23. doi: 10.1164/rccm.201812-2276ST.

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