Was your answer to Fridays CHEST Challenge question C? Nice work, you were correct! A 53-year-old woman is being evaluated for pulmonary hypertension. A previous workup has included pulmonary function testing (Fig 73-A) and arterial blood gas measurements (Pao2, 62 mm Hg; Paco2, 41; pH, 7.42). A representative 10-min compressed tracing from her overnight polysomnogram is shown in Figure 73-B. Which of the following treatments should be recommended for this patient? A. Continuous positive airway pressure (CPAP). B. Adaptive servo-ventilation. C. Nocturnal nasal oxygen. D. Reassurance. RATIONALE: The tracing shows regular breathing (flow); mild snoring; and persistent, sustained oxygen saturations of 85% (see Fig 73-B). According to the Centers for Medicare and Medicaid Services guidelines, nocturnal home oxygen therapy is considered medically necessary for patients who desaturate only during sleep to an arterial oxygen saturation of _ 88% for _ 30% of the night or with evidence of an otherwise unexplained pulmonary hypertension, corpulmonale, edema secondary to right-side heart failure, or erythrocytosis with a hematocrit level _ 55%. This therapy is also considered medically necessary for patients in whom obstructive sleep apnea (OSA) and other nocturnal apnea or hypoventilation syndromes have been ruled out. If OSA is present, persistent desaturation despite correction of apnea-hypopnea index (respiratory disturbance index) by CPAP must be documented. This patient, with sustained saturations of 85% and a history of pulmonary arterial hypertension, meets these criteria (choice C is correct). Based on the flow-volume loop (see Fig 73-A), she has airflow obstruction, which is the likely cause of the nocturnal hypoxemia. Her arterial blood gas measurements establish that she has a normal Paco2 and is unlikely to have hypoventilation or CO2 retention with supplemental oxygen. This coverage is largely based on the landmark Nocturnal Oxygen Therapy Trial in 1980, which demonstrated that long-term oxygen therapy use improves both the length and quality of life of patients with hypoxemic COPD; thus, not addressing this problem is incorrect (choice D is incorrect). There are no scoreable respiratory events, including central or obstructive apneas, hypopneas, or respiratory effort-related arousals, so treatment with PAP or with adaptive servo-ventilation are not indicated (choices A and B are incorrect). Nocturnal Oxygen Th erapy Trial Group. Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinial trial. Ann Intern Med. 1980;93(3):391-398. Petty TL, Casaburi R. Recommendations of the Fifth Oxygen Consensus Conference: writing and organizing committees. Respir Care. 2000;45(8):957-961. Department of Health and Human Services, Office of Inspector General. Usage and documentation of home oxygen therapy. oig.hhs.gov/ oei/reports/oei-03-96-00090.pdf. Accessed May 20, 2010.
Posted on: Mon, 21 Jul 2014 13:00:00 +0000
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