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Letter
Authors’ reply
  1. M Wildman,
  2. C Sanderson
  1. Respiratory Medicine Department, Northern General Hospital, Sheffield, UK
  1. Correspondence to Dr M Wildman, Respiratory Medicine Department, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK; martin.wildman{at}sth.nhs.uk

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Thank you for giving us an opportunity to comment on the letter by Añon and Garcia de Lorenzo. We agree that further information about patients on long-term oxygen therapy (LTOT) is important, especially as, anecdotally, some clinicians seem to consider LTOT to be an absolute contraindication to intubation. Table 1 summarises the outcomes for intubated patients with chronic obstructive pulmonary disease (COPD) in the COPD and Asthma Outcome Study (CAOS), comparing those who were on LTOT before admission with those who were not. It can be seen that, although the two groups of patients had similar 180-day survival rates, the LTOT group had significantly lower EuroQol scores. These differences partly reflect differences in health status before the onset of the acute episode (at that stage 63% of the LTOT group were housebound, chairbound or bedbound compared with 27% of the rest) and partly the higher proportion of the LTOT group who felt that their health at 180 days was worse than it had been before onset. Nevertheless, in our data, 86% would choose ICU and intubation again. The actual number of patients on LTOT who responded to the follow-up questionnaire was small and the confidence interval wide (58–98%). It is also possible that the small numbers of patients with COPD on LTOT currently being admitted to critical care are atypically positive about invasive procedures, at least in retrospect. Nonetheless, the straightforward interpretation of these data is that, from the perspective of the patient with COPD, intubation is not futile—even for those on LTOT. If so, patient preferences must often be frustrated by limits on the availability of ICU beds. What the threshold should be for intubation in terms of probability of survival and how patients’ (or carers’) perspectives might be brought into decisions on intubation are currently unanswered questions.

Table 1

EuroQol (EQ) and other outcomes reported by intubated patients with chronic obstructive pulmonary disease (COPD) who survived 180 days: comparison of those on long-term oxygen therapy (LTOT) on admission vs the rest

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Footnotes

  • Competing interests None.

  • Provenance and peer review Not commissioned; not externally peer reviewed.

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