Home oxygen and domestic fires

Three Deaths Associated With Facial and Upper Airway Burns Related to Oxygen Use

ABSTRACT

Despite the implementation of numerous strategies to prevent unintentional burns, fire-related thermal injuries remain a significant source of morbidity and mortality. Unfortunately, fires that occur in the setting of medical oxygen do so despite many safeguards and warnings that accompany oxygen therapy. Oxygen-related accidental fires can occur both within the home and medical settings, and burns associated with these events tend to produce injuries of the face and upper airways. Thermal burns of the face and upper airway are of particular concern because of the vital respiratory function of these anatomic structures, and may initially appear minor, but due to the inhalational injury mechanism, can contribute to death. In this report, three deaths associated with accidental oxygen therapy-related facial/upper airway burns are reported, one occurring during surgery, and two occurring during home-oxygen use.

A National Mandate for Thermal Fuses for Home Oxygen Users is Cost-effective in the Prevention of Burn Morbidity, Mortality and Property Loss

Smoking while using home oxygen leads to explosions which cause cutaneous burns, death, and loss of property. Thermal fuses interrupt the propagation of ignited oxygen-lines and reduce the risk of injury. Prior to mandating thermal fuses for all home oxygen users in the US, cost-effectiveness analysis should be performed. A Markov model was constructed for suffering thermal injury while smoking on home oxygen. Societal and Medicare perspectives were adopted evaluating the costs of a federal policy including purchasing/shipping thermal fuses to all home oxygen users. Costs included the healthcare required to treat burn patients and extending lives in advanced chronic obstructive pulmonary disease. Cost savings included the avoided property loss. Effectiveness was measured in gains in quality adjusted life years (QALYS). In the status quo, the 10-year societal cost was $28.67 billion compared to $28.36 billion in the policy mandate (saving $305.40 million at ten years). 1,812 QALYs were gained with the policy mandate, yielding and ICER of -$160,317. For the Medicare payor perspective, the incremental cost-effectiveness ratio (ICER) was $64,981. Deterministic and probabilistic sensitivity analyses showed little variation in the ICER under multiple scenarios. The discrepancy between the dominant ICER for societal perspective and cost-effective ICER for Medicare perspective reflected savings from averted property loss not realized by Medicare. A national policy mandating and paying for thermal fuses for all home oxygen users is dominant from a societal perspective and cost-effective from a Medicare perspective. The US government should adopt such a policy.

Palliative home oxygen: practical framework for clinicians

The British Thoracic Society 2015 guidelines on home oxygen use in adults have been pivotal in guiding clinicians on the use of long-term oxygen therapy in improving survival outcomes for patients. However, guidance for use of home oxygen in the palliative care setting has not been as robust owing to the lack of evidence-based studies. Therefore, this narrative review aims to provide a clinical framework on the use of palliative home oxygen therapy by considering its prognostic and symptomatic benefits as well as offering pragmatic advice for palliative home oxygen in end-of-life care.

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 From Smoking Electronic Cigarettes While on Supplemental Oxygen

Many reports pertaining to burns from e-cigarette battery explosions exist, as do injuries from smoking conventional cigarettes while on home-oxygen therapy. However, literature regarding burn injuries from e-cigarettes while on oxygen therapy is limited. The heating coil of the device can rise to temperatures that facilitates ignition of oxygen. The purpose of this study is to describe and characterize this novel and under-reported mechanism of injury. This study was a descriptive review of 2013-2016 National Burn Repository (NBR) data, with a query for "oxygen," "O2," "electronic cigarettes," and various permutations/abbreviations/misspellings. Demographics, injury characteristics, and outcomes were reported. Also, a Google search for lay-press articles and a PubMed/Scopus search using similar terms was conducted to find literature. Of approximately 60,000 NBR entries, 8 records of injury while smoking e-cigarettes on oxygen were found. Patients were predominantly male, 63 ± 9 years old, with 3.4% ± 4 TBSA burns, and LOS of 5.8 ± 7 days (an LOS O/E ratio of 1.5). Two patients sustained full-thickness burns (0.5% and 11% TBSA). Three were intubated, with mean of 3.33 ventilator-days. Most injuries occurred at home (88%). All patients survived. A google search revealed five lay-press articles. Only three partially relevant scientific articles were found to only mention the phenomenon, without granular data. Although uncommon, smoking e-cigarettes on supplemental oxygen can result in injury without a lithium-ion battery explosion. Limitations in the database may have resulted in underestimation of injuries. A paucity of relevant literature exists, necessitating more research. Patients who receive home-O2 should be warned about this potential danger.

Mortality From Burns Sustained on Home Oxygen Therapy Exceeds Predicted Mortality

The Boston Criteria and the Abbreviated Burn Severity Index are two widely accepted models for predicting mortality in burn patients. We aimed to elucidate whether these models are able to predict the risk of mortality in patients who sustain burns while smoking on home oxygen given their clinical fragility. We conducted a retrospective chart review of 48 patients admitted to our burn center from November 2013 to September 2017 who sustained a burn while smoking on home oxygen. Yearlong mortality was the primary outcome of the investigation; secondary outcomes included discharge to facility, length of stay, and need for tracheostomy. We calculated the expected mortality rate for each patient based on Boston Criteria and Abbreviated Burn Severity Index and compared the mortality rate observed in our cohort. Patients in our cohort suffered a 54% mortality rate within a year of injury, compared to a 23.5% mortality predicted by Boston Criteria, which was found to be statistically significant by chi-square analysis (P < .05). Abbreviated Burn Severity Index predicted mortality was 19.7%. While the absolute value of the difference in mortality was greater, this was not significant on chi-square analysis due to sample size. Our secondary outcomes revealed 42% discharge to facility, the average length of stay of 6.2 days, and 6.25% required tracheostomy. Patients whose burns are attributable to smoking on home oxygen may have an increased risk of mortality than prognostication models would suggest. This bears significant clinical impact, particularly regarding family and provider decision making in pursuing aggressive management.

Long-term oxygen therapy-related adverse outcomes resulting in hospitalisation: 3-year experience of an Australian metropolitan health service

The aim of this study was to evaluate the incidence of long-term oxygen therapy (LTOT)-related adverse outcomes in our health service. LTOT patients retrospectively recruited had their medical records reviewed for the period of 1 January 2014 to 30 June 2018. Burns, physical injuries, any falls attributable to LTOT requiring admission were the outcomes measured. Of 291 patients, four patients required admission due to LTOT-related adverse events where three admissions were related to falls secondary to tripping over oxygen tubing.

Home oxygen therapy in patients with COPD: safety issues for nurse prescribers

Two landmark studies demonstrated survival benefit in chronic obstructive pulmonary disease (COPD) complicated by chronic hypoxaemia with the prescription of long-term oxygen therapy (LTOT). Best practice evidence therefore recommends that individuals with stable COPD and resting hypoxaemia (PaO₂≤7.3 kPa) should be assessed for long-term oxygen therapy. However, it is estimated that up to one-quarter of COPD patients prescribed LTOT continue to smoke. Oxygen therapy consequently presents an obvious fire hazard in the case of such patients, who are therefore at greater risk of death or sustaining devastating head and neck burns. This article critically analyses, through the context of a care study, the professional, ethical and legal issues involved in making a safe prescribing decision for LTOT in an individual with COPD who is a current smoker. Home oxygen prescription is a growing trend in the COPD population, and it is important for nurse prescribers to be aware of the issues highlighted in the article to ensure safe prescribing practices.

British Thoracic Society quality standards for home oxygen use in adults

Introduction

The purpose of the quality standards document is to provide healthcare professionals, commissioners, service providers and patients with a guide to standards of care that should be met for home oxygen provision in the UK, together with measurable markers of good practice. Quality statements are based on the British Thoracic Society (BTS) Guideline for Home Oxygen Use in Adults.

Methods

Development of BTS Quality Standards follows the BTS process of quality standard production based on the National Institute for Health and Care Excellence process manual for the development of quality standards.

Results

10 quality statements have been developed, each describing a key marker of high-quality, cost-effective care for home oxygen use, and each statement is supported by quality measures that aim to improve the structure, process and outcomes of healthcare.

Discussion

BTS Quality Standards for home oxygen use in adults form a key part of the range of supporting materials that the society produces to assist in the dissemination and implementation of a guideline’s recommendations.