Domiciliary oxygen and smoking: an explosive combination

Outcomes of Patients with Burns Associated with Home Oxygen Therapy: An Institutional Retrospective Review

Home oxygen therapy (HOT) burns carry high morbidity and mortality. Many patients are active smokers, which is the most frequent cause of oxygen ignition. We conducted a retrospective review at our institution to characterize demographics and outcomes in this patient population. An IRB-approved single-institution retrospective review was conducted for home oxygen therapy burn patients between July 2016 and January 2021. Demographic and clinical outcome data were compared between groups. We identified 100 patients with oxygen therapy burns. Mean age was 66.6 years with a male to female ratio of 1.3:1 and median burn surface area of 1%. In these patients, 97% were on oxygen for COPD and smoking caused 83% of burns. Thirteen were discharged from the emergency department, 35 observed for less than 24 hours, and 52 admitted. For admitted patients, 69.2% were admitted to the ICU, 37% required intubation, and 11.5% required debridement and grafting. Inhalational injury was found in 26.9% of patients, 3.9% underwent tracheostomy, and 17.3% experienced hospital complications. In-hospital mortality was 9.6% and 7.7% were discharged to hospice. 13.5% required readmission within 30 days. Admitted patients had significantly higher rates of admission to the ICU, intubation, and inhalational injury compared to those that were not admitted (p < .01). Most HOT-related burns are caused by smoking and can result in significant morbidity and mortality. Efforts to educate and encourage smoking cessation with more judicious HOT allocation would assist in preventing these unnecessary highly morbid injuries.

Nexobrid Treatment for Burn Injuries in Patients With Chronic Obstructive Pulmonary Disease and Home Oxygen Therapy

There is an increased risk for burn injuries associated with home oxygen therapy of patients with chronic obstructive pulmonary disease since 10 to 50 % of these patients continue to smoke. Enzymatic eschar removal of facial burns is gaining popularity but intubation of this specific patient group often leads to prolonged weaning and can require tracheostomy. This study dealt with the question if enzymatic debridement in these patients can also be performed in analgosedation. A selective review of the literature regarding burn trauma associated with home oxygen use in patients with COPD was performed, as well as a retrospective analysis of all patients with burn injuries associated with home oxygen use and chronic obstructive pulmonary disease that were admitted to the study clinic. In the literature 1746 patients with burns associated with home oxygen use are described, but none of them received enzymatic debridement. In this study seventeen patients were included. All three patients in this study with facial full-thickness burn injuries received enzymatic debridement. The mortality rate in this cohort was 17.6 % (3/17). Up to date, there is limited experience performing regional anesthesia debridement in patients with COPD. This is the first manuscript describing the use of enzymatic debridement in patients with COPD and home oxygen therapy. We could confirm other studies that intubation of these patients leads to prolonged ventilation hours and increases the probability for poor prognosis. Therefore, we described the treatment of enzymatic debridement in analgosedation without intubation.

The risk of burn injury during long-term oxygen therapy: a 17-year longitudinal national study in Sweden

BACKGROUND

Long-term oxygen therapy (LTOT) improves the survival time in hypoxemic chronic obstructive pulmonary disease. Despite warnings about potential dangers, a considerable number of patients continue to smoke while on LTOT. The incidence of burn injuries related to LTOT is unknown. The aim of this study was to estimate the rate of burn injury requiring health care contact during LTOT.

METHODS

Prospective, population-based, consecutive cohort study of people starting LTOT from any cause between January 1, 1992 and December 31, 2009 in the Swedish National Register of Respiratory Failure (Swedevox).

RESULTS

In total, 12,497 patients (53% women) were included. The mean (standard deviation) age was 72±9 years. The main reasons for starting LTOT were chronic obstructive pulmonary disease (75%) and pulmonary fibrosis (15%). Only 269 (2%) were active smokers when LTOT was initiated. The median follow-up time to event was 1.5 years (interquartile range, 0.55-3.1). In total, 17 patients had a diagnosed burn injury during 27,890 person-years of LTOT. The rate of burn injury was 61 (95% confidence interval, 36-98) per 100,000 person-years. There was no statistically significant difference in the rate of burn injury between ever-smokers and never-smokers, or between men and women.

CONCLUSION

The rate of burn injuries in patients on LTOT seems to be low in Sweden. The strict requirements in Sweden for smoking cessation before LTOT initiation may contribute to this finding.

Home oxygen and domestic fires

To highlight the risk of domestic fires in the home use of oxygenTo recommend measures to reduce the risk.

Burn injury associated with home oxygen use in patients with chronic obstructive pulmonary disease

OBJECTIVES

To quantify the risk of burn injury associated with home oxygen use and to examine the risk factors associated with the development of this injury.

PATIENTS AND METHODS

We used a nested case-control and a retrospective cohort design to study enrollment and claims data from a national sample of Medicare beneficiaries 66 years and older with a diagnosis of chronic obstructive pulmonary disease (COPD) from January 1, 2001, through December 31, 2010. The primary outcome was burn injury in patients with COPD prescribed home oxygen.

RESULTS

In the nested case-control method, patients with burn injury were twice (odds ratio, 2.43; 95% CI, 1.57-3.78) as likely to be prescribed oxygen in the preceding 90 days compared with those without burn injury. In the retrospective cohort study, the absolute risk of burn injury in patients prescribed oxygen therapy was 2.98 per 1000 patients compared with 1.69 per 1000 patients not prescribed oxygen during a 22-month period. The excess risk of a burn injury associated with oxygen was 0.704 per 1000 patients per year, and the number needed to harm was 1421. In multivariable analysis, factors associated with burn injury included male sex, low socioeconomic status, oxygen therapy use, and the presence of 3 or more comorbidities.

CONCLUSION

The benefits of oxygen therapy in patients with COPD outweigh the modest risk of burn injury associated with home oxygen use. However, with the increasing number of patients being prescribed oxygen, health care professionals must educate and counsel patients regarding the potential risk of burn injury.

Resolving moral distress when caring for patients who smoke while using home oxygen therapy

More than 1 million people in the United States use home oxygen therapy and its demand is growing. However, there are dangers associated with its use, such as burns and home fires, and smoking is the most common cause of these incidents. As a result, home healthcare nurses feel intense emotional distress when caring for patients who smoke while using home oxygen therapy. This distress arises from the nurse's competing sense of moral duties toward these patients. The purpose of this article is to describe this distress, then to propose a 3-step process of taking concrete actions to resolve the distress.

Review of burn injuries secondary to home oxygen

The use of long-term home oxygen therapy (HOT) has become increasingly common for treatment of chronic pulmonary diseases. Although illegal to smoke while on HOT, there is an increasing incidence of burn injuries in those patients who smoke while on HOT. The importance of recognition of the prevalence of this injury, the obstacles faced when treating these patients, and understanding the proposed algorithmic approach to be taken with patients on HOT, including prescription, reassessment, and prevention of burn injury are outlined in this review. Retrospective epidemiological data including circumstances, admission, treatment, and disposition were collected and reviewed on the patients treated from 1999 to 2008 with burns secondary to smoking while on HOT. Seventeen patients sustained injuries secondary to smoking on HOT over the 9-year period; 9 patients were female and 8 were male. All the patients were on HOT for chronic obstructive pulmonary disease. Mean patient age was 69.1 ± 2.5 years and mean TBSA 2.8 ± 0.4%; 11.8% (2/17) sustained inhalation injury requiring intubation and 23.5% (4/17) required wound debridement and skin grafting. Mean hospital stay was 42.8 ± 12.5 days; 10.3 ± 5.4 days in the burn intensive care unit and 32.5 ± 11.0 days in the ward. Before the burn injury, 23.5% (4/17) lived in long-term care facilities. On discharge from hospital, 47.1% (8/17) were transferred to extended care facilities or other acute care hospitals, and 11.8% (2/17) died during their hospitalization. After recovery, there was a 35.3% reduction in patients able to return home and/or live independently. A significant number of burn injuries secondary to smoking while on HOT was observed. These patients differ from standard burn patients because they are older in age, have higher rates of inhalation injury, and have much longer lengths of hospitalization, despite smaller TBSA injuries. Prevention of this injury would improve the safety of the patient and those around them as well as healthcare resource allocation. A proactive multidisciplinary algorithmic approach is presented which can be used to manage patients on HOT at risk for continued smoking to decrease the incidence and the impact of burn injuries in this patient population.

Smoking and home oxygen therapy--a preventable public health hazard

Patients who continue to smoke while on home oxygen therapy endanger themselves, family members, neighbors, and firefighters and create an expense to society for their medical care. This phenomenon was studied in our burn center. Fourteen patients were identified prospectively during the last 2 years. All were smoking while on nasal oxygen. The 14 patients (10 males) were 45 to 87 years of age. All suffered facial burns. Only one patient had a significant burn (30% TBSA, 20% 3rd degree), but all suffered from an exacerbation of chronic obstructive pulmonary disease. Two patients gave a history of stage IV lung cancer and four patients had newly found squamous cell cancer seen on bronchoscopy. All six patients with lung cancer and one with severe chronic obstructive pulmonary disease died. Of the seven survivors, only one patient quit smoking. Total charges were $2,861,526 and total costs were $938,311. All patients had Medicare or Medicaid on admission. Hospital loss ($432,561) was incurred in those patients admitted more than 4 days whereas a profit ($33,285) was realized in patients admitted less than 4 days. These deaths and financial loss could be reduced by better testing and more precise guidelines as to which patients can safely receive home oxygen. Patients can have their saliva tested for the nicotine breakdown product of cotinine; the test takes 10 minutes. The American Burn Association, in conjunction with the American College of Chest Physicians, should address this issue and develop guidelines for physicians who order home oxygen therapy and for state departments of public health who should regulate the companies that deliver home oxygen.

Long-term oxygen treatment in chronic obstructive pulmonary disease: recommendations for future research: an NHLBI workshop report

Long-term oxygen treatment (LTOT) prolongs life in patients with chronic obstructive pulmonary disease (COPD) and severe resting hypoxemia. Although this benefit is proven by clinical trials, scientific research has not provided definitive guidance regarding who should receive LTOT and how it should be delivered. Deficiencies in knowledge and in current research activity related to LTOT are especially striking in comparison to the importance of LTOT in the management of COPD and the associated costs. The National Heart, Lung, and Blood Institute, in collaboration with the Centers for Medicare and Medicaid Services, convened a working group to discuss research on LTOT. Participants in this meeting identified specific areas in which further investigation would likely lead to improvements in the care of patients with COPD or reductions in the cost of their care. The group recommended four clinical trials in subjects with COPD: (1) efficacy of ambulatory O(2) supplementation in subjects who experience oxyhemoglobin desaturation during physical activity but are not severely hypoxemic at rest; (2) efficacy of LTOT in subjects with severe COPD and only moderate hypoxemia; (3) efficacy of nocturnal O(2) supplementation in subjects who show episodic desaturation during sleep that is not attributable to obstructive sleep apnea; and (4) effectiveness of an activity-dependent prescription for O(2) flow rate that is based on clinical tests performed at rest, during exercise, and during sleep.

Adult domiciliary oxygen therapy. Position statement of the Thoracic Society of Australia and New Zealand

Patients with chronic obstructive pulmonary disease and a stable daytime PaO2 of < or = 55 mmHg (7.3 kPa) live longer and have a better quality of life if provided with long-term continuous oxygen therapy. It is reasonable to offer continuous oxygen therapy also to patients with other lung diseases that cause chronic hypoxaemia. Indications for supplemental oxygen therapy during exercise (ambulatory oxygen therapy) and sleep (nocturnal oxygen therapy) are less clear.

Burns in inpatients by simultaneous use of cigarettes and oxygen therapy

Two inpatients with chronic obstructive pulmonary disease (COPD), treated with oxygen in the respiratory intensive care unit (RICU), sustained burns from explosion of oxygen delivery system while illicitly smoking. The authors discuss incidence and possible etiology with literature review.

Home Oxygen Therapy: Adjunct or Risk Factor?

The use of home oxygen therapy has become increasingly commonplace and is frequently prescribed by medical specialists. In this study, we have identified a generally unexpected risk of home oxygen therapy. We performed a retrospective review of 3673 consecutive patients treated at our adult burn center over a 10-year period from 1992 to 2001. We identified 27 patients with burns directly attributable to oxygen therapy and also noted an increased incidence of these injuries over the study period. The average age of the patients was 68.1 +/- 9.2 years (range, 40-82 years). Twenty-three were using oxygen at home, three in nursing homes, and one was an inpatient in an acute care facility. Twenty-five patients (93%) were receiving oxygen therapy for the diagnosis of chronic obstructive pulmonary disease. Twenty-four patients (89%) were smoking while using oxygen, two were lighting pilot lights, and one was lighting his wife's cigarette. Four patients (15%) sustained burns greater than 10% TBSA. Seventeen patients (63%) had only partial thickness burns. Thirteen patients (48%) required admission for treatment of their burn injuries. The average length of stay for those admitted was 4.4 days. The average hospital charge for admitted patients was US dollars 8055. There were four deaths (15%), all of which were correlated only with the extent of injury. Although intuitively obvious to most health care professionals, not all patients understand that oxygen therapy and cigarettes or open flame can result in a significant injury. Although some practitioners have advocated not prescribing home oxygen for those who continue to smoke, an alternative means of reducing the incidence of this preventable complication appears warranted. Prevention efforts should focus on the counseling of patients and their caregivers as well as educating primary care physicians, nurses, and home health providers as to the dangers of oxygen use.

A hazard of home oxygen therapy

Although it is generally safe, there are morbidities associated with home oxygen use. Experience in our burn unit led to an analysis of burn complications from this therapy. A retrospective review of records during a 12-year period identified 23 patients with burns associated with home oxygen use. Average age of the patients was 70 years, with chronic obstructive pulmonary disease the most prevalent indication for use. Concomitant cigarette smoking was the most common inciting mechanism of the burns (70%). Average burn size was 3.9% of total body surface area. Eleven patients presented in the first 10 years of the study period, whereas 12 presented in the last 2 years. We have seen a rise in injuries with the use of home oxygen. The absolute number of injuries sustained is unknown, because many are likely unreported. To decrease the morbidity and costs associated with these injuries, the need for continuing safety education is apparent.

Fire injuries, disasters, and costs from cigarettes and cigarette lights: a global overview

BACKGROUND

Fires cause 1% of the global burden of disease. Fire (includes explosion) disasters have immense health, social, and environmental costs. We will provide initial estimates of overall U. S. and global fire tolls from smoking.

METHODS

We tabulated and summarized smoking-related fire and disaster tolls from published documents. We compared those tolls to U.S. fire, burn, and fire death rates per billion cigarettes extrapolated globally. Smoking-attributable percentages of adult and child access to cigarette lighter and match ignitions (lights), and resultant fires, burns, and deaths ignited by young children, were estimated from likely smoking-attributable lights usage. Cigarette plus cigarette lights fire tolls were multiplied times published and estimated fire costs.

RESULTS

Smoking is the leading cause of residential or total fire death in all eight countries with available statistics. Smoking is a leading cause of fires in many more countries. Cigarettes cause numerous fire disasters. Cigarette lights cause an estimated 100,000 U.S. and one million global, child-playing fires per year. Cigarette lights fire injuries likely rival U.S., and possibly global, cigarette fire injury numbers. Smoking causes an estimated 30% of U. S. and 10% of global fire death burdens. Smoking's estimated U.S. and global fire costs were $6.95 (sensitivity range $5.34-22.8) and $27.2 (sensitivity range $8.2-89.2) billion, respectively, in 1998 U. S. dollars.

CONCLUSIONS

Smoking likely causes large global fire tolls. U.S. fire tolls have fallen when smoking decreased. Further reducing smoking can substantially reduce fire and disaster tolls.

The human and financial costs of smoking

Smoking causes about 20% of United States adult deaths and numerous diseases. Health care for cancer, cardiovascular, and pulmonary diseases from smoking costs tens of billions of dollars per year. Yet those costs are likely far exceeded by costs from bereavement, lost productivity, pain and suffering, and health care for debilities from smoking. Though sometimes more difficult to precisely quantify than costs for fatalities, the lost productivity, suffering, or familial costs of smoking are often much larger, more immediate, and more understandable threats to smokers, their families, and society. This article summarizes qualitative and quantitative human and financial tolls from smoking. The tolls range from cigarette burns, to cigarette ignited fire disasters, to caring for dying smokers and replacing their financial and social contributions to their spouses, children, grandchildren, and the tax base. In the face of such costs, smoking cessation and prevention services are likely to be highly cost-effective.