Oxygen has been a therapeutic agent since 1922, mainly for hospice patients with pulmonary conditions. Cooper (2015) described this gas as a savior and a killer. For patients with Chronic Obstructive Pulmonary Disease (COPD) or cardiovascular conditions, oxygen can increase the chance of survival and provide relief. This kind of treatment is common in hospice patients who are unable to breathe naturally. However, smoking while on oxygen therapy poses a significant risk of fire, as the gas is highly combustible. Several studies have explored various ethical aspects of this topic of fire safety and oxygen use in dying patients. Some have proposed the use of inline filters to stop the leakage of the gas in nasal cannulas. Others have recommended teaching these patients on safety precautions to prevent fire accidents. In this paper, the author reviews and analyzes literature form 12 publications on this topic.
Studies have shown that patients under home oxygen therapy, particularly smokers, have high risks of burn. Having a flame or source of heat near this gas that supports combustion can cause a fire that burns faster and hotter. Currently, the percentage of active smokers on oxygen ranges between 15 and 25 ( Ahrens, 2019). A significant number continue to smoke while on oxygen therapy due to either ignorance or the inability to stop. Healthcare providers prescribing this treatment have a hard time trying to balance the risk of fire hazards and benefits in those who continue to smoke while on oxygen.
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The incidence of burns caused by smokers on oxygen therapy is high. Studies report different values depending on the timing and location, but the trend remains the same in all of them. Between 2002 and 2005, 209 home fires involving oxygen administration equipment occurred in the US, with 20% of them, resulting in fatalities ( Brinkerhoff, 2009). The report indicated that smoking was by far the leading cause of ignition.
Several researchers identified s moking as the most significant hazard for oxygen users (Cooper, 2015; Lindford et al. (2016) and Chang et al., 2011). According to Lindford et al. (2016), more than 43% of patients using oxygen suffer from burns related to smoking. Cooper et al. (2015) reported 38 deaths caused by fires attributed to smoking in four American states. In Chang et al. (2011), 54% of fire incidences resulted from smoking, with seven sustained injuries requiring medical attention.
Numerous studies have proposed finding alternatives for cannula tubes and masks to reduce the risk involved. Carlos et al. (2016), Nishimura (2015 ), Lindford et al. (2016), and Cooper (2015) agree that these open oxygen delivery systems increase the risk of fire. The gas can leak easily, creating an oxygen-enriched environment, which increases the potential of burning. Cooper (2015) reported that an amount of oxygen sufficient to sustain a flame leaks into the surrounding. In such cases, smokers risk causing a fire if they light cigarettes with the gas floating around the atmosphere. Lindford et al. (2016) reported similar findings. Patients in their survey described that lighting a cigar triggers an outburst, and the sudden pop catches one by surprise, which worsens the burns as they take time to put out the fire.
According to Nishimura (2015 ), manufacturers use Polyvinyl Chloride (PVC) to make nasal cannulas because it is cheap, durable, and stable in industrial conditions. This material is highly combustible in the presence of oxygen, causing severe burn injuries. Cooper (2015) also opposed the use of PVC for similar reasons, as well as the fact that the tubing emits large amounts of toxic smoke that harms the lungs further. Carlos et al. (2016) provided similar recommendations but argued that the new material should not contain Diethylhexyl Phthalate (DEHP) since it has adverse health effects.
Safety education is paramount for all patients on oxygen. It is particularly vital for active smokers since they have higher risks of fire accidents. All researchers who investigate this issue agree that quitting smoking is the ideal way to ensure safety for patients on oxygen therapy. However, most of the patients are either unwilling or unable to comply with this guideline. Carlos et al. (2016) , Brinkerhoff (2009), and Chang et al. (2011) called for ongoing education for oxygen users about the dangers of smoking. These authors insisted that there should strictly be no smoking in rooms where oxygen is used, and the source should be at least 10 feet from electronics and fire sources.
During health education, nurses should emphasize on the no-smoking policy while using oxygen. They should insist and help put ‘NO SMOKING’ signs on hospice facilities and oxygen cylinders to remind patients and guests to avoid smoking ( Brinkerhoff, 2009). Chang et al. (2011) also called for an insistence on the dangers of combining a potential fire source and oxygen. Stakeholders, including physicians, nurse educators, social workers, and discharge planners, should ensure patients comply with guidelines regarding the safe use of oxygen before allowing them to go home with this potentially dangerous gas. Chang et al. (2011) revealed that 30% of the patients did not quit smoking after initiating home oxygen therapy. Lindford et al. (2016) reported a higher value of 51% from their analysis. Despite these differences, these statistics show that a significant proportion of oxygen users do not comply with the guidelines, thus posing a considerable risk to their health.
Wong et al. (2010) brought a new aspect of maintaining patients’ autonomy during safety education. Their article notes that when a patient is charged with taking care of their life, the motivation is intrinsic, and results are better. A study carried out by Pepin et al. in 2016, in a general ward also echoed similar sentiments. Patients involved in making medical decisions viewed the facility as better operated than in those where medical practitioners made all decisions and were more likely to comply with the guidelines.
The studies also showed that the patients who fail to comply with the smoking guidelines should be strongly encouraged to attend a smoking cessation program. If this effort fails and having oxygen in the house will pose more risks than benefits, Chang et al. (2011) called the withdrawal of the gas until they comply with safety guidelines. Carlos et al. (2016) also adopted a similar approach. They proposed having aggressive education about oxygen safety, implementing smoking cessation efforts, and eventually withholding oxygen from patients who insist on smoking while on therapy. Cooper (2015) called for similar actions against such patients. The author recommended withdrawing oxygen if it poses a risk to the user and others.
There have been heated debates about the ethical nature of withholding oxygen from smokers. It is an ongoing controversy where proponents like Chang et al. (2011), Carlos et al. (2016 and Cooper (2015) support the decision to protect. They reasoned that healthcare providers have an obligation of care to everyone in an environment with an oxygen user who smokes, and not just the patient. They have a moral and legal duty to protect caregivers, neighbors, and relatives from a potential fire accident (Cooper, 2015).
On the other hand, opponents argue that withholding oxygen from smokers is a form of discrimination as it denies them the right to treatment. Lacasse et al. (2006) claim that smoking is an addiction and a handicap, and denying someone life-saving oxygen on the grounds of being a smoker violates charters of human rights. These authors identify real contributions to the safety and health of a patient as the only valid reason for physicians to refuse oxygen therapy. According to Senderovich (2016), it is unethical and unfair to deny someone treatment life choices since every person has a right to do whatever they want. These authors insist that every patient deserves equal and fair treatment, which contradicts provisions by Chang et al. (2011), Carlos et al. (2016 and Cooper (2015).
All oxygen concentrators should have safety devices per ISO 8359 amendment. They can reduce the acceleration of fires and the consequent deaths and serious injuries. According to Cooper (2015), flow-stop devices in the tubing, and fire-breaks like metal plates or metal fittings at the outlet of the cylinder can help reduce the extent of fire accidents. This author argued that these devices stop the flame immediately at the point of installation by pulsing the flow of oxygen, which reduces the intensity of the fire.
A 2020 study by Mastropieri et al. also reported similar findings. They found that hospitalizations due to smoking-related oxygen burns reduced by 54.1% in one year. Similarly, a study by Ahrens (2019) showed that mandatory installment of fire-breaks in the UK significantly reduced the fatality rate of oxygen fire accidents related to smoking. This rate was substantially lower compared to other countries like Japan and the US, where this policy was not mandatory. Based on this evidence, it is plausible to conclude that fire-breaks are effective in reducing severe burn cases among active smokers on oxygen.
Hardavella et al. (2019) adopted a different approach and criticized the use of fire-breaks. They claimed that these devices do not reduce fire incidences. The authors also opposed this strategy because it does not alert individuals who fall asleep while smoking when a fire occurs. In addition, fire-breaks do not put off secondary fires that result from the ignition of surrounding items. Hardavella et al. (2019) also argued that these devices are useless if patients insert them the wrong way since fire can by-pass them by jumping sections of the coiled tubing. The fact that they offer resistance to flow necessitates their removal during pulse-flow delivery, which further diminishes their effectiveness . Despite these criticisms, fire-breaks remain one of the most effective strategies in curbing the problem of oxygen fires caused by smoking, as shown by Cooper (2015), Mastropieri et al. (2020), and Ahrens (2019).
Conclusion
From the above analysis, it is evident that oxygen smoking and oxygen therapy should never go hand-in-hand. Physicians, nurses, caregivers, social workers, medical equipment manufacturers, and patients have a collective responsibility to prevent fire accidents among smokers. Smoking while on oxygen therapy is a danger that most patients underestimate; thus, there is a need for better education on the issue. Continuous education about the danger posed by oxygen and safety measures should be mandatory. Active smokers should also be encouraged to quit the habit and supported through a cessation program for everyone’s safety.
In extreme cases, healthcare providers can seek legal withdrawal or withholding of this useful yet potentially dangerous gas if it poses more risks than benefits to the user and others. Some patients may see this approach as discrimination and violation of their rights and might try to sue the one responsible, resulting in a legal battle. Companies also need to invest in the safety of oxygen systems and equipment as an additional measure for patients who cannot resist the urge to smoking. Such injuries are preventable with little effort. According to the available literature, manufacturers and medics work to provide a safe environment for smokers on oxygen therapy, and the patients must strive to keep themselves safe by adhering to set guidelines.
References
Ahrens, M. (2019). Home Cooking Fires. National Fire Protection Association, Quincy, MA .
Brinkerhoff, S. (2009). Oxygen therapy in the home: safety precautions and implications for home healthcare clinicians. Home Healthcare Now , 27 (7), 417-420.
Carlos, W. G., Baker, M. S., McPherson, K. A., Bosslet, G. T., Sood, R., & Torke, A. M. (2016). Smoking-related home oxygen burns injuries: continued cause for alarm. Respiration , 91 (2), 151-155.
Chang, T. T., Lipinski, C. A., & Sherman, H. F. (2011). A hazard of home oxygen therapy. The Journal of burn care & rehabilitation , 22 (1), 71-74.
Cooper, B. G. (2015). Home oxygen and domestic fires. Breathe, 11(1), 4-12.
Hardavella, G., Karampinis, I., Frille, A., Sreter, K., & Rousalova, I. (2019). Oxygen devices and delivery systems. Breathe, 15(3), e108-e116.
Lacasse, Y., LaForge, J., & Maltais, F. (2006). Got a match? Home oxygen therapy in current smokers.
Lindford, A. J., Tehrani, H., Sassoon, E. M., & O’Neill, T. J. (2016). Home oxygen therapy and cigarette smoking: a dangerous practice. Annals of Burns and Fire Disasters , 19 (2), 99.
Mastropieri, C., Leonard, G., & Holmes, J. (2020). 18 Stop the Burn: A Smoking and Home Oxygen Safety Initiative with Use of Firebreaks. Journal of Burn Care & Research, 41(Supplement_1), S15-S16.
Nishimura, M. (2015). High-flow nasal cannula oxygen therapy in adults. Journal of intensive care , 3 (1), 15.
Pepin, J. L., Barjhoux, C. E., Deschaux, C., & Brambilla, C. (2016). Long-term oxygen therapy at home: compliance with a medical prescription and effective use of therapy. Chest , 109 (5), 1144-1150.
Senderovich, H. (2016). How can we balance ethics and law when treating smokers?. Rambam Maimonides Medical Journal, 7(2).
Wong, C., Visram, F., Cook, D., Griffith, L., Randall, J., O’Brien, B., & Higgins, D. (2010). Development, dissemination, implementation, and evaluation of a clinical pathway for oxygen therapy. Cmaj , 162 (1), 29-33.
