Smoking, oxygen and COPD

In this edition of Inside the Ethics Committee the question is, ‘should home oxygen therapy be allowed in patients with severe chronic obstructive pulmonary disease (COPD) who continue to smoke?’

I don’t have time for a ‘proper blog’ but here are some brief notes and links.

The reasons that oxygen might not be allowed are because in the presence of oxygen, things (like oxygen tubing, facial hair, clothing, etc.) are much more flammable and patients, including one of mine, have set fire to their heads resulting in serious burns and occasionally even death.

Oxygen therapy is used in patients who have Chronic Obstructive Pulmonary Disease (COPD), and is delivered through plastic tubes that go up the patients’ nostrils. Quite a lot comes out of the nostrils and effectively bathes the face, head and clothing. Patients have set fire to themselves when not smoking, for example lighting stoves, and one patient was killed when an e-cigarette exploded.

The tubes that the oxygen goes through are made of PVC which is quite flammable and releases highly flammable vinyl chloride gas when it burns.

Oxygen therapy is used in patients with COPD to reduce the risk of complications like pulmonary hypertension, heart failure (caused by the strain of pushing blood through the damaged lungs) and polycythaemia (thickened blood). In very severe COPD when the oxygen levels fall below about 92% patients feel confused or ‘foggy headed’ and the oxygen helps with this. Stopping smoking is a far more effective way of reducing these complications than oxygen therapy.

An assessment for oxygen therapy is often completed when a patient has been admitted to hospital with a deterioration of their COPD, for example with a chest infection. Unfortunately the assessment is not often repeated after the patient has been discharged. This is unfortunate because by then the patients’ condition has considerably improved and oxygen may no longer be necessary.

The symbolic value of oxygen.

Everybody knows that you need oxygen to live, and without it you die.

Taking oxygen away from patients is very difficult.

The perception (I’ve spoken to some of my patients about this) is that once you need oxygen, it’s pretty much the only thing that’s keeping you alive, and if anyone takes it away, pretty soon afterwards, you’ll die. Hearing these concerns, taking them seriously and working through them is difficult. I left the programme not entirely convinced that we had explored this issue enough.

Whole person care.

Anxiety, depression and feelings of shame and guilt are very common among patients with severe breathlessness, especially among smokers who quite frequently blame themselves for being a burden on their families and others. A smoker interviewed for the program who set fire to himself while using oxygen was too ashamed to go to hospital and waited until the next day when the pain was unbearable, before going. The more we punish and shame people the more isolated and self destructive the are likely to become. Our job is to help people who need it. Oxygen therapy provides relief from some of the anxiety, but sadly effective psychological support is often lacking and oxygen is a kind of substitute.

The bottom line.

I think that we should only prescribe oxygen therapy to smokers if certain conditions are met:

• we have done everything we can to help them stop smoking
• they are fully aware of the risks and awareness is not impeded by intoxication or other reasons, e.g. dementia
• they have demonstrated the ability to smoke safely, i.e. stop the oxygen for 10 minutes and then going outside before smoking
•  we have made every possible effort to help them with underlying anxiety, shame and depression (where it exists)
• they have been given every opportunity to discuss their understanding about the risks and actual (and symbolic) benefits of oxygen therapy
• We have done what we can to mitigate the risks, e.g. good ventilation, safer oxygen delivery systems
• We have repeated the assessment to show that oxygen therapy is still effective and no safer alternatives exist

It seems very unlikely that in the case of the last patient discussed in the programme, that these conditions could be met and oxygen should not therefore be prescribed.

Links 

Use of oxygen therapy in COPD 

In New Calculus on Smoking, It’s Health Gained vs. Pleasure Lost. A little-known cost-benefit calculation that public health experts see as potentially poisonous is the happiness quotient. It assumes that the benefits from reducing smoking — fewer early deaths and diseases of the lungs and heart — have to be discounted by 70 percent to offset the loss in pleasure that smokers suffer when they give up their habit. NY Times August 6th 2014

Doctors, patients and shame – stigma, shame and blame experienced by patients with associated with lung cancer.

Some patients said that family or friends had not been in touch since they heard about the diagnosis. One patient with mesothelioma said that his daughter had not telephoned because she felt “dirtied” by contact with cancer.

Long-term oxygen therapy and quality of life in elderly patients hospitalised due to severe exacerbation of COPD. A 1 year follow-up study: In conclusion, the future need for LTOT cannot be judged after a few days treatment in hospital due to exacerbations with hypoxaemia in elderly patients with COPD. A standardised oxygen withdrawal test can be safely done. Health-related QOL is low in patients during the stay in hospital, but improves after returning home.

Home Oxygen Therapy and Cigarette Smoking: a Dangerous Practice: Patients are told not to smoke, but recent surveys show the percentage of home oxygen users still smoking to be between 14 and 51%. The use of a less combustible material for cannula tubing and a more efficient oxygen delivery system may reduce the incidence of such burns. Another suggestion would be labelling the oxygen cylinders with large stickers emphasizing the danger of smoking in the presence of oxygen.

Got a match? Home oxygen therapy in current smokers  Fortunately, at least 30% of patients meeting the criteria for domiciliary oxygen after 1 month of apparent stability no longer met the same criteria after an additional 3 months of observation

Smoking and Home Oxygen: Doubling the Danger There is no safe way to smoke when using home oxygen. Until patients quit, they can practice safer smoking. Should an individual need to smoke, it’s important to first turn off the tank, and wait 10 full minutes before going outside to smoke. This practice should decrease the amount of oxygen in the home and on the person. The best way for patients to protect themselves, their families, neighbors, and emergency responders is to quit smoking.

Home oxygen therapy. Adjunct or risk factor? 27 patients were admitted to a burns unit as a result of burns sustained while using oxygen therapy over 10 years, 25% were had terminal illnesses and ‘many’ were receiving hospice care. 24 were smoking, 2 were lighting pilot lights, 1 was lighting wife’s cigarette. 4 (15%) Died

Palliative care in chronic obstructive pulmonary disease: a review for clinicians.