Conner Moslander is a Resident in the Department of Internal Medicine; Tasnim Lat is Faculty and Rachael Pattison is a Fellow, both in the Division of Pulmonary/Critical Care Medicine; all at Baylor Scott & White in Temple, Texas. Badri Giri is an Assistant Professor at Virginia Tech Carilion School of Medicine in the Pulmonary, Critical Care and Sleep Medicine Carilion Clinic in Roanoke, Virginia. John Coppin is a Statistician in the Department of Research, and Udaya Bhat is Associate Program Director for the Pulmonary and Critical Care Fellowship Program, both at Central Texas Veterans Health Care System. Udaya Bhat is Chief, Pulmonary/Critical Care Section and Assistant Professor of Medicine at Texas A&M University in College Station. Correspondence: Udaya Bhat (udaya.bhat@va.gov)
Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
Introduction: Two large major trials showed that long-term oxygen therapy (LTOT) improved mortality in patients with chronic obstructive pulmonary disease (COPD) and hypoxemia. Although oxygen accelerates combustion and is an obvious fire hazard, LTOT has traditionally been prescribed to veterans who are actively smoking.
Methods: We conducted a retrospective chart review of all veterans with COPD at a single center who were prescribed new LTOT between October 2010 and September 2015. Of the 158 patients who met the study criteria, 152 were male. Bayesian logistic regression was used to model the outcome variable fire-related incident with the predictors smoking status, age, race, depression, posttraumatic stress disorder, and type of oxygen used.
Results: The mean age of the 158 patients with COPD in the study was 71.3 years in nonsmokers and 65.9 years in smokers. The model-estimated odds (SD) of a fire-related incident occurring in a smoker were 31.6 (5.1-372.7) times the odds of a fire-related incident occurring in a nonsmoker.
Conclusions: Patients who smoke and remain on LTOT put themselves at greater risk of having a fire-related incident than do nonsmokers.
Chronic obstructive pulmonary disease (COPD) has been the third leading cause of death in the US since 2008. 1 Current management of COPD includes smoking cessation, adequate nutrition, medication therapy, pulmonary rehabilitation, and vaccines. 2 Outside of pharmacologic management, oxygen therapy has become a staple treatment of chronic hypoxemic respiratory failure due to COPD. Landmark trials, including the Nocturnal Oxygen Therapy Trial (NOTT) and Medical Research Council (MRC) study, demonstrated improved survival in patients with COPD and hypoxemia, particularly if these patients received oxygen for 18 hours per day. 3,4 NOTT prospectively evaluated 203 patients at 6 centers who were randomly allocated to either continuous oxygen therapy or 12-hour nocturnal oxygen therapy. The overall mortality in the nocturnal oxygen therapy group was 1.94 times that in the continuous oxygen therapy group (P = .01). 3 The MRC study included 87 patients who were randomized to oxygen therapy or no oxygen; risk of death was 12% per year in the treated group vs 29% per year in the control group (P = .04). 4 The effectiveness of long-term oxygen therapy (LTOT) in active smokers continues to be a source of debate; although 50% of patients in the NOTT trial were smokers, there was no subgroup analysis of whether smoking status had an impact on survival in those on continuous oxygen therapy.
Although many therapies are available for the treatment of COPD, the most effective treatment to prevent the progression of COPD is smoking cessation. Resources like smoking cessation programs, nicotine patches, and medications, such as bupropion and varenicline, are available to aid smoking cessation. 5 However, many patients are unable to quit tobacco use despite their best efforts using available resources, and they continue to smoke even with progressive COPD. Long-time smokers also are likely to continue smoking while on LTOT, which increases their risk for fire-related injury. 6-8
Traditional indications are being scrutinized after the LTOT trial found no benefit with respect to time to death or first hospitalization among patients with stable COPD and resting or exercise-induced moderate desaturation. 9
Although oxygen accelerates combustion and is a potential fire hazard, LTOT has been prescribed even to active smokers as the 2 landmark trials did not exclude patients who were active smokers from receiving oxygen therapy. 3,4 Therefore, LTOT has traditionally been prescribed to veterans who are actively smoking, despite the fire hazard. Attempts at mitigating hazards related to oxygen therapy in active smokers include counseling extensively about safety measures (which includes avoiding open flames such as candles, large fires, or sparks when on LTOT and providing Home Safety Agreements—a written contract between prescriber and patient wherein the patient agrees to abide by the terms of the US Department of Veterans Affairs (VA) to mitigate hazards related to LTOT in order to receive LTOT (eAppendix
) . These clinical techniques ensure that patients who choose to smoke on LTOT do so only with a full understanding of the dangers.
Methods
With this practice in mind, we conducted an institutional review board approved retrospective chart review of all veterans with diagnosis of COPD within the Central Texas Veterans Health Care System (CTVHCS) who were prescribed new LTOT between October 1, 2010 and September 30, 2015. Given the retrospective nature of the chart review, patient consent was not obtained. Inclusion criteria were veterans aged > 18 years who had a confirmed diagnosis of COPD by spirometry and who met criteria for either continuous or ambulation- only oxygen therapy.
