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containers and oxygen systems. Patients should be advised never to smoke or light a match while using oxygen or allow others in the same room to do so. Patients should also be advised not to smoke in bed. Every home should have at least one working smoke detector on every level and near all bedrooms. As many people on home oxygen therapy have limited mobility, home sprinkler systems can add an extra layer of protection (www.fireservice.co.uk/safety/smokealarms.php). They also need to inform their home and car insurers that oxygen therapy will be used, as well as the local Fire Brigade. They should also be reassured that a full written package of training on safe use and storage of equipment will be provided by the contractor supplying their home oxygen.

Nurses in primary and community care should advise everyone who smokes to try to stop and refer them to an intensive support service (for example, NHS Stop Smoking Services). If they are unwilling or unable to accept this referral they should be offered pharmacotherapy, in line with NICE guidance, and additional support. Nurses who are trained NHS Stop Smoking counsellors may ‘refer’ to themselves where appropriate. The smoking status of those who are not ready to stop should be recorded and reviewed with the individual once a year, where possible. The NICE recommendations include the following advice.

Ask patients who smoke how interested they are in stopping.

If they want to stop, refer them to an intensive support service such as NHS Stop Smoking Services.

If they are unwilling or unable to accept a referral, offer a stop smoking aid (for example, nicotine replacement therapy (NRT), varenicline or bupropion).

A range of NHS agencies can offer advice and support on how to stop smoking.

Monitoring systems should be set up so that health professionals know whether or not their patients smoke (NICE 2006).

Complications

Carbon dioxide narcosis

Carbon dioxide is the chemical that most directly influences respiration by its effect on the efficiency of alveolar ventilation. The normal partial pressure of carbon dioxide in the blood is 4.0–6.0 kPa (30–45 mmHg). When this level rises, the pH of the CSF drops which in turn causes excitation of the central chemoreceptors, and hyperventilation occurs (Marieb et al. 2010).

In people who always retain carbon dioxide and are therefore usually hypercapnic because of chronic pulmonary disease such as chronic bronchitis, the chemoreceptors are no longer sensitive to a raised level of carbon dioxide. In these cases the falling PaO2 becomes the principal respiratory stimulus (the hypoxic drive) (Marieb et al. 2010). Therefore, if a high level of supplementary oxygen was delivered to such patients in non-emergency situations severe respiratory depression would ensue and ultimately unconsciousness and death. The Resuscitation Council UK and British Thoracic Society advise the administration of high-flow oxygen during an acute respiratory distress or arrest situation. Start with 15 litres of oxygen per minute and wean down to the flow rate required to maintain adequate peripheral saturations of 94–98% (BTS 2008).

Oxygen toxicity

Pulmonary toxicity following prolonged higher percentages of oxygen therapy is recognized clinically, but there is still much to be learnt about the condition. The degree of injury is related to the length of time of exposure and percentage of oxygen to which the individual is exposed. The pattern is one of decreasing lung compliance as a result of a sequence of events, tracheal bronchial inflammation, haemorrhagic interstitial and intra-alveolar oedema, leading ultimately to fibrosis (Bersten et al. 2009, Pierce 1995, Pierson 2000).

Where possible, long periods (i.e. 24 hours or more) of oxygen therapy above 50% should be avoided (Bryan-Brown and Dracup 2000, Cooper 2002).

Retrolental fibroplasia

Retrolental fibroplasia is a disease affecting premature babies that weigh under 1200 g (about 28 weeks’ gestation) if they are exposed to high concentrations of oxygen within the first 3–4 weeks of life. It appears