Fires involving oxygen in the home are a serious public health issue in many countries around the world. Data on the scale of the problem can, however, be difficult to obtain. Now though, pioneering new research by BPR Medical has for the first time provided important evidence about the nature and gravity of home oxygen fires in the US, revealing that the issue is far greater than previously thought.
Background: How home oxygen fires start
Oxygen therapy is commonly prescribed to individuals with a cardiac or respiratory condition – such as Chronic Obstructive Pulmonary Disease (COPD) – that causes low oxygen levels in the blood. Oxygen is delivered in a variety of forms, including liquid oxygen in pressurized containers, an oxygen concentrator that filters oxygen from the surrounding atmosphere, or compressed gas in cylinder form.
Patients’ conditions are generally caused by long term tobacco use, and in many cases they continue to smoke after diagnosis. In fact, despite education by home oxygen providers about the risks of smoking around oxygen, researchers estimate that up to 50% of home oxygen users continue to smoke.1 In the United States, that’s the equivalent of around 750,000 patients.
As we know, oxygen is not flammable, but its presence in increased concentrations will enable fires to start much more easily and burn more fiercely. Materials that do not burn in ambient air may ignite in elevated oxygen concentrations. The risk is increased significantly by the presence of naked flames, such as gas stoves or birthday candles, or cigarettes or electronic vaping devices. In fact, the conditions created when a patient smokes while using oxygen therapy means that it is almost inevitable that a fire will start, probably when they inhale.
What then follows takes place so quickly, the patient does not have time to react. The outside of the cigarette ignites as it reaches the high oxygen concentration around the face. The burning cigarette then heats and ignites the underside of the nasal cannula, which proceeds to burn up towards the higher oxygen concentration. The oxygen tubing then ignites and tracks back to the oxygen source at around one meter per minute, releasing toxic hydrogen chloride.
Fires often result in serious facial injuries as the flame moves along the cannula around the patient’s cheeks. A quarter of oxygen fires get beyond the immediate surrounding area to become ‘whole house’ fires according to the US National Fire Protection Association (NFPA).2 These are directly correlated with single or even multiple deaths.
The study: New evidence on the scale of home oxygen fires in the US
In order to understand the true scale and impact of home oxygen fires, BPR Medical conducted an analysis using the Google Alerts service to identify online media reports of residential fires involving home oxygen therapy in the US. The findings provided the most accurate data on the issue of home oxygen fires to date. The resulting report ‘The prevalence and impact of home oxygen fires in the US’ was published on World Patient Safety Day in September 2019.
The findings: The home oxygen fire death toll is likely to be double previous estimates
The research recorded a total of 311 incidents during the 20-month period between December 2017 and August 2019. These fires resulted in 164 deaths, 71 serious injuries, and 119 minor injuries, equating to more than one patient death every four days. It found that incidents were widespread, occurring in 45 of the 50 US States during that period.
The work suggests that the true annual death toll from home oxygen fires is likely to be double previous estimates. Until now the only data available has been estimates by the NFPA that put the number of people killed each year from home oxygen fires in the US at around 70.3 The NFPA does, however, emphasize that these are ‘likely underestimates’. BPR’s new analysis would put the figure at between 100 and 150 deaths per year.
Even though oxygen users only represent 0.5% of the overall population, this figure represents between 4% and 6% of the total fire deaths in the US. This means you are between 8 and 12 times more likely to die in a residential fire if you are a home oxygen user in the States.
More than 70% of the oxygen fires were reported to be either caused, or probably caused, by patients smoking while using oxygen therapy.
Fires present a major risk to third parties
Home oxygen fires not only put the oxygen users themselves at extreme risk, but third parties too. In fact, among the 164 recorded deaths, 11 were family members, other residents and a residential care home worker. In the reports from nine of the incidents, it was not clear whether the death was that of the oxygen user or another resident.
This risk of death increases if the third-party attempts to assist with evacuation. Around one in five incidents involved either firefighters or police, members of the public, and family members or other residents entering the building to assist with evacuation.
Cylinder explosions are a major risk
One of the most shocking outcomes of the research was the number of incidents involving exploding cylinders. Even a limited home fire can create the conditions that increase gas pressure and weaken cylinder strength sufficiently to trigger an explosion. In fact, the study reported a cylinder explosion in a staggering one in three incidents.
Cylinder explosions therefore present an additional and somewhat unpredictable risk to oxygen users and third parties, especially to those attempting to help evacuate a resident from a burning home, who may enter the building unaware of the presence or location of an oxygen cylinder.
In one very unfortunate incident in South Dakota in October 2018, a volunteer firefighter attending a residential fire was hit by shrapnel from an exploding cylinder. The fire was caused by an oxygen user smoking, the propane cylinder explosion was secondary and this, sadly, resulted in the firefighter’s death.
This potential for damage is amplified by the presence of several cylinders in the home. It is not uncommon for a home oxygen service provider to provide up to ten cylinders in one delivery. BPR’s study found anecdotal evidence that some oxygen users have stores of up to 20 or 30 cylinders in and around their home. Alarmingly, one incident reported in the study found a total of 28 cylinders in the building!
Structural damage amounts to millions of dollars
In addition to the obvious human misery associated with every home oxygen fire, there is practical loss and damage to family homes and belongings. The study revealed that nearly two thirds of homes were either destroyed or severely damaged in incidents. This puts the estimated total cost of damage over the 311 incidents in the order of $15 million.
To make matters worse, reports suggested that many people were not insured, and therefore relied on the American Red Cross and Just Giving campaigns to recover their losses.
Displacement affects the wider community
Losses are not restricted to the oxygen user and their family, however. In 45 of the incidents, neighboring buildings were damaged, and people were evacuated and displaced. Often this involved elderly people in residential complexes. In fact, the study reported cases where 50, 60, 70, 100 and 110 people were forced to relocate for more than one day as a result of an oxygen fire.
Incident count remains a likely underestimate
Although the results of the study are already shocking, it is likely that the figure of 311 incidents remains an underestimate. The media reports identified are very likely to represent actual events and can be considered solid evidence. However, not all media reports will have been discovered by Google Alerts, not all media reports will contain the search keywords, and not all home oxygen fires will be newsworthy. Therefore, the true scale of the problem may well be even higher.
An NFPA report ‘Fires and Burns Involving Home Medical Oxygen’4 from a decade ago estimated the number of burn victims attending US emergency rooms to be around 1,190 each year. The majority of these were caused by smoking while on oxygen.
Furthermore, COPD sufferers already have a severe respiratory impairment and may also have other comorbidities. Therefore, many oxygen users may subsequently die as a result of injuries sustained in the oxygen fire episode, but this is likely to go unreported.
When considered alongside the NFPA data, this suggests that the number of oxygen fires and fatalities is likely to be higher than identified by the study.
Worldwide recognition of the problem is growing
Recognition of the problem of home oxygen fires has been slow to take hold, but the number of countries around the world taking decisive action is increasing.
The UK is the model of best practice. There is strong regulation, a culture of stakeholders working together to reduce risk, and the fitting of thermal fuses (also known as firebreaks or fire stops) – which cut the flow of oxygen in the event of a fire in the tube – has been mandatory since 2006.5 Together, these measures have significantly reduced the impact of home oxygen fires.
Regulation is in place elsewhere in Europe too. In Germany for example, firebreaks have been mandatory since 20126, while across Europe the fitting of oxygen firebreaks is a requirement for home oxygen installations under the Medical Device Directive (MDD) and Medical Device Regulation (MDR)7.
There is hope for further adoption in the future. Japan is introducing legislation to make firebreaks mandatory by 2021, and other industry authorities are also looking closely at the issue.
Some progress has been made in the US. In March 2018, the Veterans Health Administration (VA) mandated the fitting of thermal fuses to all 85,000 veterans’ home oxygen installations. Meanwhile, a new initiative has been launched in Wyoming after it was revealed that more than fifty percent of deaths in residential structure fires throughout the State are in homes with medical oxygen. Dubbed the 307 CRR initiative, the aim is to install inline oxygen firebreaks in 100% of homes using medical oxygen in an effort to reduce fire deaths and injuries by 2024.8
While encouraging, these initiatives still represent a small minority of the home oxygen users in the US, and the risk of death in a home oxygen fire is still 20 times higher than in England, where only one death was recorded as a result of a home oxygen fire between 2013 and 2017.9
Greater action is urgently needed. In 2018, guidance on reducing surgical oxygen fires was produced by regulators in the US, based on clear evidence of the problem. This new study provides valuable data to support the changes required to address what remains a material public health issue.
For more information, go to www.bprmedical.com
References
- Wolff, B. K.; et al. (July 11, 2016). “Flash Burns While on Home Oxygen Therapy: Tracking Trends and Identifying Areas for Improvement”. American Journal of Medical Quality.
- Wolff, B. K.; et al. (July 11, 2016). “Flash Burns While on Home Oxygen Therapy: Tracking Trends and Identifying Areas for Improvement”. American Journal of Medical Quality.
- Ahrens, Marty (August 1, 2008). “Fires and Burns Involving Home Medical Oxygen”. NFPA.
- Ahrens, Marty (August 1, 2008). “Fires and Burns Involving Home Medical Oxygen”. NFPA.
- Cooper, Brendan G. (2015). “Home Oxygen and Domestic Fires”. Breathe. 11: 5–12.
- Federal Institute for Drugs and Medical Devices (BfArM) Assessment notice (Case no. 2676/10)
- The status of home oxygen service providers under EU regulation and the legal requirement to fit oxygen firebreaks. BPR Medical. July 2017.
- Fire break campaign. Jackson Hole Fire EMS. 2020.
- “An international comparison of fatalities from home oxygen fires: 2013-2017”; BPR Medical Ltd; 2019
About the Author
Richard Radford is Managing Director of BPR Medical, one of the world’s leading specialist medical gas design engineering companies. Radford co-founded BPR Medical in 1990 and is one of the world’s leading experts on medical oxygen fire safety, having overseen numerous research studies into the issue.
