Oxygen therapy in palliative care
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Oxygen therapy is used for reducing breathlessness in patients who have low levels of oxygen in their blood (hypoxaemia). It can be given at home and in residential care settings. Here we explain some of the risks associated with oxygen therapy, as well as things you can do to support patients using oxygen therapy.
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What is oxygen therapy?
Oxygen therapy is a treatment for patients who have a health condition which causes low levels of oxygen in the blood (hypoxaemia).
Breathing in air with added oxygen increases the level of oxygen in the blood. This helps to reduce symptoms such as breathlessness and can make day-to-day activities easier to manage.
Illnesses that can cause hypoxaemia include:
- cancer
- chronic obstructive pulmonary disease (COPD)
- pulmonary fibrosis
- heart failure
- obesity-related hypoventilation
- pulmonary hypertension
- neurodegenerative conditions such as motor neurone disease
- cystic fibrosis (CF)
- anaemia.
Assessment for oxygen therapy
Before oxygen is prescribed, a specialist clinical team will carry out an assessment. This team may include the GP and a respiratory specialist.
They will first make sure that the patient is being treated for any underlying conditions and that any reversible causes of breathlessness are being managed.
Read more about treatments for breathlessness.
They will measure the level of oxygen in the patient’s blood using a blood test or a pulse oximeter.
If the patient is found to have low levels of oxygen in the blood (hypoxaemia), they may be prescribed oxygen.
Oxygen is not suitable for all patients with breathlessness.
Prescribing oxygen therapy
Oxygen is prescribed by a doctor or specialist nurse. Oxygen should be thought of as a drug and the prescription should be followed accurately. The doctor or specialist nurse will prescribe a flow rate of oxygen which is measured in litres per minute (L/min) and a target oxygen saturation percentage (sats).
The oxygen flow rate should not be increased outside the prescribed range without authorisation from a doctor or specialist nurse, even if the patient or someone involved in their care asks for it to be increased. Too much oxygen can be harmful and can cause further breathing problems.
Setting up oxygen therapy
The doctor or specialist nurse will send a home oxygen order form (HOOF) to the local oxygen supplier. In Scotland, this form is known as a Scottish home oxygen order form (SHOOF), and in Northern Ireland, a home oxygen order form Northern Ireland (HOOF NI).
An engineer will visit the home to install the equipment and carry out a risk assessment. They will also provide important information such as how to order oxygen refills.
If your patient lives at home, they may have a copy of the HOOF in the house for health care professionals to refer to. If not, you can request it from the pharmacy. The patient’s prescription will also be written on the back of the oxygen concentrator, and it should be listed in their care plan.
How often oxygen therapy is given
Oxygen can be used for short periods during the day when doing certain activities, or it can be used for longer periods during the day and night.
After the first few days, the doctor may review the patient to see if the oxygen is making an improvement. If the patient’s experience of breathlessness does not improve, oxygen therapy should be stopped.
Oxygen therapy equipment
It is useful to know about the different pieces of equipment involved in oxygen therapy, including the oxygen source and the delivery system.
Oxygen source
The most common oxygen source is an oxygen concentrator. An oxygen concentrator is an electronic device which takes room air and passes it through a filter. The filter removes nitrogen and other elements from the air, leaving a higher concentration of oxygen.
Concentrators can either be fixed in one room in the home, or they can be portable and carried by the patient around the home as well as outside.
Oxygen can also be supplied in cylinders. These are metal containers containing oxygen at high pressure. They have a regulator (tap) which can be turned up or down to alter the flow of oxygen.
Cylinders should be stored in a cool place. Storing the empty cylinders in a separate place from the unused cylinders can make it easier to know which have been used and which are still full.
The choice between a concentrator and cylinder will be based on the patient’s individual needs. Generally, concentrators will be used if the patient needs oxygen over a long period of time.
Oxygen delivery systems
Nasal cannulae (nasal specs) are most commonly used to deliver low levels of oxygen into the patient’s body.
Oxygen masks which cover the nose and mouth can be used as well. They can be useful for people who do not tolerate nasal cannulae, or for patients who need higher levels of oxygen.
The choice of mask or cannulae will depend on the patient’s preference and the rate of oxygen they’ve been prescribed. Their preference should be detailed in their care plan.
Trans-tracheal devices for patients with a tracheostomy are rarely used at home and require care from a specialist team.
Other equipment
Trolleys and backpacks to carry portable oxygen sources can be provided for mobile patients.
Oxygen humidifiers are normally used for patients who are receiving high levels of oxygen. They will also be used for patients with a tracheostomy receiving trans-tracheal oxygen.
Risks of oxygen therapy
It’s important that you are aware of the significant safety risks involved with oxygen.
Fire safety
A high concentration of oxygen in the air increases the risk of fire. The oxygen supplier will carry out a risk assessment in the home. The Fire and Rescue service might do a home visit to discuss fire safety, smoke alarms and safe exit routes in the event of a fire. Patients will normally be given written safety information. Home Safety Assessment details can be also found on local fire service websites.
You should never let anyone smoke in the vicinity while someone is using oxygen. This includes the patient, any family members, friends or others involved in their care.
Oxygen can remain on clothing and fabrics after it’s been used, which can make them more flammable. Patients should be careful about leaving their oxygen mask on fabrics – for example, taking their mask off to use the toilet, and placing it on the bed.
Oxygen sources should be kept at least six feet away from flames or heat sources such as gas cookers and heaters. Patients should also be advised not to use e-cigarettes and chargers near the oxygen supply.
Oil-based emollients and petroleum jelly, such as Vaseline, can increase risk of fire in the presence of oxygen and shouldn’t be used. Patients should be made aware that only water-based products should be used on the hands and face or inside the nose while using oxygen.
Trips and falls
Oxygen equipment including tubing and electric cables can be a trip hazard in the home. Be aware of how the equipment will affect how your patient moves around their home, especially if they are visually impaired or have mobility difficulties.
Skin care
Nasal cannulae and oxygen masks can cause pressure damage if they are fitted too tightly. Check the patient’s skin around the ears, nose and cheeks regularly for discolouration and discomfort. Discolouration might show as redness on lighter skin tones, and in darker skin tones you may see a change to a colour different from the surrounding area (usually a darker colour).
If the mask or cannulae are too tight, loosen the straps. Gauze can be applied between the plastic and their skin if it’s uncomfortable. Cannulae should be changed regularly – normally every month.
Oxygen can dry out the mouth, lips and nasal passages. Use moisturisers regularly to keep the skin in good condition but remember to avoid petroleum jelly and oil-based products as they can increase the risk of fire.
Supporting someone on oxygen therapy
There are different ways you can support your patient if they’re on oxygen therapy. It’s always important to check their care plan first, to see if anything has been recommended:
- Help the patient get into a comfortable position – this will often be upright, but be guided by what’s comfortable for them. If they are breathless, they might find it comfortable to lean forward, supported by a cushion, as this can help to expand the lungs.
- Keep the patient’s skin moisturised and offer them fluid regularly, as oxygen can dry out the mouth, lips and nose. Read more about how to help a patient with a dry mouth.
- Make sure the patient’s equipment is comfortable. There may be pressure where the mask or cannulae fits on their face.
- Check their equipment regularly, to make sure it’s working properly. There’s more information on how to check equipment below.
Some patients may ask you to increase their oxygen supply if they feel they’re not getting enough. It can be dangerous to increase their oxygen level above the prescribed rate. It’s important to take some time to explain this to the patient.
Speak to the patient's medical team or your manager if you have questions about their prescription.
When to ask for help
If you are worried about the patient’s oxygen supply, there are some things you can check:
- If they use a concentrator, is it plugged in and the socket turned on?
- If they use a cylinder, is the oxygen valve in the “on” position?
- Is the tubing connected properly, and is it damaged, cracked, or twisted?
- Is the mask damaged or the cannulae blocked?
If you have any concerns about the patient’s oxygen supply – for example, if you think the equipment is faulty – contact the provider of the patient’s oxygen. There should be contact details for the oxygen provider in the patient’s home. You should also contact the patient’s district nurse, GP, or specialist respiratory team, if they have one.
If there’s a power cut
If the patient is using an oxygen concentrator and there’s a power cut, try not to panic. If you are based in a nursing home or care home, speak to a senior health professional immediately.
If the patient is at home, you may be able to switch them onto a cylinder, if you’ve had the appropriate training. If you aren’t trained or don’t feel comfortable doing this, contact the patient’s doctor or nurse straight away.
Useful resources
British Thoracic Society Guidelines for Home Oxygen Use in Adults
Key points
- Oxygen can be given in the home for patients with breathlessness because of hypoxaemia.
- Oxygen therapy is not appropriate for all patients with breathlessness.
- Be aware of safety issues, including risk of fire, and trips and falls over equipment.
- Do not use oil-based emollients or petroleum jelly such as Vaseline.
- Never let anyone smoke in the room while the patient is using oxygen. This includes e-cigarettes.
- Provide good mouth care and skin care as the mouth, lips and nasal passages can become dry.
- Check that the nasal cannulae or oxygen mask fit properly and are comfortable.
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This information is not intended to replace any training, national or local guidelines, or advice from other health or social care professionals.
The Palliative Care Knowledge Zone is not intended for use by people living with a terminal illness or their family and friends, who should access our information for the public.
