Can a patient be discharged home with high oxygen requirements, specifically 10 liters per minute (lpm) via nasal canula?

Home Discharge with High Oxygen Requirements (10 L/min via Nasal Cannula)

Patients requiring 10 L/min of oxygen via nasal cannula should not be discharged home due to safety concerns, technical limitations of home oxygen equipment, and increased risk of adverse outcomes.

Assessment of Home Oxygen Suitability

The British Thoracic Society guidelines for home oxygen use in adults provide clear direction on this issue:

Flow Rate Limitations

• Oxygen concentrators are only recommended for delivering long-term oxygen therapy (LTOT) at flow rates of 4 L/min or less 1
• Standard home oxygen equipment is not designed to safely or effectively deliver 10 L/min continuously

Technical Considerations

• Nasal cannulae at flow rates above 6 L/min:
  • Are uncomfortable for patients
  • Cause nasal dryness and irritation
  • May not effectively deliver the intended oxygen concentration due to dilution with room air
  • May generate aerosols at high flow rates 1

Safety Concerns

• High oxygen flow rates increase risk of:
  • Fire hazards
  • Rapid oxygen depletion of portable tanks
  • Inadequate humidification leading to mucosal damage
  • Potential CO₂ retention in susceptible patients

Alternative Approaches

For Patients Requiring >4 L/min

1. Extend hospitalization until oxygen requirements decrease to ≤4 L/min
2. Consider specialized care facilities with capabilities for higher oxygen flow rates
3. Evaluate for high-flow nasal cannula (HFNC) systems in select cases, though these typically require specialized care settings 2

For Patients at Risk of Hypercapnic Respiratory Failure

• Use Venturi masks (24-28%) rather than high-flow nasal cannula 1
• Target oxygen saturation of 88-92% rather than 94-98% 3
• Monitor for signs of CO₂ retention and respiratory acidosis

Discharge Planning for High Oxygen Requirements

Step-Down Approach

1. Gradually reduce oxygen requirements to ≤4 L/min before considering discharge
2. For patients with chronic respiratory conditions, aim for stable oxygen requirements on 1-2 L/min via nasal cannula 1
3. Ensure patient can maintain target saturation for at least 24 hours on stable settings

Special Considerations

• Early discharge with home oxygen for COVID-19 patients has been associated with high readmission rates (17.8%) and should be approached with caution 4
• Patients with interstitial lung disease at risk of CO₂ retention require careful monitoring and lower oxygen targets 3

Conclusion

Discharging a patient requiring 10 L/min of oxygen via nasal cannula is not recommended based on current guidelines. The technical limitations of home oxygen equipment, safety concerns, and increased risk of adverse outcomes make this approach unsafe. Patients should remain hospitalized until their oxygen requirements decrease to levels that can be safely managed at home (≤4 L/min).