Oxygen targets in the intensive care unit during mechanical ventilation for acute respiratory distress syndrome: a rapid review

Cumpstey, Andrew F.; Oldman, Alex H.; Smith, Andrew F; Martin, Daniel; Grocott, Michael P.W.

doi:10.1002/14651858.cd013708

Cited by 12 publications

(13 citation statements)

References 23 publications

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“…The pathophysiological mechanisms of this phenomenon are being discussed currently [13] [14] [15] [16] [17] as well as the impact of happy hypoxemia on respiratory management [14] [18]. A recent Cochrane review did not find evidence, that higher oxygen targets benefit patients with respiratory failure [19]. Hypoxemia can either be caused by intrapulmonary shunting or ventilation-perfusion mismatch which in Covid 19 is mainly caused by diffusion impairment.…”

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confidence: 99%

Conservative management of COVID-19 associated hypoxaemia

et al. 2021

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BackgroundInvasive mechanical ventilation of hypoxemic Covid 19 patients is associated with mortality rates of more than 50%. We evaluated clinical outcome data of two hospitals that agreed on a predefined protocol for restrictive use of invasive ventilation where the decision to intubate was based on the clinical presentation and oxygen content rather than on the degree of hypoxemia.MethodData analysis of patients with positive PCR-testing for SARS-CoV-2, typical history, and symptoms and pulmonary infiltrates who exhibited oxygen saturation values of less than 93%.ResultsWe identified 78 patients who met the inclusion criteria. The SaO2 nadir was 84.4±6.5% for the whole group. Fifty-three patients (68%) received nasal oxygen (group1), 17 patients (22%) were treated with nasal high-flow, CPAP, non-invasive ventilation, or a combination thereof (group 2) and 8 patients (10%) were intubated (group 3). The Horovitz index was 216±8 for group 1, 157±13 for group 2, and 106±15 for group 3. Oxygen content was 14.5±2.5, 13.4±1.9, and 11.6±2.6 mL·dL−1 for the three respective groups. Overall mortality was 7.7%, the mortality of intubated patients was 50%. 93% of patients could be discharged on room air.ConclusionPermissive hypoxemia where decisions for the level of respiratory therapy were based on the clinical presentation and oxygen content resulted in low intubation rates, low overall mortality, and a low number of patients who require oxygen after discharge.

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confidence: 99%

Conservative management of COVID-19 associated hypoxaemia

et al. 2021

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“…There is no published randomized clinical trial on oxygenation targets in ICU patients with COVID‐19. 2 Therefore, oxygen therapy in COVID‐19 patients is guided by the SSC recommendation of a maximum SpO 2 target of 96%. 18 The sparse evidence is based on data from a retrospective study in critically ill patients with hypoxia being associated with poor outcomes, 19 a systematic review and meta‐analysis in acutely ill adults being associated with increased mortality, 20 a clinical practice guideline for acutely ill medical patients, 21 the ICU‐ROX trial of mechanically ventilated ICU patients with equipoise between a lower oxygenation target and a higher oxygenation target, 10 and the LOCO 2 trial of ARDS patients with potential harm in the lower oxygenation target group.…”

Section: Discussionmentioning

confidence: 99%

“…The high incidence of mechanically ventilated COVID‐19 patients may partly be explained by the restricted use of high flow nasal cannula during the first phase of the pandemic. 22 , 24 The currently available evidence on targeting oxygen therapy in patients with ARDS is of very low certainty due to lack of data 2 with only one randomized clinical trial conducted, the LOCO 2 trial. 8 This trial was stopped prematurely due to a high proportion of intestinal ischemia in the lower oxygenation group, 8 an observation which could be by chance as no differences in severe ischemic events occurred in neither the main HOT‐ICU trial 9 nor in the present subgroup of COVID‐19 patients.…”

Section: Discussionmentioning

confidence: 99%

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Oxygenation targets in ICU patients with COVID‐19: A post hoc subgroup analysis of the HOT‐ICU trial

Rasmussen

Klitgaard

Perner

et al. 2021

Acta Anaesthesiol Scand

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Background Supplemental oxygen is the key intervention for severe and critical COVID‐19 patients. With the unstable supplies of oxygen in many countries, it is important to define the lowest safe dosage. Methods In spring 2020, 110 COVID‐19 patients were enrolled as part of the Handling Oxygenation Targets in the ICU trial (HOT‐ICU). Patients were allocated within 12 h of ICU admission. Oxygen therapy was titrated to a partial pressure of arterial oxygen (PaO 2 ) of 8 kPa (lower oxygenation group) or a PaO 2 of 12 kPa (higher oxygenation group) during ICU stay up to 90 days. We report key outcomes at 90 days for the subgroup of COVID‐19 patients. Results At 90 days, 22 of 54 patients (40.7%) in the lower oxygenation group and 23 of 55 patients (41.8%) in the higher oxygenation group had died (adjusted risk ratio: 0.87; 95% confidence interval, 0.58–1.32). The percentage of days alive without life support was significantly higher in the lower oxygenation group ( p = 0.03). The numbers of severe ischemic events were low with no difference between the two groups. Proning and inhaled vasodilators were used more frequently, and the positive end‐expiratory pressure was higher in the higher oxygenation group. Tests for interactions with the results of the remaining HOT‐ICU population were insignificant. Conclusions Targeting a PaO 2 of 8 kPa may be beneficial in ICU patients with COVID‐19. These results come with uncertainty due to the low number of patients in this unplanned subgroup analysis, and insignificant tests for interaction with the main HOT‐ICU trial. Trial registration number: ClinicalTrials.gov number, NCT03174002. Date of registration: June 2, 2017.

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“…Pups were randomized into baseline control, 90 min normoxia time control, and 90 min hypoxia (8% O 2 ). An inspired O 2 of 8% gives a SpO 2 of 80%–85% which is clinically relevant in the NICU (Borenstein‐Levin et al., 2020; Bruder, Taylor, et al., 2008; Cumpstey et al., 2020). The 90‐min normoxic samples are the control for hypoxia and serve to evaluate the effects of fasting on glucose and insulin without and with concomitant hypoxia.…”

Section: Methodsmentioning

confidence: 99%

Insulin and glucose responses to hypoxia in male and female neonatal rats: Effects of the androgen receptor antagonist flutamide

et al. 2021

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Oxygen targets in the intensive care unit during mechanical ventilation for acute respiratory distress syndrome: a rapid review

Abstract: Oxygen targets in the intensive care unit during mechanical ventilation for acute respiratory distress syndrome: a rapid review (Review)

Cited by 12 publications

References 23 publications

Conservative management of COVID-19 associated hypoxaemia

Conservative management of COVID-19 associated hypoxaemia

Oxygenation targets in ICU patients with COVID‐19: A post hoc subgroup analysis of the HOT‐ICU trial

Insulin and glucose responses to hypoxia in male and female neonatal rats: Effects of the androgen receptor antagonist flutamide

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