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Supplemental oxygen: More isn’t always better

J Fam Pract. 2019 November;68(9):E10-E11

References

1. Chu DK, Kim LH, Young PJ, et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet. 2018;391:1693-1705.

2. Hale KE, Gavin C, O’Driscoll BR. Audit of oxygen use in emergency ambulances and in a hospital emergency department. Emerg Med J. 2008;25:773-776.

3. O’Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017;72(suppl 1):ii1-ii90.

4. Kallstrom TJ, American Association for Respiratory Care. AARC Clinical Practice Guideline: oxygen therapy for adults in the acute care facility—2002 revision and update. Respir Care. 2002;47:717-720.

5. Henry TD, Torbati S. Oxygen for ACS: too much, too little, or just right? May 15, 2017. https://www.acc.org/latest-in-cardiology/articles/2017/05/15/08/34/oxygen-for-acs. Accessed October 1, 2019.

6. Hafner S, Beloncle F, Koch A, et al. Hyperoxia in intensive care, emergency, and peri-operative medicine: Dr. Jekyll or Mr. Hyde? A 2015 update. Ann Intensive Care. 2015;5:42.

7. Helmerhorst HJ, Schultz MJ, van der Voort PH, et al. Self-reported attitudes versus actual practice of oxygen therapy by ICU physicians and nurses. Ann Intensive Care. 2014;4:23.

8. Kelly CA, Lynes D, O’Brien MR, et al. A wolf in sheep’s clothing? Patients’ and healthcare professionals’ perceptions of oxygen therapy: an interpretative phenomenological analysis. Clin Respir J. 2018;12:616-632.

9. Meyhoff CS, Wetterslev J, Jorgensen LN, et al. Effect of high perioperative oxygen fraction on surgical site infection and pulmonary complications after abdominal surgery: the PROXI randomized clinical trial. JAMA. 2009;302:1543-1550.

10. Stub D, Smith K, Bernard S, et al. A randomized controlled trial on oxygen therapy in acute myocardial infarction Air Verses Oxygen in Myocardial infarction study (AVOID Study). Am Heart J. 2012;163:339-345.E1.

11. Girardis M, Busani S, Damiani E, et al. Effect of conservative vs conventional oxygen therapy on mortality among patients in an intensive care unit: the oxygen-ICU randomized clinical trial. JAMA. 2016;316:1583-1589.

12. Helmerhorst HJ, Roos-Blom MJ, van Westerloo DJ, et al. Association between arterial hyperoxia and outcome in subsets of critical illness: a systematic review, meta-analysis, and meta-regression of cohort studies. Crit Care Med. 2015;43:1508-1519.

13. Pope JV, Jones AE, Gaieski DF, et al. Multicenter study of central venous oxygen saturation (ScvO(2)) as a predictor of mortality in patients with sepsis. Ann Emerg Med. 2010;55:40-46.E1.

14. Kim V, Benditt JO, Wise RA, et al. Oxygen therapy in chronic obstructive pulmonary disease. Proc Am Thorac Soc. 2008;5:513-518.

15. Austin MA, Wills KE, Blizzard L, et al. Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial. BMJ. 2010;341:C5462.

WHAT’S NEW

High-quality evidence points to the dangers of liberal O₂ therapy

This comprehensive meta-analysis is the first high-quality evidence to suggest that liberal use of oxygen in acutely ill adults above a specific SpO₂ level increases all-cause mortality. Previous small RCTs and observational studies have examined the effect of liberal oxygen only on specific presenting conditions, thus making more generalizable conclusions challenging.^9-12

CAVEATS

Varied definitions of “liberal” and “conservative”

This review included studies with variable ranges of SpO₂ defined as liberal vs conservative supplementation. However, in all of these, SpO₂ above 96% was correlated with unfavorable outcomes.

This meta-analysis is the first high-quality evidence to suggest that liberal use of oxygen in acutely ill adults above a specific SpO₂ level increases all-cause mortality.

The study excluded 2 potentially important patient groups: patients with chronic respiratory diseases and pregnant patients. Increased oxygen supplementation in patients with chronic respiratory diseases in noncritical settings has been shown to be deleterious.^13-15While this study does not address the issue of oxygen supplementation in acutely ill patients with chronic respiratory disease, use should be considered with caution. The results from this study may not be generalizable to women who are pregnant.

CHALLENGES TO IMPLEMENTATION

Reversing the tide

Liberal oxygen administration continues to be practiced in many health care settings. The main challenges to implementing the conclusions of this study are these pervasive practices.

ACKNOWLEDGMENT

The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

References

2. Hale KE, Gavin C, O’Driscoll BR. Audit of oxygen use in emergency ambulances and in a hospital emergency department. Emerg Med J. 2008;25:773-776.

3. O’Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017;72(suppl 1):ii1-ii90.

5. Henry TD, Torbati S. Oxygen for ACS: too much, too little, or just right? May 15, 2017. https://www.acc.org/latest-in-cardiology/articles/2017/05/15/08/34/oxygen-for-acs. Accessed October 1, 2019.

6. Hafner S, Beloncle F, Koch A, et al. Hyperoxia in intensive care, emergency, and peri-operative medicine: Dr. Jekyll or Mr. Hyde? A 2015 update. Ann Intensive Care. 2015;5:42.

7. Helmerhorst HJ, Schultz MJ, van der Voort PH, et al. Self-reported attitudes versus actual practice of oxygen therapy by ICU physicians and nurses. Ann Intensive Care. 2014;4:23.

13. Pope JV, Jones AE, Gaieski DF, et al. Multicenter study of central venous oxygen saturation (ScvO(2)) as a predictor of mortality in patients with sepsis. Ann Emerg Med. 2010;55:40-46.E1.

14. Kim V, Benditt JO, Wise RA, et al. Oxygen therapy in chronic obstructive pulmonary disease. Proc Am Thorac Soc. 2008;5:513-518.

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Supplemental oxygen: More isn’t always better

References

WHAT’S NEW

High-quality evidence points to the dangers of liberal O2 therapy

CAVEATS

Varied definitions of “liberal” and “conservative”

CHALLENGES TO IMPLEMENTATION

Reversing the tide

ACKNOWLEDGMENT

Pages

Online-Only Materials

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High-quality evidence points to the dangers of liberal O₂ therapy