Automatic versus Manual Oxygen Titration in Patients Requiring Supplemental Oxygen in the Hospital: A Systematic Review and Meta-Analysis

Abstract

<b><i>Background:</i></b> Closed-loop oxygen titration devices have been developed to avoid periods of hypoxemia and hyperoxemia, both detrimental to patients hospitalized for respiratory failure and requiring supplemental oxygen. However, their clinical impact remains unknown. <b><i>Objective:</i></b> To compare the effect of automatic versus manual oxygen titration on clinical outcomes in pediatric and adult patients requiring supplemental oxygen in the hospital. <b><i>Methods:</i></b> We conducted a systematic review and meta-analysis of randomized controlled trials. We searched MEDLINE, EMBASE, and CENTRAL electronic databases (from inception to August 2018), and conference proceedings of major societies in respiratory medicine (2015–2018). Randomized controlled trials were included if they compared automatic to manual oxygen titration in hypoxemic inpatients and if they assessed at least one of the following: length of hospital stay (primary outcome), length of oxygen therapy, need and duration of mechanical ventilation, mortality, percentage of time within, above, and below the oxygen saturation target range, as well as the percentage of time spent in hypoxemia and hyperoxemia. <b><i>Results:</i></b> We included 9 trials (354 patients, adults and preterm infants, with or without ventilatory assistance). Eight of these trials were at high risk of bias due to lack of blinding and selective reporting. Automatic titration was associated with a significant decrease in the length of hospital stay (mean difference: –2.2 days; 95% CI: –3.8 to –0.6; <i>p</i> = 0.009; <i>I</i><sup>2</sup> = 0%; n = 237, 2 trials), and a decrease in the length of oxygen therapy (mean difference: –1.6 days; 95% CI: –3.1 to 0.0; <i>p</i> = 0.05; <i>I</i><sup>2</sup> = 0%; <i>n</i> = 237; 2 trials). We did not observe a reduction in the need for ventilatory assistance or in mortality in the automatic titration period. An increase in the percentage of time spent within target (mean difference: 18.23%; 95% CI: 10.93–25.52; <i>I</i><sup>2</sup> = 81%; <i>n</i> = 351, 7 trials) and a significant reduction in the percentage of time spent in both hypoxemia and hyperoxemia with automatic compared to manual oxygen titration were, however, observed. <b><i>Conclusions:</i></b> In patients requiring supplemental oxygen in the hospital, automatic oxygen titration was associated with a reduction in length of both hospital stay and oxygen therapy, as well as a greater percentage of time spent within the saturation target range. However, it was not associated with a significant difference in the need for mechanical ventilation or in mortality. Results should be interpreted with caution due to the small number of included trials and their high risk of bias.

A randomised crossover trial of closed loop automated oxygen control in preterm, ventilated infants

“…As less time was spent making manual adjustments, it would be important in a future study to determine whether staff were able to devote this “saved” time to other care giving tasks. A recently reported meta‐analysis of nine trials (354 adults and preterm infants with or without ventilator assistance) demonstrated that automatic titration was associated with significant decrease on length of hospital stay and a decrease in the length of oxygen therapy 20 . Eight of the trials however were at high risk of bias due to lack of blinding and selective reporting.…”

“…A recently reported meta-analysis of nine trials (354 adults and preterm infants with or without ventilator assistance) demonstrated that automatic titration was associated with significant decrease on length of hospital stay and a decrease in the length of oxygen therapy. 20 Eight of the trials however were at high risk of bias due to lack of blinding and selective reporting. Nevertheless, whether such advantages occur in an exclusively prematurely born population merits testing.…”

COVID-19: Pulse oximeters in the spotlight

“…It intends to reverse the paradigm from a constant oxygen flow with a variable SpO 2 value, to a constant target SpO 2 set by the physician with continuous oxygen flow variations. The use of such devices has been associated with a greater percentage of time spent within the SpO 2 target range, as well as shorter duration of oxygen administration and hospital length-of-stay [6].…”

Closed-loop oxygen control for patients with hypoxaemia during hospitalisation: a living systematic review and meta-analysis protocol

“… 10–12 Delivery oxygen devices based on closed-loop technology have been developed and used in patient care in order to provide a real-time adjustment of oxygen titration, based on patients’ SpO 2 preventing episodes of hypoxaemia or hyperoxia. 11 12 The adoption of new technologies of AI and ML in clinical practice, may reduce the healthcare professionals’ workload at the bedside; however, there is low certainty evidence for their safety and benefits. 11 12 It is still unclear whether closed-loop oxygen control devices could improve clinical outcomes, and with the technological advances, new randomised clinical trials (RCTs) 13–21 have been published since the last two systematics reviews were conducted.…”

“… 11 12 The adoption of new technologies of AI and ML in clinical practice, may reduce the healthcare professionals’ workload at the bedside; however, there is low certainty evidence for their safety and benefits. 11 12 It is still unclear whether closed-loop oxygen control devices could improve clinical outcomes, and with the technological advances, new randomised clinical trials (RCTs) 13–21 have been published since the last two systematics reviews were conducted. 11 12 Thus, the aim of this systematic review is to investigate the effectiveness, efficacy and safety of the closed-loop oxygen control for patients during hospitalisation.…”