High intraoperative inspiratory oxygen fraction and risk of major respiratory complications

Staehr‐Rye, A. K.; Meyhoff, Christian S.; Scheffenbichler, Flora T.; Melo, Marcos F. Vidal; Gätke, Mona Ring; Walsh, J.; Ladha, Karim; Grabitz, Stephanie D.; Nikolov, Milcho; Kurth, Tobias; Rasmussen, Lars S.; Eikermann, Matthias

doi:10.1093/bja/aex128

Cited by 145 publications

(149 citation statements)

References 37 publications

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“…Secondary analysis did not show any significant differences between groups in the odds of atelectasis (odds ratio 1.11, 0.75 to 1.66; P=0.60), pneumonia (0.95, 0.61 to 1.48; P=0.82), or respiratory failure (1.27, 0.78 to 2.07; P=0.34). Additional prospective trials are needed to determine the proper risk/benefit ratio of a higher FiO 2 , as a recent large database study of 74 000 surgical patients associated an intraoperative FiO 2 of 80% with a doubling of the odds of major pulmonary complications (odds ratio 1.99, 1.72 to 2.31; P=0.05) 106. Given these results, use of a high FiO 2 only as necessary to correct hypoxia may be prudent, as lower concentrations may help to prevent atelectasis.…”

Section: Additional Considerationsmentioning

confidence: 99%

Perioperative lung protective ventilation

O’Gara

Talmor

2018

BMJ

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Perioperative lung injury is a major source of postoperative morbidity, excess healthcare use, and avoidable mortality. Many potential inciting factors can lead to this condition, including intraoperative ventilator induced lung injury. Questions exist as to whether protective ventilation strategies used in the intensive care unit for patients with acute respiratory distress syndrome are equally beneficial for surgical patients, most of whom do not present with any pre-existing lung pathology. Studied both individually and in combination as a package of intraoperative lung protective ventilation, the use of low tidal volumes, moderate positive end expiratory pressure, and recruitment maneuvers have been shown to improve oxygenation and pulmonary physiology and to reduce postoperative pulmonary complications in at risk patient groups. Further work is needed to define the potential contributions of alternative ventilator strategies, limiting excessive intraoperative oxygen supplementation, use of non-invasive techniques in the postoperative period, and personalized mechanical ventilation. Although the weight of evidence strongly suggests a role for lung protective ventilation in moderate risk patient groups, definitive evidence of its benefit for the general surgical population does not exist. However, given the shift in understanding of what is needed for adequate oxygenation and ventilation under anesthesia, the largely historical arguments against the use of intraoperative lung protective ventilation may soon be outdated, on the basis of its expanding track record of safety and efficacy in multiple settings.

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Section: Additional Considerationsmentioning

confidence: 99%

Perioperative lung protective ventilation

O’Gara

Talmor

2018

BMJ

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“…The median Injury Severity Score (ISS) was 10 [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] and the first recorded Glasgow Coma Scale (GCS) score in the trauma bay was 13 [3][4][5][6][7][8][9][10][11][12][13][14][15] (Table 1).…”

Section: Re Sultsmentioning

confidence: 99%

“…10 Of note, the only trial on trauma patients (traumatic brain injury [TBI]) that was included did not report mortality data but, conversely, showed that degree of disability was significantly higher at 6 months in the group that had received restrictive oxygen compared to liberal oxygen. 12,13 For example, a recent retrospective study found hyperoxaemia to be an independent risk factor for ventilator associated pneumonia. 12,13 For example, a recent retrospective study found hyperoxaemia to be an independent risk factor for ventilator associated pneumonia.…”

Section: Introductionmentioning

confidence: 99%

“…13 patients were on mechanical ventilation throughout the intervention for a median of 4[3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] hours and a medianFiO 2 of 0.84 [0.80-0.96]. There were seven episodes in four patients of desaturation (SpO 2 below 90%) in the restrictive group (median 87% [87-89]) and one episode of SpO 2 below 90% in the liberal group (saturation = 89%).…”

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confidence: 99%

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Restrictive vs liberal oxygen for trauma patients‐the TRAUMOX1 pilot randomised clinical trial

Baekgaard

Isbye

Ottosen

et al. 2019

Acta Anaesthesiol Scand

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Introduction:Hyperoxaemia is commonly observed in trauma patients but has been associated with pulmonary complications and mortality in some patient populations.The objectives of this study were to evaluate whether maintenance of normoxia is feasible using a restrictive oxygen strategy in the initial phase after trauma and to evaluate the incidence of 30-day mortality and/or major pulmonary complications. Methods: Forty-one adult trauma patients admitted to our trauma centre were randomised to 24 hours of restrictive oxygen therapy (no supplemental oxygen if the arterial oxyhaemoglobin saturation (SpO 2 ) was at least 94%, n = 21) or liberal oxygen therapy (intubated patients: FiO 2 1.0 in the trauma bay, 0.8-1.0 elsewhere; spontaneously breathing patients: 15 L/min via a non-rebreather mask, n = 20). Two blinded anaesthesiologists evaluated major in-hospital pulmonary complications within 30 days. Results: Protocol compliance was high, as the median arterial oxygen tension was significantly lower in the restrictive group (10.8 kPa [9.7-12.0] vs 30.4 kPa [23.7-39.0], P < 0.0001). There were seven episodes of SpO 2 below 90% in the restrictive group and one episode in the liberal group. Thirty-day mortality and/or major in-hospital pulmonary complications occurred in 4/20 (20%) in the restrictive group and in 6/18 (33%) in the liberal group: two patients in each group died within 30 days and the incidence of major in-hospital pulmonary complications was 2/20 (10%) in the restrictive group and 4/18 (22%) in the liberal group.Conclusion: Maintenance of normoxia using a restrictive oxygen strategy following trauma is feasible. This pilot study serves as the basis for a larger clinical trial.

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“…It is routine practice during general anaesthesia (GA) to administer more than the 21% oxygen in which we mostly spend our lives. It is essential to understand the physiology underlying this practice if we are to keep patients safe by avoiding both hypoxaemia and hyperoxia during GA. 1 Four pathophysiological changes occur, which explain the answer to the question posed in the title of this article.…”

mentioning

confidence: 97%

Why do patients need extra oxygen during a general anaesthetic?

Lumb

2019

BJA Education

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It is routine practice during general anaesthesia (GA) to administer more than the 21% oxygen in which we mostly spend our lives. It is essential to understand the physiology underlying this practice if we are to keep patients safe by avoiding both hypoxaemia and hyperoxia during GA. 1 Four pathophysiological changes occur, which explain the answer to the question posed in the title of this article.(i) Abnormal respiratory muscle activity Induction of GA is followed within seconds by profound relaxation of all skeletal muscles, to a much greater extent than seen with physiological sleep. The effects on airway muscles are well known to all anaesthetists, and artificial airways are used routinely to bypass this part of the respiratory tract. The spinal muscles relax, increasing thoracic spinal curvature; relaxation of intercostal muscles leads to a reduction in the cross-sectional area of the ribcage; and the diaphragm is displaced in a cephalad direction, particularly in dependent regions because of the weight of the abdominal contents. Together, these three changes to the chest cavity shape cause an immediate reduction in functional residual capacity (FRC) of 15e20% compared to the value when awake and supine. In effect, the patient takes a prolonged expiration as they lose consciousness and when breathing recommences, this is from a lower lung volume. The reduction in FRC is similar in patients breathing spontaneously and those whose lungs are ventilated artificially, and is much greater in obese patients. 2 (ii) Formation of atelectasisIn older patients, the reduced FRC may be less than the closing capacity and so airway collapse will occur throughout the lung. Even if FRC remains above the closing capacity, the changes in chest wall and diaphragm shape commonly result in direct compression of lung tissue in the caudal and dependent regions behind the diaphragm. This leads to atelectasis in 75e90% of patients, which is easily detected by CT. There is some evidence that use of oxygen 100% at various stages of GA may exacerbate the formation of atelectasis. Blood flow through atelectasis constitutes an intrapulmonary pathological shunt and will adversely affect arterial oxygenation. The amount of shunt through these areas varies between individuals and is likely to be influenced by the efficacy of their hypoxic pulmonary vasoconstriction reflex. 3 This becomes particularly important during one-lung ventilation. Increasing F I O 2 will have no effect on this situation as the extra oxygen does not reach these closed lung regions. Atelectasis can be reduced at induction by avoiding oxygen 100%: in one study the use of 80 or 60% oxygen before induction reduced the atelectasis area on CT scans by 76 and 96%, respectively, compared with oxygen 100%. 4 Alternatively, use of moderate amounts of CPAP (6 cm H 2 O) before induction of anaesthesia prevents atelectasis formation. 5 During maintenance of anaesthesia the use of PEEP helps to limit the amount of atelectasis that forms, but once formed, a recruitment manoeuvre wi...

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High intraoperative inspiratory oxygen fraction and risk of major respiratory complications

Abstract: NCT02399878.

Cited by 145 publications

References 37 publications

Perioperative lung protective ventilation

Perioperative lung protective ventilation

Restrictive vs liberal oxygen for trauma patients‐the TRAUMOX1 pilot randomised clinical trial

Why do patients need extra oxygen during a general anaesthetic?

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