Pulse oximetry for the diagnosis and management of acute respiratory distress syndrome

Wick, Katherine D.; Matthay, Michael A.; Ware, Lorraine B.

doi:10.1016/s2213-2600(22)00058-3

Cited by 49 publications

(31 citation statements)

References 119 publications

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“…The main analysis compared three thresholds for initiation of invasive ventilation: saturation-to-inspired oxygen ratio (SF) of < 110, < 98, and < 88. We chose the SF ratio because it is a simple yet accurate measure of hypoxemia that is applicable to acute care settings worldwide, and can be measured without causing pain or discomfort to patients [ 36 , 37 ]. Lower SF values indicate more severe hypoxemia.…”

Section: Methodsmentioning

confidence: 99%

Oxygenation thresholds for invasive ventilation in hypoxemic respiratory failure: a target trial emulation in two cohorts

et al. 2023

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Background The optimal thresholds for the initiation of invasive ventilation in patients with hypoxemic respiratory failure are unknown. Using the saturation-to-inspired oxygen ratio (SF), we compared lower versus higher hypoxemia severity thresholds for initiating invasive ventilation. Methods This target trial emulation included patients from the Medical Information Mart for Intensive Care (MIMIC-IV, 2008–2019) and the Amsterdam University Medical Centers (AmsterdamUMCdb, 2003–2016) databases admitted to intensive care and receiving inspired oxygen fraction ≥ 0.4 via non-rebreather mask, noninvasive ventilation, or high-flow nasal cannula. We compared the effect of using invasive ventilation initiation thresholds of SF < 110, < 98, and < 88 on 28-day mortality. MIMIC-IV was used for the primary analysis and AmsterdamUMCdb for the secondary analysis. We obtained posterior means and 95% credible intervals (CrI) with nonparametric Bayesian G-computation. Results We studied 3,357 patients in the primary analysis. For invasive ventilation initiation thresholds SF < 110, SF < 98, and SF < 88, the predicted 28-day probabilities of invasive ventilation were 72%, 47%, and 19%. Predicted 28-day mortality was lowest with threshold SF < 110 (22.2%, CrI 19.2 to 25.0), compared to SF < 98 (absolute risk increase 1.6%, CrI 0.6 to 2.6) or SF < 88 (absolute risk increase 3.5%, CrI 1.4 to 5.4). In the secondary analysis (1,279 patients), the predicted 28-day probability of invasive ventilation was 50% for initiation threshold SF < 110, 28% for SF < 98, and 19% for SF < 88. In contrast with the primary analysis, predicted mortality was highest with threshold SF < 110 (14.6%, CrI 7.7 to 22.3), compared to SF < 98 (absolute risk decrease 0.5%, CrI 0.0 to 0.9) or SF < 88 (absolute risk decrease 1.9%, CrI 0.9 to 2.8). Conclusion Initiating invasive ventilation at lower hypoxemia severity will increase the rate of invasive ventilation, but this can either increase or decrease the expected mortality, with the direction of effect likely depending on baseline mortality risk and clinical context.

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Section: Methodsmentioning

confidence: 99%

Oxygenation thresholds for invasive ventilation in hypoxemic respiratory failure: a target trial emulation in two cohorts

et al. 2023

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“…We also looked at direct evidence from trials comparing patient outcomes using different SpO 2 target ranges. We explored literature regarding context-specific considerations that could impact the choice of best-practice SpO 2 range in LMICs, including the relative inaccuracy of pulse oximetry in patients with darker skin pigmentation and shock, the need to conserve oxygen resources for all patients ( 24 , 25 ), the lack of consistent access to arterial blood gases, which necessitates consideration of hypercapnic patients, and the impact of altitude on SpO 2 ( 26 – 28 ).…”

Section: Methodsmentioning

confidence: 99%

Oxygen saturation targets for adults with acute hypoxemia in low and lower-middle income countries: a scoping review with analysis of contextual factors

et al. 2023

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Knowing the target oxygen saturation (SpO2) range that results in the best outcomes for acutely hypoxemic adults is important for clinical care, training, and research in low-income and lower-middle income countries (collectively LMICs). The evidence we have for SpO2 targets emanates from high-income countries (HICs), and therefore may miss important contextual factors for LMIC settings. Furthermore, the evidence from HICs is mixed, amplifying the importance of specific circumstances. For this literature review and analysis, we considered SpO2 targets used in previous trials, international and national society guidelines, and direct trial evidence comparing outcomes using different SpO2 ranges (all from HICs). We also considered contextual factors, including emerging data on pulse oximetry performance in different skin pigmentation ranges, the risk of depleting oxygen resources in LMIC settings, the lack of access to arterial blood gases that necessitates consideration of the subpopulation of hypoxemic patients who are also hypercapnic, and the impact of altitude on median SpO2 values. This process of integrating prior study protocols, society guidelines, available evidence, and contextual factors is potentially useful for the development of other clinical guidelines for LMIC settings. We suggest that a goal SpO2 range of 90-94% is reasonable, using high-performing pulse oximeters. Answering context-specific research questions, such as an optimal SpO2 target range in LMIC contexts, is critical for advancing equity in clinical outcomes globally.

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“…It can be measured without blood sampling. (22,23) Clinically, the three target values correspond to steeper parts of the oxyhemoglobin dissociation curve at high inspired oxygen fractions. Using a non-linear formula to impute arterial-to-inspired oxygen ratios (PF), SF 88, 98, and 110 correspond to PF of at least 55, 68, and 85 mmHg.…”

Section: Strategiesmentioning

confidence: 97%

Costs, quality-adjusted life years, and value-of-information of different thresholds for the initiation of invasive ventilation in hypoxemic respiratory failure

Yarnell

Barrett

Heath

et al. 2023

Preprint

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Objective: To estimate costs, quality-adjusted life-years, and the value of undertaking a future randomized controlled trial for different oxygenation thresholds used to initiate invasive ventilation in hypoxemic respiratory failure. Design: Model-based cost-utility estimation with individual-level simulation and value-of-information analysis. Setting: Critical care units. Participants: Adults admitted to critical care receiving non-invasive oxygen. Interventions: We compared four strategies: initiation of invasive ventilation at thresholds of saturation-to-inspired oxygen fraction ratio (SF) < 110, < 98, or < 88, and usual care. Main results: An invasive ventilation initiation threshold of SF < 110, compared to usual care, resulted in more predicted invasive ventilation (62% vs 31%), hospital survival (78.4% vs 75.5%), quality-adjusted life years (QALYs) (8.48 vs 8.34), and lifetime costs (86,700 Canadian dollars (CAD) vs 75,600 CAD). Among the four strategies, threshold SF < 110 had the highest expected net monetary benefit (761,000 CAD), but there was significant uncertainty, because all four strategies had similar probability (range: 23.5% to 27.5%) of having the best net monetary benefit. The expected value to society over the next 10 years of a 400-person randomized trial of oxygenation thresholds was 4.27 billion CAD, and remained high (2.64 billion CAD) in a scenario analysis considering a hypothetical threshold that resulted in less invasive ventilation and similar survival compared to usual care. Conclusion: The preferred threshold to initiate invasive ventilation in hypoxemic respiratory failure is uncertain. It would be highly valuable to society to identify thresholds that, in comparison to usual care, either improve survival or reduce invasive ventilation without reducing survival.

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Pulse oximetry for the diagnosis and management of acute respiratory distress syndrome

Cited by 49 publications

References 119 publications

Oxygenation thresholds for invasive ventilation in hypoxemic respiratory failure: a target trial emulation in two cohorts

Oxygenation thresholds for invasive ventilation in hypoxemic respiratory failure: a target trial emulation in two cohorts

Oxygen saturation targets for adults with acute hypoxemia in low and lower-middle income countries: a scoping review with analysis of contextual factors

Costs, quality-adjusted life years, and value-of-information of different thresholds for the initiation of invasive ventilation in hypoxemic respiratory failure

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