Too Much Oxygen: Hyperoxia and Oxygen Management in Mechanically Ventilated Patients

Pannu, Sonal

doi:10.1055/s-0035-1570359

Cited by 27 publications

(22 citation statements)

References 43 publications

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“…35 High oxygen tension leads to the creation of reactive oxygen species that cause inflammation, edema, damage to cellular components, and cell death. 36,37 In air with high F IO 2 , nitrogen is replaced by oxygen, which washes out nitrogen from alveoli. Oxygen is then readily absorbed into the lung tissues, leading to alveolar collapse, absorptive atelectasis, and increased intrapulmonary shunting.…”

Section: Discussionmentioning

confidence: 99%

Mechanical Ventilation in Children on Venovenous ECMO

et al. 2020

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BACKGROUND: Venovenous extracorporeal membrane oxygenation (VV-ECMO) is used when mechanical ventilation can no longer support oxygenation or ventilation, or if the risk of ventilator-induced lung injury is considered excessive. The optimum mechanical ventilation strategy once on ECMO is unknown. We sought to describe the practice of mechanical ventilation in children on VV-ECMO and to determine whether mechanical ventilation practices are associated with clinical outcomes. METHODS: We conducted a multicenter retrospective cohort study in 10 pediatric academic centers in the United States. Children age 14 d through 18 y on VV-ECMO from 2011 to 2016 were included. Exclusion criteria were preexisting chronic respiratory failure, primary diagnosis of asthma, cyanotic heart disease, or ECMO as a bridge to lung transplant. RESULTS: Conventional mechanical ventilation was used in about 75% of children on VV-ECMO; the remaining subjects were managed with a variety of approaches. With the exception of PEEP, there was large variation in ventilator settings. Ventilator mode and pressure settings were not associated with survival. Mean ventilator F IO 2 on days 1-3 was higher in nonsurvivors than in survivors (0.5 vs 0.4, P 5 .009). In univariate analysis, other risk factors for mortality were female gender, higher Pediatric Risk Estimate Score for Children Using Extracorporeal Respiratory Support (Ped-RESCUERS), diagnosis of cancer or stem cell transplant, and number of days intubated prior to initiation of ECMO (all P < .05). In multivariate analysis, ventilator F IO 2 was significantly associated with mortality (odds ratio 1.38 for each 0.1 increase in F IO 2 , 95% CI 1.09-1.75). Mortality was higher in subjects on high ventilator F IO 2 (6 0.5) compared to low ventilator F IO 2 (> 0.5) (46% vs 22%, P 5 .001). CONCLUSIONS: Ventilator mode and some settings vary in practice. The only ventilator setting associated with mortality was F IO 2 , even after adjustment for disease severity. Ventilator F IO 2 is a modifiable setting that may contribute to mortality in children on VV-ECMO.

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Section: Discussionmentioning

confidence: 99%

Mechanical Ventilation in Children on Venovenous ECMO

et al. 2020

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“…Oxygenation, maintaining ventilation, and achieving ideal pulmonary gas exchange are particularly important. Practice has proven that high oxygen levels are harmful (2,3). The need for a small tidal volume in lung protective ventilation has been recognized (4,5).…”

Section: Introductionmentioning

confidence: 99%

Effects of Quality Control Targets (SpO2≠100%, PaCO2/<40 mmHg, Pmean/>10 cmH2O) on Outcomes in Patients in the ICU

Pan

Zhang

et al. 2020

Front. Med.

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Objectives: A series of quality control (QC) targets (SpO2 =100%, PaCO2≮40 mmHg, Pmean≯10 cmH2O) was put forward and widely used in a single intensive care unit (ICU) setting. The aim of this study was to assess whether these QC targets could improve the outcomes of critically ill patients. Methods: The real-time clinical data of patients undergoing mechanical ventilation at ICU admission between May 2013 and May 2017 in the Department of Critical Care Medicine of Peking Union Medical College Hospital were collected and analyzed. Results: A total of 7,670 patients [mean age, 58 years; 3,943 (51.5%) male] were divided into the before QC (n = 3,936) and after QC (n = 3,734) groups. QC targets (SpO2, PaCO2, and Pmean) and respiratory parameters (FiO2%, PaO2, PEEP, tidal volume, and respiratory rate) within 72 h of ICU admission, primary outcomes (ICU mortality, 28-, 60-, and 90-day mortality) and secondary outcomes (discharge against medical advice, ICU admission days, mechanical ventilation times, and central venous pressure) were measured and compared between the before and after QC groups. The 72 h average of the Pmean, FiO2%, PaO2, and VT were significantly lower and PaCO2 was higher in the after QC than in the before QC group (P < 0.05). A lower 90-day mortality rate, less discharge against medical advice, fewer ICU admission days, and reduced mechanical ventilation times were found in the after QC group compared with the before QC group (P < 0.05). Interestingly, CVP was significantly lower in the after QC group than in the before QC group (P < 0.05). Conclusions: The QC targets (SpO2 =100%, PaCO2≮40 mmHg, Pmean≯10 cmH2O) contributed to avoiding high oxygen level hazards, protecting against lung injury, and improving circulatory function, which resulted in a better prognosis of critically ill patients.

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“…Hyperoxia is a state of excess oxygen concentration, and hyperoxemia is the state of higher than normal arterial oxygen levels. 3 Administering oxygen at higher concentrations for prolonged periods of time is associated with longer hospital stay, long-term mortality, and an increased risk of death. 4 Hyperoxia is a well-known adverse effect of oxygen therapy, yet it is routinely underes-timated by most clinicians.…”

Section: Introductionmentioning

confidence: 99%

“…Observational studies have reported that subjects in the ICU are regularly managed with excessive F IO 2 and remain hyperoxemic for long periods of time. 2,3 Oxygen-weaning protocols and guidelines are designed to pace the titration of oxygen therapy to prevent complications and improve outcomes. 5 Applying the steps of a weaning protocol is essential to improve patient outcomes.…”

Section: Introductionmentioning

confidence: 99%

Adherence to an Oxygen-Weaning Protocol in Mechanically Ventilated Adults in the Medical ICU

et al. 2020

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BACKGROUND: Patients undergoing mechanical ventilation in the ICU often receive supplemental oxygen. If not closely monitored, this may lead to hyperoxia. The use of an oxygen-weaning protocol may reduce this risk by pacing the titration of oxygen therapy to patient needs. ICU protocols are correlated with decreased mortality and length of stay and have great potential for cost savings. The goals of this study were to determine whether the oxygen-weaning protocol at a university-affiliated hospital was followed and to measure the length of time respiratory therapists took to wean patients once the oxygen-weaning parameters were met. METHODS: This was a retrospective chart review of subjects > 18 y of age admitted to the medical ICU who underwent intubation and mechanical ventilation and were placed on an oxygen therapy protocol. The following data were collected: demographics, arterial blood gases, the length of time to change F IO 2 after meeting weaning parameters, and the percent change in F IO 2. RESULTS: Data were collected from 30 subjects. The most common oxygen saturation parameter measured via pulse oximetry (S pO 2) used to initiate weaning oxygen was 92%. The mean 6 SD F IO 2 administered to subjects was 39.6 6 15.3% prior to extubation. The majority of subjects exhibited adequate oxygenation prior to extubation (mean 6 SD): P aO 2 99.3 6 6.7 mm Hg, S aO 2 95.1 6 26.9%. The mean 6 SD length of time to the first change in F IO 2 from the time a subject met the weaning criteria was 9.1 6 10.6 h (range 1-39 h; interquartile range 2-13 h). CONCLUSIONS: Subjects admitted to the medical ICU who were intubated, mechanically ventilated, and placed on the oxygen therapy protocol experienced a significant delay in oxygen weaning. Closer monitoring and adherence to the oxygen-weaning protocol should be considered to reduce the potential risk for hyperoxia. Key words: oxygen weaning; weaning protocols; oxygen titration protocol; patient-driven protocols; protocol adherence; weaning indices.

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Too Much Oxygen: Hyperoxia and Oxygen Management in Mechanically Ventilated Patients

Cited by 27 publications

References 43 publications

Mechanical Ventilation in Children on Venovenous ECMO

Mechanical Ventilation in Children on Venovenous ECMO

Effects of Quality Control Targets (SpO2≠100%, PaCO2/<40 mmHg, Pmean/>10 cmH2O) on Outcomes in Patients in the ICU

Adherence to an Oxygen-Weaning Protocol in Mechanically Ventilated Adults in the Medical ICU

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