Scientific Letter
Oxygen therapy. Considerations regarding its use in acute ill patients
Oxigenoterapia. Consideraciones sobre su uso en el enfermo agudo
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Consideraciones sobre su uso en el enfermo agudo" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "102" "paginaFinal" => "103" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Oxygen Therapy. Considerations Regarding its Use in Acute Ill Patients" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1103 "Ancho" => 1508 "Tamanyo" => 98722 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Valores de mortalidad hospitalaria según PaO<span class="elsevierStyleInf">2</span> (mmHg). Los tamaños de los círculos representan el número de pacientes con el mismo valor de PaO<span class="elsevierStyleInf">2</span>. 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Consideraciones sobre su uso en el enfermo agudo" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "102" "paginaFinal" => "103" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Oxygen Therapy. Considerations Regarding its Use in Acute Ill Patients" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1103 "Ancho" => 1508 "Tamanyo" => 98722 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Valores de mortalidad hospitalaria según PaO<span class="elsevierStyleInf">2</span> (mmHg). 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Tomado de De Jonge et al.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> con autorización.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "José Manuel Valencia Gallardo, Jordi Solé Violán, Felipe Rodríguez de Castro" "autores" => array:3 [ 0 => array:2 [ "nombre" => "José Manuel" "apellidos" => "Valencia Gallardo" ] 1 => array:2 [ "nombre" => "Jordi" "apellidos" => "Solé Violán" ] 2 => array:2 [ "nombre" => "Felipe" "apellidos" => "Rodríguez de Castro" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S1579212921003918" "doi" => "10.1016/j.arbr.2021.10.017" "estado" => "S200" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212921003918?idApp=UINPBA00003Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289621001228?idApp=UINPBA00003Z" "url" => "/03002896/0000005800000001/v1_202201130549/S0300289621001228/v1_202201130549/es/main.assets" ] ] "en" => array:16 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific Letter</span>" "titulo" => " Oxygen therapy. Considerations regarding its use in acute ill patients" "tieneTextoCompleto" => true "saludo" => "To the Director:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "T102" "paginaFinal" => "T103" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "José Manuel Valencia Gallardo, Jordi Solé Violán, Felipe Rodríguez de Castro" "autores" => array:3 [ 0 => array:4 [ "nombre" => "José Manuel" "apellidos" => "Valencia Gallardo" "email" => array:1 [ 0 => "jvalgal@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Jordi" "apellidos" => "Solé Violán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Felipe" "apellidos" => "Rodríguez de Castro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Neumología, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Oxigenoterapia. Consideraciones sobre su uso en el enfermo agudo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1103 "Ancho" => 1508 "Tamanyo" => 95161 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">In-hospital mortality values, on average, according to PaO<span class="elsevierStyleInf">2</span> (mmHg). The size of the circles represents the number of patients with the same PaO<span class="elsevierStyleInf">2</span> value. Adapted from De Jonge et al.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> with permission.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The current SARS-CoV-2 pandemic offers an opportunity to reflect on the use of oxygen therapy in the management of acute respiratory failure that often accompanies Covid-19. At a time when scientific evidence filters all clinical practice, it is easy to see that oxygen therapy is often implemented in patients with acute respiratory failure with no real scientific basis<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Retrospective studies already show that excessive oxygen use does not improve the prognosis of critically ill patients, and that hyperoxia is associated with higher mortality<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a>. In the 1970s, Douglas et al.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> found that high oxygen levels (FiO<span class="elsevierStyleInf">2</span> > 0.7) increased pulmonary venous admixture due to the appearance of absorption atelectasis and the suppression of the hypoxic pulmonary vasoconstriction reflex. Other authors have shown that lower FiO<span class="elsevierStyleInf">2</span> levels (even only 0.3) can cause the same alterations in patients with pre-existing lung disease<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Excessive oxygen intake can impair gas exchange by increasing oxidative stress and inflammation (the Lorrain-Smith effect). In the current epidemiological context, oxidative stress has been placed in the spotlight by the recent description of the hypercytokinemia associated with SARS-CoV-2 pneumonia<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>. Excessive doses of oxygen increase the production of reactive nitrogen and oxygen species (RNS, ROS), the recruitment and activation of inflammatory cells, and the release of pro-inflammatory mediators (IL-1α, IL-6, IL-8, or TNF-α), with local (lung damage and infection and sepsis) and distant (tissue damage and multiorgan failure) consequences. Although these effects are magnified when high FiO<span class="elsevierStyleInf">2</span> levels are maintained for prolonged periods (>12–24 h), shorter periods of hyperoxia are also associated with increased morbidity and mortality<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>. Hyperoxia, then, could be an indirect marker of poor prognosis in severe patients<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Paradoxically, hyperoxia can reduce systemic oxygen consumption, probably due to the redistribution of blood flow to protect vital organs from the non-physiological effects of high FiO<span class="elsevierStyleInf">2</span> (functional shunt). Higher than normal levels of PaO<span class="elsevierStyleInf">2</span> also trigger arteriolar vasoconstriction by local mechanisms, a phenomenon that could explain the worse progress of some patients with myocardial infarction, stroke, head injury, cardiac arrest, or sepsis. Tissue hyperoxia, furthermore, promotes lesion development in ischemia-reperfusion situations<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In short, hyperoxia can be as dangerous as hypoxemia. A multicenter retrospective study of 36,307 patients hospitalized in intensive care units (ICU) showed that PaO<span class="elsevierStyleInf">2</span> during the first 24 hours of admission was an independent predictor of hospital mortality<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>. PaO<span class="elsevierStyleInf">2</span>-related mortality formed an asymmetric U with a clear plateau at the end of the lowest PaO<span class="elsevierStyleInf">2</span> values, linear increase on the hyperoxia side, and lowest mortality rates at a PaO<span class="elsevierStyleInf">2</span> value between 110 and 150 mmHg (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">When expressed as a standardized mortality ratio<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>, hyperoxia was a predictor of mortality at PaO<span class="elsevierStyleInf">2</span> values >125 mmHg.</p><p id="par0035" class="elsevierStylePara elsevierViewall">A recent clinical trial in patients with septic shock had to be discontinued prematurely after evidence emerged of excess in-hospital mortality in hyperoxic patients<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>. Hyperoxia also appears to be of little benefit during recovery after cardiac arrest. Helmerhorst et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> showed in an observational study that in-hospital mortality after cardiorespiratory arrest was the same as in patients with normal oxygen levels (PaO<span class="elsevierStyleInf">2</span> 55–80 mmHg).</p><p id="par0040" class="elsevierStylePara elsevierViewall">Hyperoxia does not benefit patients with severe acute respiratory failure. The effect of exposure to excess FiO<span class="elsevierStyleInf">2</span> (FiO<span class="elsevierStyleInf">2</span> > 0.5 when PaO<span class="elsevierStyleInf">2</span> was >80 mmHg) was analyzed in a study in 2994 patients with acute respiratory distress syndrome (ARDS). This study found that the higher the cumulative exposure at 5 days, the higher the mortality, the number of days with mechanical ventilation, and the length of hospital stay. Mortality also affected patients with mild, moderate, or severe ARDS, which meant that the relationship observed between mortality and cumulative exposure to high FiO<span class="elsevierStyleInf">2</span> was independent of disease severity<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>. A recent multicenter randomized trial in patients with ARDS confirmed that controlled oxygen therapy (PaO<span class="elsevierStyleInf">2</span> 55–70 mmHg or SpO<span class="elsevierStyleInf">2</span> 88%–92%) did not increase mortality at 28 days<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Evidence in patients with acute chronic respiratory failure also supports controlling SpO<span class="elsevierStyleInf">2</span> values. Plant et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> showed that excessive use of oxygen therapy in patients with chronic obstructive pulmonary disease exacerbations was associated with respiratory acidosis and a greater number of ICU admissions. The authors pointed out that therapy should focus on maintaining PaO<span class="elsevierStyleInf">2</span> and SaO<span class="elsevierStyleInf">2</span> at 55–75 mmHg and SaO<span class="elsevierStyleInf">2</span> 85–92%, respectively. A subsequent controlled trial showed higher mortality among patients receiving oxygen therapy not adjusted to achieve SaO<span class="elsevierStyleInf">2</span> values of 88%–92%<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Acute respiratory care should, therefore, focus on improving lung function with the proper use of oxygen therapy, an approach that differs considerably from standard practice. Unnecessarily high FiO<span class="elsevierStyleInf">2</span> levels reduce the window of opportunity for switching treatment or adjusting FiO<span class="elsevierStyleInf">2</span> levels in the case of worsening respiratory status<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>. In acutely hypoxic patients, an SpO<span class="elsevierStyleInf">2</span> of 90%–94% seems to be a reasonable range. It accommodates normal fluctuations and is safe enough to prevent damage. High-flow systems (e.g., Venturi masks) that can be adjusted to achieve stable FiO<span class="elsevierStyleInf">2</span> are recommended for oxygen administration. The idea of setting a minimum PaO<span class="elsevierStyleInf">2</span> value to avoid tissue hypoxia should be discarded, and emphasis should be placed on setting a maximum safety value to avoid systemic toxicity (PaO<span class="elsevierStyleInf">2</span> <120 mmHg). In patients with hypercapnic respiratory failure, the SpO<span class="elsevierStyleInf">2</span> ranges should be lower (88%–92%) and ventilatory support (preferably non-invasive mechanical ventilation) should be considered if greater oxygen transport is needed (e.g., associated failure of other organs) or if hypercapnia persists despite controlled FiO<span class="elsevierStyleInf">2</span> (0.24–0.4). High-flow nasal cannula may be an alternative or a supplement to non-invasive mechanical ventilation in more severe patients<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>. In the specific case of patients with chronic obstructive pulmonary disease exacerbations, some guidelines recommend a maximum FiO<span class="elsevierStyleInf">2</span> of 0.28, a practice that is also advisable in the prehospital setting<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>. In the absence of hypoxemia, oxygen therapy should be avoided in patients with acute myocardial infarction, stroke, head injury, after cardiorespiratory arrest, and in patients with sepsis. In patients admitted to the ICU, restrictive oxygen therapy protocols (aimed at maintaining PaO<span class="elsevierStyleInf">2</span> within the physiological range) are well tolerated and may improve prognosis<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In conclusion, a more liberal oxygen prescription is at odds with modern requirements for the development and approval of a treatment of any type. The use of automated oxygen flow titration devices could improve morbidity and mortality and reduce care costs, although they are unlikely to replace clinical monitoring<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>. In the meantime, we must stress that oxygen is a drug that must be prescribed for defined indications where the benefits outweigh the risks, and that the dose, the delivery system, the duration of administration, and response monitoring must be clearly specified<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have not received funding for this study.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interests</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interests" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Valencia Gallardo JM, Solé Violán J, Rodríguez de Castro F. Oxigenoterapia. Consideraciones sobre su uso en el enfermo agudo. Arch Bronconeumol. 2022;58:102–3.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1103 "Ancho" => 1508 "Tamanyo" => 95161 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">In-hospital mortality values, on average, according to PaO<span class="elsevierStyleInf">2</span> (mmHg). The size of the circles represents the number of patients with the same PaO<span class="elsevierStyleInf">2</span> value. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 3 | 14 |
| 2024 October | 96 | 15 | 111 |
| 2024 September | 103 | 17 | 120 |
| 2024 August | 104 | 49 | 153 |
| 2024 July | 55 | 20 | 75 |
| 2024 June | 67 | 20 | 87 |
| 2024 May | 112 | 32 | 144 |
| 2024 April | 58 | 19 | 77 |
| 2024 March | 57 | 12 | 69 |
| 2024 February | 48 | 32 | 80 |
| 2024 January | 51 | 28 | 79 |
| 2023 December | 47 | 18 | 65 |
| 2023 November | 79 | 15 | 94 |
| 2023 October | 61 | 26 | 87 |
| 2023 September | 76 | 33 | 109 |
| 2023 August | 74 | 27 | 101 |
| 2023 July | 74 | 19 | 93 |
| 2023 June | 86 | 16 | 102 |
| 2023 May | 80 | 15 | 95 |
| 2023 April | 176 | 20 | 196 |
| 2023 March | 144 | 18 | 162 |
| 2023 February | 150 | 20 | 170 |
| 2023 January | 117 | 36 | 153 |
| 2022 December | 146 | 27 | 173 |
| 2022 November | 185 | 31 | 216 |
| 2022 October | 168 | 46 | 214 |
| 2022 September | 225 | 26 | 251 |
| 2022 August | 103 | 38 | 141 |
| 2022 July | 202 | 59 | 261 |
| 2022 June | 249 | 45 | 294 |
| 2022 May | 240 | 37 | 277 |
| 2022 April | 205 | 52 | 257 |
| 2022 March | 202 | 56 | 258 |
| 2022 February | 164 | 20 | 184 |
| 2022 January | 22 | 4 | 26 |
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