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Martin DS, Shahid T, Gould DW, Richards-Belle A, Doidge JC, Camsooksai J, Charles WN, Davey M, Francis Johnson A, Garrett RM, Grocott MPW, Jones J, Lampro L, Miller L, O’Driscoll BR, Rostron AJ, Sadique Z, Szakmany T, Young PJ, Rowan KM, Harrison DA, Mouncey PR. Evaluating the clinical and cost-effectiveness of a conservative approach to oxygen therapy for invasively ventilated adults in intensive care: Protocol for the UK-ROX trial. J Intensive Care Soc 2024; 25:223-230. [PMID: 38737312 PMCID: PMC11086723 DOI: 10.1177/17511437241239880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024] Open
Abstract
Background In the United Kingdom, around 184,000 adults are admitted to an intensive care unit (ICU) each year with over 30% receiving mechanical ventilation. Oxygen is the commonest therapeutic intervention provided to these patients but it is unclear how much oxygen should be administered for the best clinical outcomes. Methods The UK-ROX trial will evaluate the clinical and cost-effectiveness of conservative oxygen therapy (the minimum oxygen concentration required to maintain an oxygen saturation of 90% ± 2%) versus usual oxygen therapy in critically ill adults receiving supplemental oxygen when invasively mechanically ventilated in ICUs in England, Wales and Northern Ireland. The trial will recruit 16,500 patients from approximately 100 UK adult ICUs. Using a deferred consent model, enrolled participants will be randomly allocated (1:1) to conservative or usual oxygen therapy until ICU discharge or 90 days after randomisation. Objectives The primary clinical outcome is all cause mortality at 90 days following randomisation. Discussion The UK-ROX trial has received ethical approval from the South Central - Oxford C Research Ethics Committee (Reference: 20/SC/0423) and the Confidentiality Advisory Group (Reference: 22/CAG/0154). The trial commenced in May 2021 and, at the time of publication, 95 sites had opened to recruitment.
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Affiliation(s)
- Daniel S Martin
- Peninsula Medical School, University of Plymouth, Plymouth, UK
- Intensive Care Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Tasnin Shahid
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), Napier House, London, UK
| | - Doug W Gould
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), Napier House, London, UK
| | - Alvin Richards-Belle
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), Napier House, London, UK
| | - James C Doidge
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), Napier House, London, UK
| | - Julie Camsooksai
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), Napier House, London, UK
| | - Walton N Charles
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), Napier House, London, UK
| | - Miriam Davey
- Critical Care, Maidstone and Tunbridge Wells NHS Foundation Trust, Kent, UK
| | - Amelia Francis Johnson
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), Napier House, London, UK
| | | | - Michael PW Grocott
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton, UK
| | - Joanne Jones
- Critical Care, Maidstone and Tunbridge Wells NHS Foundation Trust, Kent, UK
| | - Lamprini Lampro
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), Napier House, London, UK
| | - Lorna Miller
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), Napier House, London, UK
| | - B Ronan O’Driscoll
- Respiratory Medicine, Northern Care Alliance NHS Foundation Trust, Salford Royal University Hospital, Salford, UK
| | - Anthony J Rostron
- Integrated Critical Care Unit, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Tamas Szakmany
- Critical Care, Aneurin Bevan University Health Board, Cwmbran, UK
| | - Paul J Young
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - Kathryn M Rowan
- Intensive Care Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - David A Harrison
- Intensive Care Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Paul R Mouncey
- Intensive Care Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
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Li XY, Dai B, Hou HJ, Zhao HW, Wang W, Kang J, Tan W. Conservative versus liberal oxygen therapy for intensive care unit patients: meta-analysis of randomized controlled trials. Ann Intensive Care 2024; 14:68. [PMID: 38668955 PMCID: PMC11052962 DOI: 10.1186/s13613-024-01300-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/19/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND It remains unclear whether conservative oxygen therapy (COT) or liberal oxygen therapy (LOT) is more beneficial to the clinical outcomes of intensive care unit (ICU) patients. We systematically reviewed the efficacy and safety of conservative versus liberal oxygen therapy for ICU patients. METHODS We systematically searched PubMed, Embase, Web of Science, Scopus, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, MedRxiv, and BioRxiv for reports on randomized controlled trials (RCTs) that compared the effects of COT versus LOT on the clinical outcomes of ICU patients published in English before April 2024. The primary outcome was the mortality rate, secondary outcomes included ICU and hospital length of stay, days free from mechanical ventilation support (MVF), vasopressor-free time (VFT), and adverse events. RESULTS In all, 13 RCTs involving 10,632 patients were included in analyses. Meta-analysis showed COT did not reduce mortality at 30-day (risk ratio [RR] = 1.01, 95% confidence interval [CI] 0.94 to 1.09, I2 = 42%, P = 0.78), 90-day (RR = 1.01, 95% CI 0.95 to 1.08, I2 = 9%, P = 0.69), or longest follow-up (RR = 1.00, 95% CI 0.95 to 1.06, I2 = 22%, P = 0.95) compared to LOT in ICU patients. In subgroup analyses, no significant difference was observed between the two groups in terms of the different ICU, baseline P/F, and actual PaO2. In addition, COT did not affect ICU length of stay, hospital length of stay, or VFT, it only affected MVF days. CONCLUSIONS COT did not reduce all-cause mortality in ICU patients. Further RCTs are urgently needed to confirm the impact of COT strategy on specific populations.
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Affiliation(s)
- Xin-Yu Li
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, No.155, Nanjing North Street, Heping District, Shenyang, China
| | - Bing Dai
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, No.155, Nanjing North Street, Heping District, Shenyang, China
| | - Hai-Jia Hou
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, No.155, Nanjing North Street, Heping District, Shenyang, China
| | - Hong-Wen Zhao
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, No.155, Nanjing North Street, Heping District, Shenyang, China
| | - Wei Wang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, No.155, Nanjing North Street, Heping District, Shenyang, China
| | - Jian Kang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, No.155, Nanjing North Street, Heping District, Shenyang, China
| | - Wei Tan
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, No.155, Nanjing North Street, Heping District, Shenyang, China.
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Møller MH, Granholm A, Al Duhailib Z, Alhazzani W, Belley-Cote E, Oczkowski S, Vijayaraghavan BKT, Sjövall F, Butler E, Zampieri FG, Mac Sweeney R, Derde LPG, Ruzycki-Chadwick A, Mer M, Burns KEA, Ergan B, Al-Fares A, Sjoding MW, Valley TS, Rasmussen BS, Schjørring OL, Prescott HC. Higher versus lower oxygenation targets in adult ICU patients: A rapid practice guideline. Acta Anaesthesiol Scand 2024; 68:302-310. [PMID: 38140827 DOI: 10.1111/aas.14366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/17/2023] [Accepted: 12/01/2023] [Indexed: 12/24/2023]
Abstract
The aim of this Intensive Care Medicine Rapid Practice Guideline (ICM-RPG) was to provide evidence-based clinical guidance about the use of higher versus lower oxygenation targets for adult patients in the intensive care unit (ICU). The guideline panel comprised 27 international panelists, including content experts, ICU clinicians, methodologists, and patient representatives. We adhered to the methodology for trustworthy clinical practice guidelines, including the use of the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty of evidence, and used the Evidence-to-Decision framework to generate recommendations. A recently published updated systematic review and meta-analysis constituted the evidence base. Through teleconferences and web-based discussions, the panel provided input on the balance and magnitude of the desirable and undesirable effects, the certainty of evidence, patients' values and preferences, costs and resources, equity, feasibility, acceptability, and research priorities. The updated systematic review and meta-analysis included data from 17 randomized clinical trials with 10,248 participants. There was little to no difference between the use of higher versus lower oxygenation targets for all outcomes with available data, including all-cause mortality, serious adverse events, stroke, functional outcomes, cognition, and health-related quality of life (very low certainty of evidence). The panel felt that values and preferences, costs and resources, and equity favored the use of lower oxygenation targets. The ICM-RPG panel issued one conditional recommendation against the use of higher oxygenation targets: "We suggest against the routine use of higher oxygenation targets in adult ICU patients (conditional recommendation, very low certainty of evidence). Remark: an oxygenation target of SpO2 88%-92% or PaO2 8 kPa/60 mmHg is relevant and safe for most adult ICU patients."
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Affiliation(s)
- Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Guidelines in Intensive Care Medicine, Development and Evaluation (GUIDE) Group, Hamilton, Canada
| | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Guidelines in Intensive Care Medicine, Development and Evaluation (GUIDE) Group, Hamilton, Canada
| | - Zainab Al Duhailib
- Guidelines in Intensive Care Medicine, Development and Evaluation (GUIDE) Group, Hamilton, Canada
- Critical Care Medicine Department, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Waleed Alhazzani
- Guidelines in Intensive Care Medicine, Development and Evaluation (GUIDE) Group, Hamilton, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Emilie Belley-Cote
- Guidelines in Intensive Care Medicine, Development and Evaluation (GUIDE) Group, Hamilton, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Simon Oczkowski
- Guidelines in Intensive Care Medicine, Development and Evaluation (GUIDE) Group, Hamilton, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Fredrik Sjövall
- Department for Intensive and Perioperative Care, Skane University Hospital, Malmö, Sweden
- Department for Clinical sciences, Lund University, Lund, Sweden
| | - Ethan Butler
- Department of Intensive Care, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Fernando G Zampieri
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Alberta Health Services, Edmonton, Alberta, Canada
| | - Rob Mac Sweeney
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
| | - Lennie P G Derde
- Intensive Care Center, Division Vital Functions, University Medical Center Utrecht, Utrecht, the Netherlands
- Julius Center for Health Sciences and Primary Care, Utrecht, the Netherlands
| | - Ally Ruzycki-Chadwick
- Department of Respiratory Therapy General Site, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Mervyn Mer
- Department of Medicine, Divisions of Critical Care and Pulmonology, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Karen E A Burns
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto-St. Michael's Hospital, Toronto, Ontario, Canada
| | - Begüm Ergan
- Department of Pulmonary and Critical Care, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey
| | - Abdulrahman Al-Fares
- Department of Anesthesia, Critical Care Medicine and Pain Medicine, Al-Amiri Hospital, Minister of Health, Kuwait City, Kuwait
- Kuwait Extracorporeal Life Support Program, Al-Amiri Center for Advance Respiratory and Cardiac Failure, Ministry of Health, Kuwait City, Kuwait
| | - Michael W Sjoding
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Thomas S Valley
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- VA Center for Clinical Management Research, Ann Arbor, Michigan, USA
| | - Bodil S Rasmussen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Olav L Schjørring
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Hallie C Prescott
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- VA Center for Clinical Management Research, Ann Arbor, Michigan, USA
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Martin DS, Mckenna HT, Rowan KM, Gould DW, Mouncey PR, Grocott MPW, Harrison DA. The effect of conservative oxygen therapy on mortality in adult critically ill patients: A systematic review and meta-analysis of randomised controlled trials. J Intensive Care Soc 2023; 24:399-408. [PMID: 37841302 PMCID: PMC10572476 DOI: 10.1177/17511437231192385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023] Open
Abstract
Background Oxygen is the commonest intervention provided to critically ill patients requiring mechanical ventilation. Despite this, it is unclear how much oxygen should be administered to patients in order to promote the best clinical outcomes and it has been suggested that a strategy of conservative oxygen therapy (COT) may be advantageous. We therefore sought to answer the question of whether COT versus usual or liberal oxygen therapy was beneficial to adult patients receiving mechanical ventilation on an intensive care unit (ICU) by performing a systematic review and meta-analysis. Methods Studies were included if they were randomised controlled trials comparing COT to liberal or usual oxygen therapy strategies in acutely ill adults (aged ⩾18 years) admitted to an ICU, and reported an outcome of interest. Studies were excluded if they were limited to a specific single disease diagnosis. The review was registered on PROSPERO (CRD42022308436). Risk of bias was assessed using a modified Cochrane Risk of Bias assessment tool. Effect estimates were pooled using a random effects model with the between study variance estimated using restricted maximum likelihood and standard errors calculated using the method of Hartung-Knapp/Sidik-Jonkman. Between study heterogeneity was quantified using the I2 statistic. The certainty in the body of evidence was assessed using GRADE criteria. Results Nine eligible studies with 5727 participants fulfilled all eligibility criteria. Trials varied in their definitions of COT and liberal or usual oxygen therapy. The pooled estimate of risk ratio for 90 day mortality for COT versus comparator was 0.99 (95% confidence interval 0.88-1.12, 95% prediction interval 0.82-1.21). There was low heterogeneity among studies (I2 = 22.4%). The finding that mortality was similar for patients managed with COT or usual/liberal oxygen therapy was graded as moderate certainty. Conclusions In critically ill adults admitted to an ICU, COT is neither beneficial nor harmful when compared to usual or liberal oxygen therapy. Trials to date have been inconsistent in defining both COT and liberal or usual oxygen therapy, which may have had an impact on the results of this meta-analysis. Future research should focus on unifying definitions and outcome measures.
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Affiliation(s)
- Daniel S Martin
- Peninsula Medical School, University of Plymouth, Plymouth, UK
- Intensive Care Unit, University Hospitals Plymouth, Plymouth, UK
| | - Helen T Mckenna
- Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Kathryn M Rowan
- Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - Doug W Gould
- Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - Paul R Mouncey
- Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - Michael PW Grocott
- Clinical & Experimental Sciences, University of Southampton, Southampton, UK
| | - David A Harrison
- Intensive Care National Audit & Research Centre (ICNARC), London, UK
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Jiang X, Qiu D. Effects of Conservative Oxygen Therapy versus Conventional Oxygen Therapy on the Mortality in ICU Patients: A Meta-Analysis. Can Respir J 2023; 2023:7023712. [PMID: 37868784 PMCID: PMC10590270 DOI: 10.1155/2023/7023712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 09/10/2023] [Accepted: 09/27/2023] [Indexed: 10/24/2023] Open
Abstract
Objective To compare the effects of conservative oxygen therapy and conventional oxygen therapy on the mortality of critically ill patients in ICU. Methods Searching for randomized controlled clinical trials (RCT) on the effect of conservative oxygen therapy and conventional oxygen therapy on the mortality of critically ill patients in computer databases, including PubMed, Embase, Cochrane Library, CNKI, VIP, and Wanfang, with postdate before August 2022. We have two researchers evaluating the quality of the literature included and extracting data as per the inclusion and exclusion criteria and then analyzed it with RevMan 5.4 statistical software. Primary outcome included short-term mortality (28-day mortality or ICU mortality); secondary outcome included 90-day mortality, ICU length of stay, hospital length of stay, incidence of new organ dysfunction in ICU, incidence of new infection in ICU, and incidence of ICUAW. Results A total of 5779 subjects were included in 10 articles, including 2886 in the conservative oxygen therapy group and 2893 in the conventional oxygen therapy group. The meta-analysis showed that conservative oxygen therapy had an advantage over conventional oxygen therapy in terms of short-term mortality (P=0.03). Subgroup analysis based on different conservative oxygen targets showed that this advantage was statistically significant when the target is set above 90% (RR = 0.76, 95% CI = 0.62∼0.94, P=0.01), while there was no significant difference between conservative oxygen therapy and conventional oxygen therapy when the target is set below 90% (RR = 0.95, 95% CI = 0.79∼1.16, P=0.63). In addition, in terms of the incidence of new infections in the ICU (P=0.03) and the incidence of ICUAW (P=0.03), conservative oxygen therapy also had advantages over conventional oxygen therapy, and the difference was statistically significant. But in terms of 90-day mortality (P=0.61), ICU length of stay (P=0.96), hospital length of stay (P=0.47), and incidence of new organ dysfunction in ICU (P=0.61), there was no significant difference between conservative oxygen therapy and conventional oxygen therapy. Conclusion Compared with conventional oxygen therapy, conservative oxygen therapy can reduce the short-term mortality of severe patients, especially when the conservative oxygen therapy target is set above 90%. And it can also reduce the incidence of ICU new infections and ICUAW, while having no effect on 90-day mortality, ICU length of stay, and hospital length of stay.
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Affiliation(s)
- Xinyu Jiang
- The First Affiliated Hospital of Soochow University, Suzhou 215006, China
| | - Dong Qiu
- The First Affiliated Hospital of Soochow University, Suzhou 215006, China
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Klitgaard TL, Schjørring OL, Nielsen FM, Meyhoff CS, Perner A, Wetterslev J, Rasmussen BS, Barbateskovic M. Higher versus lower fractions of inspired oxygen or targets of arterial oxygenation for adults admitted to the intensive care unit. Cochrane Database Syst Rev 2023; 9:CD012631. [PMID: 37700687 PMCID: PMC10498149 DOI: 10.1002/14651858.cd012631.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
BACKGROUND This is an updated review concerning 'Higher versus lower fractions of inspired oxygen or targets of arterial oxygenation for adults admitted to the intensive care unit'. Supplementary oxygen is provided to most patients in intensive care units (ICUs) to prevent global and organ hypoxia (inadequate oxygen levels). Oxygen has been administered liberally, resulting in high proportions of patients with hyperoxemia (exposure of tissues to abnormally high concentrations of oxygen). This has been associated with increased mortality and morbidity in some settings, but not in others. Thus far, only limited data have been available to inform clinical practice guidelines, and the optimum oxygenation target for ICU patients is uncertain. Because of the publication of new trial evidence, we have updated this review. OBJECTIVES To update the assessment of benefits and harms of higher versus lower fractions of inspired oxygen (FiO2) or targets of arterial oxygenation for adults admitted to the ICU. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Science Citation Index Expanded, BIOSIS Previews, and LILACS. We searched for ongoing or unpublished trials in clinical trial registers and scanned the reference lists and citations of included trials. Literature searches for this updated review were conducted in November 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared higher versus lower FiO2 or targets of arterial oxygenation (partial pressure of oxygen (PaO2), peripheral or arterial oxygen saturation (SpO2 or SaO2)) for adults admitted to the ICU. We included trials irrespective of publication type, publication status, and language. We excluded trials randomising participants to hypoxaemia (FiO2 below 0.21, SaO2/SpO2 below 80%, or PaO2 below 6 kPa) or to hyperbaric oxygen, and cross-over trials and quasi-randomised trials. DATA COLLECTION AND ANALYSIS Four review authors independently, and in pairs, screened the references identified in the literature searches and extracted the data. Our primary outcomes were all-cause mortality, the proportion of participants with one or more serious adverse events (SAEs), and quality of life. We analysed all outcomes at maximum follow-up. Only three trials reported the proportion of participants with one or more SAEs as a composite outcome. However, most trials reported on events categorised as SAEs according to the International Conference on Harmonisation Good Clinical Practice (ICH-GCP) criteria. We, therefore, conducted two analyses of the effect of higher versus lower oxygenation strategies using 1) the single SAE with the highest reported proportion in each trial, and 2) the cumulated proportion of participants with an SAE in each trial. Two trials reported on quality of life. Secondary outcomes were lung injury, myocardial infarction, stroke, and sepsis. No trial reported on lung injury as a composite outcome, but four trials reported on the occurrence of acute respiratory distress syndrome (ARDS) and five on pneumonia. We, therefore, conducted two analyses of the effect of higher versus lower oxygenation strategies using 1) the single lung injury event with the highest reported proportion in each trial, and 2) the cumulated proportion of participants with ARDS or pneumonia in each trial. We assessed the risk of systematic errors by evaluating the risk of bias in the included trials using the Risk of Bias 2 tool. We used the GRADEpro tool to assess the overall certainty of the evidence. We also evaluated the risk of publication bias for outcomes reported by 10b or more trials. MAIN RESULTS We included 19 RCTs (10,385 participants), of which 17 reported relevant outcomes for this review (10,248 participants). For all-cause mortality, 10 trials were judged to be at overall low risk of bias, and six at overall high risk of bias. For the reported SAEs, 10 trials were judged to be at overall low risk of bias, and seven at overall high risk of bias. Two trials reported on quality of life, of which one was judged to be at overall low risk of bias and one at high risk of bias for this outcome. Meta-analysis of all trials, regardless of risk of bias, indicated no significant difference from higher or lower oxygenation strategies at maximum follow-up with regard to mortality (risk ratio (RR) 1.01, 95% confidence interval (C)I 0.96 to 1.06; I2 = 14%; 16 trials; 9408 participants; very low-certainty evidence); occurrence of SAEs: the highest proportion of any specific SAE in each trial RR 1.01 (95% CI 0.96 to 1.06; I2 = 36%; 9466 participants; 17 trials; very low-certainty evidence), or quality of life (mean difference (MD) 0.5 points in participants assigned to higher oxygenation strategies (95% CI -2.75 to 1.75; I2 = 34%, 1649 participants; 2 trials; very low-certainty evidence)). Meta-analysis of the cumulated number of SAEs suggested benefit of a lower oxygenation strategy (RR 1.04 (95% CI 1.02 to 1.07; I2 = 74%; 9489 participants; 17 trials; very low certainty evidence)). However, trial sequential analyses, with correction for sparse data and repetitive testing, could reject a relative risk increase or reduction of 10% for mortality and the highest proportion of SAEs, and 20% for both the cumulated number of SAEs and quality of life. Given the very low-certainty of evidence, it is necessary to interpret these findings with caution. Meta-analysis of all trials indicated no statistically significant evidence of a difference between higher or lower oxygenation strategies on the occurrence of lung injuries at maximum follow-up (the highest reported proportion of lung injury RR 1.08, 95% CI 0.85 to 1.38; I2 = 0%; 2048 participants; 8 trials; very low-certainty evidence). Meta-analysis of all trials indicated harm from higher oxygenation strategies as compared with lower on the occurrence of sepsis at maximum follow-up (RR 1.85, 95% CI 1.17 to 2.93; I2 = 0%; 752 participants; 3 trials; very low-certainty evidence). Meta-analysis indicated no differences regarding the occurrences of myocardial infarction or stroke. AUTHORS' CONCLUSIONS In adult ICU patients, it is still not possible to draw clear conclusions about the effects of higher versus lower oxygenation strategies on all-cause mortality, SAEs, quality of life, lung injuries, myocardial infarction, stroke, and sepsis at maximum follow-up. This is due to low or very low-certainty evidence.
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Affiliation(s)
- Thomas L Klitgaard
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Olav L Schjørring
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Frederik M Nielsen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian S Meyhoff
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jørn Wetterslev
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Private Office, Hellerup, Denmark
| | - Bodil S Rasmussen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Capellier G, Barrot L, Winizewski H. Oxygenation target in acute respiratory distress syndrome. J Intensive Med 2023:S2667-100X(23)00022-1. [PMID: 37362867 PMCID: PMC10181914 DOI: 10.1016/j.jointm.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 03/01/2023] [Accepted: 03/22/2023] [Indexed: 06/28/2023]
Abstract
Determining oxygenation targets in acute respiratory distress syndrome (ARDS) remains a challenge. Although oxygenation targets have been used since ARDS was first described, they have not been investigated in detail. However, recent retrospective and prospective trials have evaluated the optimal oxygenation threshold in patients admitted to the general intensive care unit. In view of the lack of prospective data, clinicians continue to rely on data from the few available trials to identify the optimal oxygenation strategy. Assessment of the cost-benefit ratio of the fraction of inspired oxygen (FiO2) to the partial pressure of oxygen in the arterial blood (PaO2) is an additional challenge. A high FiO2 has been found to be responsible for respiratory failure and deaths in numerous animal models. Low and high PaO2 values have also been demonstrated to be potential risk factors in experimental and clinical situations. The findings from this literature review suggest that PaO2 values ranging between 80 mmHg and 90 mmHg are acceptable in patients with ARDS. The costs of rescue maneuvers needed to reach these targets have been discussed. Several recent papers have highlighted the risk of disagreement between arterial oxygen saturation (SaO2) and peripheral oxygen saturation (SpO2) values. In order to avoid discrepancies and hidden hypoxemia, SpO2 readings need to be compared with those of SaO2. Higher SpO2 values may be needed to achieve the recommended PaO2 and SaO2 values.
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Affiliation(s)
- Gilles Capellier
- Réanimation Médicale, CHU Jean Minjoz, Besançon 25000, France
- Department of Health, Monash University, Melbourne 3800, Australia
- Equipe d'accueil EA 3920, Université de Franche Comte, Besançon 25000, France
| | - Loic Barrot
- Réanimation Médicale, CHU Jean Minjoz, Besançon 25000, France
- Département d'Anesthésie-Réanimation, CHU Jan Minjoz, Besançon 25000, France
| | - Hadrien Winizewski
- Réanimation Médicale, CHU Jean Minjoz, Besançon 25000, France
- Equipe d'accueil EA 3920, Université de Franche Comte, Besançon 25000, France
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van der Wal LI, Grim CCA, van Westerloo DJ, Schultz MJ, de Jonge E, Helmerhorst HJF. Higher versus lower oxygenation strategies in the general intensive care unit population: A systematic review, meta-analysis and meta-regression of randomized controlled trials. J Crit Care 2022; 72:154151. [PMID: 36182731 DOI: 10.1016/j.jcrc.2022.154151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 08/18/2022] [Accepted: 09/06/2022] [Indexed: 01/10/2023]
Abstract
PURPOSE Oxygen therapy is vital in adult intensive care unit (ICU) patients, but it is indistinct whether higher or lower oxygen targets are favorable. Our aim was to update the findings of randomized controlled trials (RTCs) comparing higher and lower oxygen strategies. MATERIALS AND METHODS MEDLINE, EMBASE, and Web of Science were searched. RCTs comparing higher (liberal, hyperoxia) and lower (conservative, normoxia) oxygen in adult mechanically ventilated ICU patients were included. The main outcome was 90-day mortality; other outcomes include serious adverse events (SAE), support free days and length of stay (LOS). RESULTS No significant difference was observed for 90-day mortality. A lower incidence was found for SAEs, favoring lower oxygenation (OR, 0.86; 95%CI, 0.77-0.96; I 2 13%). No differences were observed in either support free days at day 28 or ICU and hospital LOS. CONCLUSIONS No difference was found for 90-day mortality, support free days and ICU and hospital LOS. However, a lower incidence of SAEs was found for lower oxygenation. These findings may have clinical implications for practice guidelines, yet it remains of paramount importance to continue conducting clinical trials, comparing groups with a clinically relevant contrast and focusing on the impact of important side effects.
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Affiliation(s)
- Lea Imeen van der Wal
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands; Department of Anesthesiology, Leiden University Medical Centre, Leiden, the Netherlands.
| | - Chloe C A Grim
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands; Department of Anesthesiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - David J van Westerloo
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centre, Location AMC, Amsterdam, the Netherlands; Mahidol - Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand; Nuffield Department of medicine, University of Oxford, Oxford, United Kingdom
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands
| | - Hendrik J F Helmerhorst
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands; Department of Anesthesiology, Leiden University Medical Centre, Leiden, the Netherlands
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Crescioli E, Krejberg KU, Klitgaard TL, Mølgaard Nielsen F, Barbateskovic M, Skrubbeltrang C, Møller MH, Schjørring OL, Rasmussen BS. Long-term effects of lower versus higher oxygenation levels in adult ICU patients - a systematic review. Acta Anaesthesiol Scand 2022; 66:910-922. [PMID: 35749059 PMCID: PMC9540426 DOI: 10.1111/aas.14107] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/01/2022] [Accepted: 06/16/2022] [Indexed: 11/28/2022]
Abstract
Background Oxygen therapy is a common treatment in the intensive care unit (ICU) with both potentially desirable and undesirable long‐term effects. This systematic review aimed to assess the long‐term outcomes of lower versus higher oxygenation strategies in adult ICU survivors. Methods We included randomised clinical trials (RCTs) comparing lower versus higher oxygen supplementation or oxygenation strategies in adults admitted to the ICU. We searched major electronic databases and trial registers. We included all non‐mortality long‐term outcomes. Prespecified co‐primary outcomes were the long‐term cognitive function measures, the overall score of any valid health‐related quality of life (HRQoL) evaluation, standardised 6‐min walk test, and lung diffusion capacity. The protocol was published and prospectively registered in the PROSPERO database (CRD42021223630). Results The review included 17 RCTs comprising 6592 patients, and six trials with 825 randomised patients reported one or more outcomes of interest. We observed no difference in cognitive evaluation via Telephone Interview for Cognitive Status (one trial, 409 patients) (mean score: 30.6 ± 4.5 in the lower oxygenation group vs. 30.4 ± 4.3 in the higher oxygenation group). The trial was judged at overall high risk of bias and the certainty of evidence was very low. Any difference was neither observed in HRQoL measured via EuroQol 5 dimensions 5 level questionnaire and EQ Visual Analogue Score (one trial, 499 patients) (mean score: 70.1 ± 22 in the lower oxygenation group vs. 67.6 ± 22.4 in the higher oxygenation group). The trial was judged as having high risk of bias, the certainty of evidence was very low. No trial reported neither the standardised 6‐min walk test nor lung diffusion test. Conclusion The evidence is very uncertain about the effect of a lower versus a higher oxygenation strategy on both the cognitive function and HRQoL. A lower versus a higher oxygenation strategy may have a little to no effect on both outcomes but the certainty of evidence is very low. No evidence was found for the effects on the standardised 6‐min walking test and diffusion capacity test.
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Affiliation(s)
- Elena Crescioli
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Thomas Lass Klitgaard
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Frederik Mølgaard Nielsen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Capital Region of Denmark, Denmark
| | | | - Morten Hylander Møller
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Olav Lilleholt Schjørring
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Bodil Steen Rasmussen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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