Download PDF
Semin Respir Crit Care Med 2016; 37(01): 016-022
DOI: 10.1055/s-0035-1570359
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

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

Sonal R. Pannu
1   Division of Pulmonary, Allergy, Critical Care & Sleep, Ohio State University, Columbus, Ohio
› Author Affiliations
Further Information

Publication History

Publication Date:
28 January 2016 (online)

    Permissions and Reprints

Abstract

Hyperoxia, or excess oxygen supplementation, prevails in the intensive care unit (ICU) without a beneficial effect and, in some instances, may cause harm. Recent interest and surge in clinical studies in mechanically ventilated critically ill patients has brought this to the attention of clinicians and researchers. Hyperoxia can cause alveolar injury, pulmonary edema, and subsequent systemic inflammatory response and is known to augment ventilator-associated lung injury. Liberal oxygenation practices are also associated with increased mortality in subsets of critically ill patients with post–cardiac arrest, stroke, and traumatic brain injury. Most clinicians agree that oxygen titration should be done and, with appropriate safeguards, lower oxygenation targets may be acceptable and possibly beneficial in many critically ill patients. However, this problem is often overlooked. The use of periodic reminders and decision support may facilitate implementation of more precise oxygen titration at the bedside of critically ill patients. For implementing practice change, studies involving education and guidance of all health care staff involved in oxygen management are critical.

Keywords

oxygen supplementation - hyperoxia - oxygen toxicity - oxygen titration
 

  • References

  • 1 Comroe J. Oxygen toxicity, the effect of breathing high concentration of oxygen for 24 hours in normal men at sea level and simulated at 18,000 feet. JAMA 1945; 128: 710-717
    CrossrefPubMedSearch in Google Scholar
  • 2 Caldwell PR, Lee Jr WL, Schildkraut HS, Archibald ER. Changes in lung volume, diffusing capacity, and blood gases in men breathing oxygen. J Appl Physiol 1966; 21 (5) 1477-1483
    PubMedSearch in Google Scholar
  • 3 Nash G, Blennerhassett JB, Pontoppidan H. Pulmonary lesions associated with oxygen therapy and artifical ventilation. N Engl J Med 1967; 276 (7) 368-374
    CrossrefPubMedSearch in Google Scholar
  • 4 Smith JL. The pathological effects due to increase of oxygen tension in the air breathed. J Physiol 1899; 24 (1) 19-35
    CrossrefPubMedSearch in Google Scholar
  • 5 Davis WB, Rennard SI, Bitterman PB, Crystal RG. Pulmonary oxygen toxicity. Early reversible changes in human alveolar structures induced by hyperoxia. N Engl J Med 1983; 309 (15) 878-883
    CrossrefPubMedSearch in Google Scholar
  • 6 Albin RJ, Criner GJ, Thomas S, Abou-Jaoude S. Pattern of non-ICU inpatient supplemental oxygen utilization in a university hospital. Chest 1992; 102 (6) 1672-1675
    CrossrefPubMedSearch in Google Scholar
  • 7 Austin MA, Wills KE, Blizzard L, Walters EH, Wood-Baker R. Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial. BMJ 2010; 341: c5462
    CrossrefPubMedSearch in Google Scholar
  • 8 Rachmale S, Li G, Wilson G, Malinchoc M, Gajic O. Practice of excessive F(IO(2)) and effect on pulmonary outcomes in mechanically ventilated patients with acute lung injury. Respir Care 2012; 57 (11) 1887-1893
    CrossrefPubMedSearch in Google Scholar
  • 9 de Jonge E, Peelen L, Keijzers PJ , et al. Association between administered oxygen, arterial partial oxygen pressure and mortality in mechanically ventilated intensive care unit patients. Crit Care 2008; 12 (6) R156
    CrossrefPubMedSearch in Google Scholar
  • 10 Damiani E, Adrario E, Girardis M , et al. Arterial hyperoxia and mortality in critically ill patients: a systematic review and meta-analysis. Crit Care 2014; 18 (6) 711
    CrossrefPubMedSearch in Google Scholar
  • 11 Ray PD, Huang BW, Tsuji Y. Reactive oxygen species (ROS) homeostasis and redox regulation in cellular signaling. Cell Signal 2012; 24 (5) 981-990
    CrossrefPubMedSearch in Google Scholar
  • 12 Jackson RM. Pulmonary oxygen toxicity. Chest 1985; 88 (6) 900-905
    CrossrefPubMedSearch in Google Scholar
  • 13 Comhair SA, Erzurum SC. Antioxidant responses to oxidant-mediated lung diseases. Am J Physiol Lung Cell Mol Physiol 2002; 283 (2) L246-L255
    CrossrefPubMedSearch in Google Scholar
  • 14 Barazzone C, Horowitz S, Donati YR, Rodriguez I, Piguet PF. Oxygen toxicity in mouse lung: pathways to cell death. Am J Respir Cell Mol Biol 1998; 19 (4) 573-581
    CrossrefPubMedSearch in Google Scholar
  • 15 Zhang Q, Raoof M, Chen Y , et al. Circulating mitochondrial DAMPs cause inflammatory responses to injury. Nature 2010; 464 (7285) 104-107
    CrossrefPubMedSearch in Google Scholar
  • 16 Habre W, Peták F. Perioperative use of oxygen: variabilities across age. Br J Anaesth 2014; 113 (Suppl. 02) ii26-ii36
    CrossrefPubMedSearch in Google Scholar
  • 17 Patel VS, Sitapara RA, Gore A , et al. High Mobility Group Box-1 mediates hyperoxia-induced impairment of Pseudomonas aeruginosa clearance and inflammatory lung injury in mice. Am J Respir Cell Mol Biol 2013; 48 (3) 280-287
    CrossrefPubMedSearch in Google Scholar
  • 18 Kennedy TP, Nelson S. Hyperoxia, HMGB1, and ventilator-associated pneumonia: reducing risk by practicing what we teach. Am J Respir Cell Mol Biol 2013; 48 (3) 269-270
    CrossrefPubMedSearch in Google Scholar
  • 19 Bailey TC, Martin EL, Zhao L, Veldhuizen RA. High oxygen concentrations predispose mouse lungs to the deleterious effects of high stretch ventilation. J Appl Physiol (1985) 2003; 94 (3) 975-982
    CrossrefPubMedSearch in Google Scholar
  • 20 Sinclair SE, Altemeier WA, Matute-Bello G, Chi EY. Augmented lung injury due to interaction between hyperoxia and mechanical ventilation. Crit Care Med 2004; 32 (12) 2496-2501
    CrossrefPubMedSearch in Google Scholar
  • 21 Bak Z, Sjöberg F, Rousseau A, Steinvall I, Janerot-Sjoberg B. Human cardiovascular dose-response to supplemental oxygen. Acta Physiol (Oxf) 2007; 191 (1) 15-24
    CrossrefPubMedSearch in Google Scholar
  • 22 Floyd TF, Clark JM, Gelfand R , et al. Independent cerebral vasoconstrictive effects of hyperoxia and accompanying arterial hypocapnia at 1 ATA. J Appl Physiol (1985) 2003; 95 (6) 2453-2461
    CrossrefPubMedSearch in Google Scholar
  • 23 Waring WS, Thomson AJ, Adwani SH , et al. Cardiovascular effects of acute oxygen administration in healthy adults. J Cardiovasc Pharmacol 2003; 42 (2) 245-250
    CrossrefPubMedSearch in Google Scholar
  • 24 Ball J, Ranzani OT. Hyperoxia following cardiac arrest. Intensive Care Med 2015; 41 (3) 534-536
    CrossrefPubMedSearch in Google Scholar
  • 25 Elmer J, Scutella M, Pullalarevu R , et al; Pittsburgh Post-Cardiac Arrest Service (PCAS). The association between hyperoxia and patient outcomes after cardiac arrest: analysis of a high-resolution database. Intensive Care Med 2015; 41 (1) 49-57
    CrossrefPubMedSearch in Google Scholar
  • 26 Eastwood GM, Young PJ, Bellomo R. The impact of oxygen and carbon dioxide management on outcome after cardiac arrest. Curr Opin Crit Care 2014; 20 (3) 266-272
    CrossrefPubMedSearch in Google Scholar
  • 27 Sutton AD, Bailey M, Bellomo R, Eastwood GM, Pilcher DV. The association between early arterial oxygenation in the ICU and mortality following cardiac surgery. Anaesth Intensive Care 2014; 42 (6) 730-735
    PubMedSearch in Google Scholar
  • 28 Helmerhorst HJ, Roos-Blom MJ, van Westerloo DJ, de Jonge E. Association between arterial hyperoxia and outcome in subsets of critical illness: a systematic review, meta-analysis, and meta-regression of cohort studies. Crit Care Med 2015; 43 (7) 1508-1519
    CrossrefPubMedSearch in Google Scholar
  • 29 Rincon F, Kang J, Maltenfort M , et al. Association between hyperoxia and mortality after stroke: a multicenter cohort study. Crit Care Med 2014; 42 (2) 387-396
    CrossrefPubMedSearch in Google Scholar
  • 30 Quintard H, Patet C, Suys T, Marques-Vidal P, Oddo M. Normobaric hyperoxia is associated with increased cerebral excitotoxicity after severe traumatic brain injury. Neurocrit Care 2015; 22 (2) 243-250
    CrossrefPubMedSearch in Google Scholar
  • 31 Jenkinson SG. Oxygen toxicity. New Horiz 1993; 1 (4) 504-511
    PubMedSearch in Google Scholar
  • 32 Crapo JD, Barry BE, Foscue HA, Shelburne J. Structural and biochemical changes in rat lungs occurring during exposures to lethal and adaptive doses of oxygen. Am Rev Respir Dis 1980; 122 (1) 123-143
    PubMedSearch in Google Scholar
  • 33 Hayatdavoudi G, O'Neil JJ, Barry BE, Freeman BA, Crapo JD. Pulmonary injury in rats following continuous exposure to 60% O2 for 7 days. J Appl Physiol 1981; 51 (5) 1220-1231
    PubMedSearch in Google Scholar
  • 34 Crapo JD, Hayatdavoudi G, Knapp MJ, Fracica PJ, Wolfe WG, Piantadosi CA. Progressive alveolar septal injury in primates exposed to 60% oxygen for 14 days. Am J Physiol 1994; 267 (6, Pt 1) L797-L806
    PubMedSearch in Google Scholar
  • 35 Shermeta DW, White JJ, DeLemos R, Haller Jr JA. Pulmonary effects of lethal and sublethal oxygen exposure in lambs. Am Surg 1970; 36 (12) 721-723
    PubMedSearch in Google Scholar
  • 36 Nagato A, Silva FL, Silva AR , et al. Hyperoxia-induced lung injury is dose dependent in Wistar rats. Exp Lung Res 2009; 35 (8) 713-728
    CrossrefPubMedSearch in Google Scholar
  • 37 Coalson JJ, Beller JJ, Greenfield LJ. Effects of 100 per cent. oxygen ventilation on pulmonary ultrastructure and mechanics. J Pathol 1971; 104 (4) 267-273
    CrossrefPubMedSearch in Google Scholar
  • 38 Douglas ME, Downs JB, Mantini EL, Ruiz BC. Alteration of oxygen tension and oxyhemoglobin saturation. A hazard of sodium bicarbonate administration. Arch Surg 1979; 114 (3) 326-329
    CrossrefPubMedSearch in Google Scholar
  • 39 Douglas ME, Downs JB, Dannemiller FJ, Hodges MR, Munson ES. Change in pulmonary venous admixture with varying inspired oxygen. Anesth Analg 1976; 55 (5) 688-695
    PubMedSearch in Google Scholar
  • 40 Downs JB, Smith RA. Increased inspired oxygen concentration may delay diagnosis and treatment of significant deterioration in pulmonary function. Crit Care Med 1999; 27 (12) 2844-2846
    CrossrefPubMedSearch in Google Scholar
  • 41 Mao C, Wong DT, Slutsky AS, Kavanagh BP. A quantitative assessment of how Canadian intensivists believe they utilize oxygen in the intensive care unit. Crit Care Med 1999; 27 (12) 2806-2811
    CrossrefPubMedSearch in Google Scholar
  • 42 Jubran A. Pulse oximetry. Intensive Care Med 2004; 30 (11) 2017-2020
    CrossrefPubMedSearch in Google Scholar
  • 43 Rice TW, Wheeler AP, Bernard GR, Hayden DL, Schoenfeld DA, Ware LB. National Institutes of Health, National Heart, Lung, and Blood Institute ARDS Network. Comparison of the SpO2/FIO2 ratio and the PaO2/FIO2 ratio in patients with acute lung injury or ARDS. Chest 2007; 132 (2) 410-417
    CrossrefPubMedSearch in Google Scholar
  • 44 Lobete C, 1 Medina A, Rey C, Mayordomo-Colunga J, Concha A, Menéndez S. Correlation of oxygen saturation as measured by pulse oximetry/fraction of inspired oxygen ratio with Pao2/fraction of inspired oxygen ratio in a heterogeneous sample of critically ill children. J Crit Care 2013; 28 (4) 538.e1-7
    CrossrefPubMedSearch in Google Scholar
  • 45 Jubran A, Tobin MJ. Reliability of pulse oximetry in titrating supplemental oxygen therapy in ventilator-dependent patients. Chest 1990; 97 (6) 1420-1425
    CrossrefPubMedSearch in Google Scholar
  • 46 Pannu S, Hotels SR, Li M, Marquez A, Kashyap R, Al-qadi MO, Wilson G, Gajic O. 826: Titration of inspired oxygen levels during mechanical ventilation through a respiratory therapist driven approach based on an electronic surveillance system (Tools). Crit Care Med 2012; 40 (12) 1-328
    PubMedSearch in Google Scholar
  • 47 Crapo RO, Jensen RL, Hegewald M, Tashkin DP. Arterial blood gas reference values for sea level and an altitude of 1,400 meters. Am J Respir Crit Care Med 1999; 160 (5, Pt 1) 1525-1531
    CrossrefPubMedSearch in Google Scholar
  • 48 Slutsky AS. Consensus conference on mechanical ventilation—January 28-30, 1993 at Northbrook, Illinois, USA. Part I. European Society of Intensive Care Medicine, the ACCP and the SCCM. Intensive Care Med 1994; 20 (1) 64-79
    CrossrefPubMedSearch in Google Scholar
  • 49 Network TA. The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000; 342 (18) 1301-1308
    CrossrefPubMedSearch in Google Scholar
  • 50 Martin DS, Grocott MP. Oxygen therapy in critical illness: precise control of arterial oxygenation and permissive hypoxemia. Crit Care Med 2013; 41 (2) 423-432
    CrossrefPubMedSearch in Google Scholar
  • 51 Budinger GR, Mutlu GM. Balancing the risks and benefits of oxygen therapy in critically III adults. Chest 2013; 143 (4) 1151-1162
    CrossrefPubMedSearch in Google Scholar
  • 52 Panwar R, Hardie M, Bellomo R , et al; CLOSE study investigators and the ANZICS Clinical Trials Group. Conservative versus liberal oxygenation targets for mechanically ventilated patients—a pilot multicenter randomized controlled trial. Am J Respir Crit Care Med 2015;
    PubMedSearch in Google Scholar
  • 53 Suzuki S, Eastwood GM, Glassford NJ , et al. Conservative oxygen therapy in mechanically ventilated patients: a pilot before-and-after trial. Crit Care Med 2014; 42 (6) 1414-1422
    CrossrefPubMedSearch in Google Scholar
  • 54 Carlo WA, Finer NN, Walsh MC , et al; SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network. Target ranges of oxygen saturation in extremely preterm infants. N Engl J Med 2010; 362 (21) 1959-1969
    CrossrefPubMedSearch in Google Scholar
  • 55 Beasley R, McNaughton A, Robinson G. New look at the oxyhaemoglobin dissociation curve. Lancet 2006; 367 (9517) 1124-1126
    CrossrefPubMedSearch in Google Scholar
  • 56 Downs JB. Has oxygen administration delayed appropriate respiratory care? Fallacies regarding oxygen therapy. Respir Care 2003; 48 (6) 611-620
    PubMedSearch in Google Scholar
  • 57 Panwar R, Capellier G, Schmutz N , et al. Current oxygenation practice in ventilated patients—an observational cohort study. Anaesth Intensive Care 2013; 41 (4) 505-514
    PubMedSearch in Google Scholar
  • 58 de Graaff AE, Dongelmans DA, Binnekade JM, de Jonge E. Clinicians' response to hyperoxia in ventilated patients in a Dutch ICU depends on the level of FiO2. Intensive Care Med 2011; 37 (01) 46-51
    CrossrefPubMedSearch in Google Scholar
  • 59 Suzuki S, Eastwood GM, Peck L, Glassford NJ, Bellomo R. Current oxygen management in mechanically ventilated patients: a prospective observational cohort study. J Crit Care 2013; 28 (5) 647-654
    CrossrefPubMedSearch in Google Scholar
  • 60 Panwar R, Young P, Capellier G. Conservative oxygen therapy in mechanically ventilated patients. Crit Care Med 2014; 42 (9) e630-e631
    CrossrefPubMedSearch in Google Scholar
  • 61 Eastwood GM, Peck L, Young H, Suzuki S, Garcia M, Bellomo R. Intensive care clinicians'. opinion of conservative oxygen therapy (SpO2 90–92%) for mechanically ventilated patients. Aust Crit Care 2014; 27 (3) 120-125
    CrossrefPubMedSearch in Google Scholar
  • 62 Helmerhorst HJ, Schultz MJ, van der Voort PH , et al. Self-reported attitudes versus actual practice of oxygen therapy by ICU physicians and nurses. Ann Intensive Care 2014; 4: 23
    PubMedSearch in Google Scholar
  • 63 Hermeto F, Bottino MN, Vaillancourt K, Sant'Anna GM. Implementation of a respiratory therapist-driven protocol for neonatal ventilation: impact on the premature population. Pediatrics 2009; 123 (5) e907-e916
    CrossrefPubMedSearch in Google Scholar
  • 64 Herasevich V, Pieper MS, Pulido J, Gajic O. Enrollment into a time sensitive clinical study in the critical care setting: results from computerized septic shock sniffer implementation. J Am Med Inform Assoc 2011; 18 (5) 639-644
    CrossrefPubMedSearch in Google Scholar
  • 65 Herasevich V, Yilmaz M, Khan H, Hubmayr RD, Gajic O. Validation of an electronic surveillance system for acute lung injury. Intensive Care Med 2009; 35 (6) 1018-1023
    CrossrefPubMedSearch in Google Scholar
  • 66 Ely EW, Bennett PA, Bowton DL, Murphy SM, Florance AM, Haponik EF. Large scale implementation of a respiratory therapist-driven protocol for ventilator weaning. Am J Respir Crit Care Med 1999; 159 (2) 439-446
    CrossrefPubMedSearch in Google Scholar
  • 67 Claure N, D'Ugard C, Bancalari E. Automated adjustment of inspired oxygen in preterm infants with frequent fluctuations in oxygenation: a pilot clinical trial. J Pediatr 2009; 155 (5) 640-5.e1 , 2
    CrossrefPubMedSearch in Google Scholar