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Oxygen Toxicity in Critically Ill Adults
Oxygen supplementation is one of the most common interventions in critically ill patients. Despite over a century of data suggesting both beneficial and detrimental effects of supplemental oxygen, optimal arterial oxygenation targets in adult patients remain unclear. Laboratory animal studies have consistently showed that exposure to a high FIO2 causes respiratory failure and early death.
Human autopsy studies from the 1960s purported to provide histologic evidence of pulmonary oxygen toxicity in the form of diffuse alveolar damage. However, concomitant ventilator-induced lung injury and/or other causes of acute lung injury may explain these findings. Although some observational studies in general populations of critically adults showed higher mortality in association with higher oxygen exposures, this finding has not been consistent. For some specific populations, such as those with cardiac arrest, studies have suggested harm from targeting supraphysiologic PaO2 levels. More recently, randomized clinical trials of arterial oxygenation targets in narrower physiologic ranges were conducted in critically ill adult patients.
Although two smaller trials came to opposite conclusions, the two largest of these trials showed no differences in clinical outcomes in study groups that received conservative versus liberal oxygen targets, suggesting that either strategy is reasonable. It is possible that some strategies are of benefit in some subpopulations, and this remains an important ongoing area of research. Because of the ubiquity of oxygen supplementation in critically ill adults, even small treatment effects could have a large impact on a global scale.
Target Audience
Pulmonologists, critical care specialists, translational researchers, and clinicians
Learning Objectives
At the conclusion of this activity, learners should be able to:
- Weigh the potential risks and benefits of oxygen-targeting strategies in clinical practice.
- Interpret the results of recent and upcoming clinical trials of arterial oxygenation targets.
- Describe important knowledge gaps regarding optimal arterial oxygenation targets.
Accreditation Statement
The American Thoracic Society is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
Disclosure Declaration
The current practice of the American Journal of Respiratory and Critical Care Medicine (AJRCCM) is to publish high quality, peer-reviewed and evidence-based original research, Concise Clinical Reviews, Guidelines and Consensus Statements. Articles published in AJRCCM include evidence-based summaries of optimal practice (Concise Clinical Reviews), evidence-based guidelines, workshop summaries and original contributions that will influence clinical practice. The publication of these articles by itself is only one piece of a multi-step process for the translation of evidence-based improvements in care to clinical practice. Articles selected for CME credit are designed to be the next step in the process of translating clinically relevant, evidence-based recommendations into clinical practice. This will be accomplished through a series of questions specifically designed by the author(s) to test that readers have the tools needed to translate recommendations for diagnostic and therapeutic clinical care into clinical practice. Members of the AJRCCM editorial board will review these questions and assess the quality of the questions based on:
- Clarity,
- Educational content, and
- The quality of the evidence supporting the response to the question. Posttest questions will assess if practitioners have understood the most important recommendations available for the diagnosis and treatment of pulmonary diseases, critical illness, and sleep disorders and are able to implement them into clinical practice.
Article Authorship Disclosures (as submitted to the ATS prior to article publication date)
Chad H. Hochberg, M.D. (Johns Hopkins University School of Medicine, Baltimore, MD, USA) reported grant NHLBI T32HL007534 from the NHLBI.
Matthew W. Semler, M.D., M.Sc. (Vanderbilt University Medical Center, Nashville, TN, USA) reported grant NHLBI K23HL143053 from the NHLBI.
Roy G. Brower, M.D. (Johns Hopkins University School of Medicine, Baltimore, MD, USA) reported no relevant financial relationships.
Off-Label Usage Disclosure
None
Disclosures of AJRCCM CME Planners
The current practice of the American Journal of Respiratory and Critical Care Medicine (AJRCCM) is to publish high quality, peer-reviewed and evidence-based original research, Concise Clinical Reviews, Guidelines and Consensus Statements. Articles published in AJRCCM include evidence-based summaries of optimal practice (Concise Clinical Reviews), evidence-based guidelines, workshop summaries and original contributions that will influence clinical practice. The publication of these articles by itself is only one piece of a multi-step process for the translation of evidence-based improvements in care to clinical practice. Articles selected for CME credit are designed to be the next step in the process of translating clinically relevant, evidence-based recommendations into clinical practice. This will be accomplished through a series of questions specifically designed by the author(s) to test that readers have the tools needed to translate recommendations for diagnostic and therapeutic clinical care into clinical practice. Members of the AJRCCM editorial board will review these questions and assess the quality of the questions based on (1) clarity, (2) educational content, and (3) the quality of the evidence supporting the response to the question. Posttest questions will assess if practitioners have understood the most important recommendations available for the diagnosis and treatment of pulmonary diseases, critical illness, and sleep disorders and are able to implement them into clinical practice.
AJRCCM CME Planners
Harold Collard, M.D.
Associate Editor, AJRCCM
Dr. Collard reported that he is on the advisory committee of Bayer, Biogen, Boehringer Ingelheim, Fibrogen, Genentech, Gilead, Intermune, and Promedior; and is a consultant at Five Prime.
Gerard J. Criner, M.D.
Associate Editor, AJRCCM
Dr. Criner reported that he has research awards from Aeris Therapeutics, AstraZeneca, Boehringer Ingelheim, Forest Laboratories, GlaxoSmithKline, Ikaria, Medimmune, Novartis, Pearl, PneumRx, Pulmonx, Respironics, Spectral Diagnostics, and Theratechnologies Inc.; and has received lecture fees from Almirall, AstraZeneca, Boehringer Ingelheim, Celerion, CSA Medical Inc., Johnson & Johnson, and Respivert.
Jadwiga A. Wedzicha, M.D.
Editor-in-Chief, AJRCCM
Dr. Wedzicha reported that she is on the advisory committee of Napp, Pfizer, and Takeda; has research awards from Chiesi, Takeda, and Vifor Pharma; and has received lecture fees from Almirall, Bayer, Boehringer Ingelheim, Novartis, and Takeda.
Instructions to Receive Credit
To receive credit for this journal article:
- Read the journal article. Keep track of how long it takes you to read it.
- Once you open the article, the Post-Test becomes available. After reading the article, answer the post-test questions. You must answer all questions correctly to earn credit. You may take the test as many times as you like.
- Once you pass the Post-Test, the Evaluation becomes available. Answer all the evaluation questions.
- Once you complete the evaluation, select the amount of credit to receive based on the time it took you to read the article.
- You can view, save and print your Certificate by pressing the Certificate button.
- To review the credits you've earned in this system and reprint certificates, go to the My Learning drop-down list. Then select Transcript.
Available Credit
- 1.00 AMA PRA Category 1 Credit(s)™The American Thoracic Society designates this for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
- 1.00 Participation