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January 24, 2020

Evolving Issues in Oxygen Therapy in Acute Care Medicine

Author Affiliations
  • 1Institute of Health Policy Management and Evaluation, Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Canada
  • 2Institute of Health Policy Management and Evaluation, Interdepartmental Division of Critical Care Medicine, Departments of Medicine and Physiology, University of Toronto; University Health Network and Mount Sinai Hospitals, Toronto, Canada
JAMA. 2020;323(7):607-608. doi:10.1001/jama.2019.22029

Oxygen therapy is one of the most ubiquitously applied therapies in modern medicine. Clinicians usually react rapidly to declining oxygen saturations. Although this response is appropriate in the setting of hypoxia, there are many circumstances in which excess oxygen is indiscriminately administered for extended periods.

Medicine has recently experienced a shift from “more is better” to “less is more” as more has been learned about the ability of the human body to adapt to extreme physiological conditions and about the inappropriate use of various therapies. Examples include hemoglobin thresholds and carbon dioxide levels. Attention in recent years has focused on the potential harms associated with excess oxygen therapy.

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    1 Comment for this article
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    Let’s Not Forget That Certain Clinical Situations Demand Hyperoxia
    Robert Weenink, MD PhD | Academic Medical Centers, Amsterdam, The Netherlands
    I would like to congratulate Dr. Munshi and Dr. Ferguson on their interesting overview of the changing attitude towards oxygen therapy. I concur that oxygen should be regarded as a drug and that its administration should be tailored to the needs of the individual patient. Having said this, I would like to warn that a too restrictive attitude toward the use of supplemental oxygen may come with risks of its own. Let’s not forget that in the midst of a growing negative opinion against oxygen, certain clinical conditions demand normobaric – and sometimes even hyperbaric – hyperoxia. Unfortunately, this is not mentioned by the authors.

    Diseases that require normobaric hyperoxia in the absence of hypoxia are, among others, cluster headache, gas embolism, and decompression sickness. Also, hyperoxia serves as a bridge to more definitive therapy in case of hypovolemia, even if the patient is not (yet) hypoxic. It should therefore continue to be one of the mainstays of resuscitation in severe trauma, at least until major blood loss has been ruled out. Hyperoxygenation before anesthetic induction provides a safety margin in case of a ‘cannot intubate, cannot oxygenate’ scenario, and may provide an equivalent safety margin if applied during the remainder of surgical cases. This is irrespective of the possible protective role that hyperoxia may have against surgical site infections, as mentioned by the authors.

    Hyperbaric oxygen treatment involves breathing 100% oxygen under conditions of increased atmospheric pressure, and has been recognized by the Undersea and Hyperbaric Medical Society as the primary or adjunctive therapy of choice in 14 disease entities. Of these, carbon monoxide poisoning, gas embolism, decompression sickness, and necrotizing soft tissue infections are the most well-known. Other conditions that respond favorably are, among others, crush injury, arterial insufficiencies, delayed radiation injury, compromised grafts and flaps, and idiopathic sudden sensorineural hearing loss.

    To conclude, current evidence shows that hyperoxia is associated with increased mortality in certain medical conditions, while on the other hand it has clear cut benefits in other populations. I hope that a more restrictive use of oxygen, which may be beneficial in certain situations, will not lead to decreased use of normobaric or hyperbaric hyperoxia in patients in whom it is an indispensable part of their medical management.
    CONFLICT OF INTEREST: None Reported
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