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August 31, 2021

Titrating Oxygen Therapy in Critically Ill Patients

Author Affiliations
  • 1Interdepartmental Division of Critical Care Medicine and the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
  • 2Division of Pulmonary, Department of Medicine, Critical Care, Allergy and Sleep Medicine, and Cardiovascular Research Institute, University of California, San Francisco
JAMA. 2021;326(10):911-913. doi:10.1001/jama.2021.9843

The development of oxygen therapy is one of the major advances of modern medicine. Oxygen therapy laid the groundwork for intensive care medicine as a specialty and has saved millions of lives. During the COVID-19 pandemic, millions of patients survived due to provision of supplemental oxygen, with or without mechanical ventilation. In some regions of the world, where oxygen supply is limited, however, there were many preventable deaths from acute hypoxemic respiratory failure.

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    1 Comment for this article
    Oxygen scarcity – Lessons from the Pandemic
    Manish Joshi, MD | CAVHS
    Supplemental oxygen, a primary intervention in respiratory illness, is perhaps the most essential bulwark of supportive-care. COVID-19 pneumonia has been no exception. As critical care physicians and pulmonologists, we could not imagine managing COVID-19 patients admitted to hospitals without adequate supply of oxygen. With pandemic surges, we witnessed a tragic shortage around the world.

    The devastating consequences of inadequate oxygen supplies in other parts of the world bring our usage of oxygen into focus. Even before the pandemic struck, people were dying due to lack of medical-oxygen. According to WHO estimates, lack of oxygen results in ~ 500,000 newborn-deaths
    every year, and 40% of adult/pediatric deaths from pneumonia are preventable with simple availability of oxygen (2). Use of oxygen in the US and other developed countries has, historically, been profligate (3). Every day, we teach during rounds that the target of 100% saturation is not prudent in patients requiring supplemental oxygen for multiple reasons. But recent events bring into focus another reason – the supply of medical-oxygen is not endless. Oxygen should be used as a drug – prescribed for specific indications with awareness of contraindications. The debate about conservative versus liberal oxygen therapy in hypoxemic respiratory failure is evolving, with ample evidence that a conservative strategy is non-inferior to a liberal strategy (3). We waste a resource without which others die.

    Manish Joshi
    Eduardo Mireles (MICU Director, Cleveland Clinic)
    Deepa Raghavan (MICU Director, CAVHS)
    Vivek Iyer (Mayo clinic)
    Thaddeus Bartter

    1. Investing in oxygen to close the access gap during COVID-19 and beyond - Clinton Health Access Initiative
    2. BTS. https://www.brit-thoracic.org.uk/media/219414/bts-emergency-oxygen-audit-report-2016-final-290416.pdf.
    3. Young PJ. Effect of Oxygen Therapy on Mortality in the ICU. NEJM 2021