How to select SpO2 targets

Artigo

Autor: Clinical Experts Group, Hamilton Medical

Data da primeira publicação: 30.09.2020

Última alteração: 30.09.2020

(Originally published 30.08.2017) Previously: chronic hypercapnia range 88-93%; brain injury range 96-99%. New screenshots.

In mechanically ventilated patients, SpO2 targets are selected according to the previous lung condition and the actual severity of the disease.

SpO2 targets according to condition

For patients with a normal lung before ICU admission, the SpO2 targets are 94%-98% (O'Driscoll BR, Howard LS, Davison AG; British Thoracic Society. BTS guideline for emergency oxygen use in adult patients [published correction appears in Thorax. 2009 Jan;64(1):91]. Thorax. 2008;63 Suppl 6:vi1-vi68. doi:10.1136/thx.2008.1029471) or 92%-96% (Beasley R, Chien J, Douglas J, et al. Thoracic Society of Australia and New Zealand oxygen guidelines for acute oxygen use in adults: 'Swimming between the flags'. Respirology. 2015;20(8):1182-1191. doi:10.1111/resp.126202). The safe lower limit for SpO2 is considered to be 90%.
For patients with previous chronic respiratory failure at risk of oxygen-induced hypercapnia, SpO2 targets are 88%-92%. The safe lower SpO2 limit is 85%.
SpO2 targets for ARDS patients are 88%-95% (Bein T, Grasso S, Moerer O, et al. The standard of care of patients with ARDS: ventilatory settings and rescue therapies for refractory hypoxemia. Intensive Care Med. 2016;42(5):699-711. doi:10.1007/s00134-016-4325-43, NIH NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary 2008-07.4).
SpO2 targets for brain injury and post-cardiac arrest patients are 94%-98% (O'Driscoll BR, Howard LS, Davison AG; British Thoracic Society. BTS guideline for emergency oxygen use in adult patients [published correction appears in Thorax. 2009 Jan;64(1):91]. Thorax. 2008;63 Suppl 6:vi1-vi68. doi:10.1136/thx.2008.1029471, Nolan JP, Soar J, Cariou A, et al. European Resuscitation Council and European Society of Intensive Care Medicine 2015 guidelines for post-resuscitation care [published correction appears in Intensive Care Med. 2016 Mar;42(3):488-9]. Intensive Care Med. 2015;41(12):2039-2056. doi:10.1007/s00134-015-4051-36).
Patients with carbon monoxide poisoning should receive normobaric hyperoxia or hyperbaric oxygen. Pulse oximetry is likely to be inaccurate in this case.
Patients previously exposed to Bleomycin or poisoned with paraquat should have SpO2 targets of 88%-92%.

Image showing oxygenation maps for all three conditions

Targets in INTELLiVENT-ASV

When using INTELLiVENT®-ASV® (Not available in the US and some other marketsA) default SpO2 target ranges vary according to the clinical condition selected by the user: 93%-97% for normal lung and ARDS patients, 88%-92% for chronic hypercapnia patients, and 94%-98% for brain injury. However, these default targets are automatically lower for high PEEP and target ranges can be adjusted by the user at any time.

Full citations below: (Vogelmeier CF, Criner GJ, Martinez FJ, et al. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report: GOLD Executive Summary [published correction appears in Eur Respir J. 2017 Jun 22;49(6):]. Eur Respir J. 2017;49(3):1700214. Published 2017 Mar 6. doi:10.1183/13993003.00214-20175)

Footnotes

A. Não disponível nos EUA e em alguns outros mercados

References

1. O'Driscoll BR, Howard LS, Davison AG; British Thoracic Society. BTS guideline for emergency oxygen use in adult patients [published correction appears in Thorax. 2009 Jan;64(1):91]. Thorax. 2008;63 Suppl 6:vi1-vi68. doi:10.1136/thx.2008.102947
2. Beasley R, Chien J, Douglas J, et al. Thoracic Society of Australia and New Zealand oxygen guidelines for acute oxygen use in adults: 'Swimming between the flags'. Respirology. 2015;20(8):1182-1191. doi:10.1111/resp.12620
3. Bein T, Grasso S, Moerer O, et al. The standard of care of patients with ARDS: ventilatory settings and rescue therapies for refractory hypoxemia. Intensive Care Med. 2016;42(5):699-711. doi:10.1007/s00134-016-4325-4
4. NIH NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary 2008-07.
5. Vogelmeier CF, Criner GJ, Martinez FJ, et al. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report: GOLD Executive Summary [published correction appears in Eur Respir J. 2017 Jun 22;49(6):]. Eur Respir J. 2017;49(3):1700214. Published 2017 Mar 6. doi:10.1183/13993003.00214-2017
6. Nolan JP, Soar J, Cariou A, et al. European Resuscitation Council and European Society of Intensive Care Medicine 2015 guidelines for post-resuscitation care [published correction appears in Intensive Care Med. 2016 Mar;42(3):488-9]. Intensive Care Med. 2015;41(12):2039-2056. doi:10.1007/s00134-015-4051-3

BTS guideline for emergency oxygen use in adult patients.

O'Driscoll BR, Howard LS, Davison AG; British Thoracic Society. BTS guideline for emergency oxygen use in adult patients [published correction appears in Thorax. 2009 Jan;64(1):91]. Thorax. 2008;63 Suppl 6:vi1-vi68. doi:10.1136/thx.2008.102947

Link to article

Thoracic Society of Australia and New Zealand oxygen guidelines for acute oxygen use in adults: 'Swimming between the flags'.

Beasley R, Chien J, Douglas J, et al. Thoracic Society of Australia and New Zealand oxygen guidelines for acute oxygen use in adults: 'Swimming between the flags'. Respirology. 2015;20(8):1182-1191. doi:10.1111/resp.12620

Link to article

The purpose of the Thoracic Society of Australia and New Zealand guidelines is to provide simple, practical evidence-based recommendations for the acute use of oxygen in adults in clinical practice. The intended users are all health professionals responsible for the administration and/or monitoring of oxygen therapy in the management of acute medical patients in the community and hospital settings (excluding perioperative and intensive care patients), those responsible for the training of such health professionals, and both public and private health care organizations that deliver oxygen therapy.

The standard of care of patients with ARDS: ventilatory settings and rescue therapies for refractory hypoxemia.

Bein T, Grasso S, Moerer O, et al. The standard of care of patients with ARDS: ventilatory settings and rescue therapies for refractory hypoxemia. Intensive Care Med. 2016;42(5):699-711. doi:10.1007/s00134-016-4325-4

Link to article

PURPOSE Severe ARDS is often associated with refractory hypoxemia, and early identification and treatment of hypoxemia is mandatory. For the management of severe ARDS ventilator settings, positioning therapy, infection control, and supportive measures are essential to improve survival. METHODS AND RESULTS A precise definition of life-threating hypoxemia is not identified. Typical clinical determinations are: arterial partial pressure of oxygen < 60 mmHg and/or arterial oxygenation < 88 % and/or the ratio of PaO2/FIO2 < 100. For mechanical ventilation specific settings are recommended: limitation of tidal volume (6 ml/kg predicted body weight), adequate high PEEP (>12 cmH2O), a recruitment manoeuvre in special situations, and a 'balanced' respiratory rate (20-30/min). Individual bedside methods to guide PEEP/recruitment (e.g., transpulmonary pressure) are not (yet) available. Prone positioning [early (≤ 48 hrs after onset of severe ARDS) and prolonged (repetition of 16-hr-sessions)] improves survival. An advanced infection management/control includes early diagnosis of bacterial, atypical, viral and fungal specimen (blood culture, bronchoalveolar lavage), and of infection sources by CT scan, followed by administration of broad-spectrum anti-infectives. Neuromuscular blockage (Cisatracurium ≤ 48 hrs after onset of ARDS), as well as an adequate sedation strategy (score guided) is an important supportive therapy. A negative fluid balance is associated with improved lung function and the use of hemofiltration might be indicated for specific indications. CONCLUSIONS A specific standard of care is required for the management of severe ARDS with refractory hypoxemia.

NIH NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary

NIH NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary 2008-07.

Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report: GOLD Executive Summary.

Vogelmeier CF, Criner GJ, Martinez FJ, et al. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report: GOLD Executive Summary [published correction appears in Eur Respir J. 2017 Jun 22;49(6):]. Eur Respir J. 2017;49(3):1700214. Published 2017 Mar 6. doi:10.1183/13993003.00214-2017

Link to article

This Executive Summary of the Global Strategy for the Diagnosis, Management, and Prevention of COPD (GOLD) 2017 Report focuses primarily on the revised and novel parts of the document. The most significant changes include: 1) the assessment of chronic obstructive pulmonary disease has been refined to separate the spirometric assessment from symptom evaluation. ABCD groups are now proposed to be derived exclusively from patient symptoms and their history of exacerbations; 2) for each of the groups A to D, escalation strategies for pharmacological treatments are proposed; 3) the concept of de-escalation of therapy is introduced in the treatment assessment scheme; 4) nonpharmacologic therapies are comprehensively presented and; 5) the importance of comorbid conditions in managing COPD is reviewed.

European Resuscitation Council and European Society of Intensive Care Medicine 2015 guidelines for post-resuscitation care.

Nolan JP, Soar J, Cariou A, et al. European Resuscitation Council and European Society of Intensive Care Medicine 2015 guidelines for post-resuscitation care [published correction appears in Intensive Care Med. 2016 Mar;42(3):488-9]. Intensive Care Med. 2015;41(12):2039-2056. doi:10.1007/s00134-015-4051-3

Link to article

The European Resuscitation Council and the European Society of Intensive Care Medicine have collaborated to produce these post-resuscitation care guidelines, which are based on the 2015 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. Recent changes in post-resuscitation care include: (a) greater emphasis on the need for urgent coronary catheterisation and percutaneous coronary intervention following out-of-hospital cardiac arrest of likely cardiac cause; (b) targeted temperature management remains important but there is now an option to target a temperature of 36 °C instead of the previously recommended 32-34 °C; (c) prognostication is now undertaken using a multimodal strategy and there is emphasis on allowing sufficient time for neurological recovery and to enable sedatives to be cleared; (d) increased emphasis on rehabilitation after survival from a cardiac arrest.

Hyperoxemia in the ICU

Hyperoxemia can be defined as an increase in arterial oxygen partial pressure (PaO2) to a level greater than 120 mmHg (16 kPa) (1, 2). It is considered to be moderate for levels ranging between 120 and 200 mmHg, and severe if PaO2 exceeds 200 mmHg (27 kPa) (3). Hyperoxemia is caused by hyperoxia (an increase in oxygen) and occurs in 22% to 50% of mechanically ventilated patients in the ICU (1, 3-6).