Self-reported attitudes versus actual practice of oxygen therapy by ICU physicians and nurses

Hendrik Jf Helmerhorst, Marcus J Schultz, Peter Hj van der Voort, Robert J Bosman, Nicole P Juffermans, Evert de Jonge, David J van Westerloo, Hendrik Jf Helmerhorst, Marcus J Schultz, Peter Hj van der Voort, Robert J Bosman, Nicole P Juffermans, Evert de Jonge, David J van Westerloo

Abstract

Background: High inspiratory oxygen concentrations are frequently administered in ventilated patients in the intensive care unit (ICU) but may induce lung injury and systemic toxicity. We compared beliefs and actual clinical practice regarding oxygen therapy in critically ill patients.

Methods: In three large teaching hospitals in the Netherlands, ICU physicians and nurses were invited to complete a questionnaire about oxygen therapy. Furthermore, arterial blood gas (ABG) analysis data and ventilator settings were retrieved to assess actual oxygen practice in the same hospitals 1 year prior to the survey.

Results: In total, 59% of the 215 respondents believed that oxygen-induced lung injury is a concern. The majority of physicians and nurses stated that minimal acceptable oxygen saturation and partial arterial oxygen pressure (PaO2) ranges were 85% to 95% and 7 to 10 kPa (52.5 to 75 mmHg), respectively. Analysis of 107,888 ABG results with concurrent ventilator settings, derived from 5,565 patient admissions, showed a median (interquartile range (IQR)) PaO2 of 11.7 kPa (9.9 to 14.3) [87.8 mmHg], median fractions of inspired oxygen (FiO2) of 0.4 (0.4 to 0.5), and median positive end-expiratory pressure (PEEP) of 5 (5 to 8) cm H2O. Of all PaO2 values, 73% were higher than the upper limit of the commonly self-reported acceptable range, and in 58% of these cases, neither FiO2 nor PEEP levels were lowered until the next ABG sample was taken.

Conclusions: Most ICU clinicians acknowledge the potential adverse effects of prolonged exposure to hyperoxia and report a low tolerance for high oxygen levels. However, in actual clinical practice, a large proportion of their ICU patients was exposed to higher arterial oxygen levels than self-reported target ranges.

Keywords: Hyperoxia; Intensive care medicine; Lung injury; Mechanical ventilation; Oxygen; Questionnaire.

Figures

Figure 1
Figure 1
Self-reported tolerance limits for short-term (15 min, open bars) and longer term (24 to 48 h, closed bars) oxygenation. Bars represent percentage of respondents (n = 200). The presented case is a young to middle-aged ARDS patient in the ICU requiring mechanical ventilation. Ventilator settings (e.g., PEEP, airway pressures, I/E ratio, flow ratio) are optimized with respect to the PaO2/FiO2 ratio and hemodynamic indices. Lung injury due to high FiO2 and/or ventilator settings is minimized. There is no evidence to indicate end-organ ischemia, and hemodynamics are stable.

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