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Practice Rapid Recommendations

Oxygen therapy for acutely ill medical patients: a clinical practice guideline

BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4169 (Published 24 October 2018) Cite this as: BMJ 2018;363:k4169

Overview of recommendations

Applies to:Patients withacute stroke or myocardialinfarction 100 99 98 97 96 95 94 93 92 91 90 89 88 87 Recommendation 1 Stop oxygen therapy no higherthan 96% saturation Recommendation 3 Do not start oxygen therapy at or above 93% saturation Recommendation 2 We suggest not starting oxygen therapy between 90-92% saturation Applies to:Acutely ill adult medical patients (with exceptions) STRONG WEAK STRONG Peripheral capillary oxygen saturation (SpO2)

Recommendation 1 - upper limit

or ≥97% target ≤96% target An upper limit of oxygen saturation target 97% or higher An upper limit of oxygen saturation target of no more than 96% Applies to: Does not apply to patients with: Including: Acutely ill adult medical patients already receiving oxygen therapy ≥97% target ≤96% target Carbon monoxide poisoning Critically ill surgical patients Sickle cell crisis Pneumothorax Cluster headaches

We recommend that oxygen saturation be maintained no higher than 96% Moredetails Strong All or nearly all informed people would likely want this option. Benefits outweigh harms for almost everyone. Weak Most people would likely want this option. Benefits outweigh harms for the majority, but not for everyone. Weak Most people would likely want this option. Benefits outweigh harms for the majority, but not for everyone. Strong All or nearly all informed people would likely want this option. Benefits outweigh harms for almost everyone.

Comparison of benefits and harms

Favours ≥97% target Favours ≤96% target Evidence quality Events per 1000 people In hospital No important difference The panel found that this difference was not important for most patients, because the intervention effects were negligible and/or very imprecise, for example confidence intervals that include both important benefit and harm

51 11 fewer Mortality Moderate More 62

Risk of Bias No serious concerns Imprecision Borderline Indirectness Serious Inconsistency No serious concerns Publication bias No serious concerns Liberal oxygen therapy probably increases mortality Note: There is a dose-response gradient with larger increases in oxygen saturation being associated with greater mortality risk

No important difference Hospital acquired infection High More 132 127

Risk of Bias No serious concerns Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Liberal oxygen therapy has little or no impact on hospital acquired infection
Mean number of days

No important difference Length of hospitalisation Moderate More 10.3 10.5

Risk of Bias No serious concerns Imprecision No serious concerns Indirectness No serious concerns Inconsistency Serious Publication bias No serious concerns Liberal oxygen therapy probably has little or no impact on length of stay in hospital
See all outcomes
When upper limits for oxygen saturation are lowered, nursing demands will increase The ideal upper limit for those receiving oxygen therapy is probably lower than 96%, for example 94% Ideal levels Almost all patients will place a high value on avoiding even a small increased risk of death Values and preferences Key practical issues Sometimes causes one or more of: claustrophobia, nasal or throat dryness, hoarseness, irritation Oxygen delivery devices may hinder patients’ freedom of movement, eating, drinking, and communication Oxygen therapy No practical issues No oxygen therapy

Recommendation 2 - lower limit (90-92%)

or Oxygen therapy No oxygen therapy Oxygen therapy No oxygen therapy Provision of supplemental oxygen No provision of supplemental oxygen Applies to people with: or + Acute stroke Acute myocardialinfarction Oxygen saturation of 90-92% on ambient air

We suggest not providing oxygen therapy More details Strong All or nearly all informed people would likely want this option. Benefits outweigh harms for almost everyone. Weak Most people would likely want this option. Benefits outweigh harms for the majority, but not for everyone. Weak Most people would likely want this option. Benefits outweigh harms for the majority, but not for everyone. Strong All or nearly all informed people would likely want this option. Benefits outweigh harms for almost everyone.

Comparison of benefits and harms - patients with stroke

Favours oxygen therapy Favours no oxygen therapy Evidence quality Events per 1000 people In hospital No important difference The panel found that this difference was not important for most patients, because the intervention effects were negligible and/or very imprecise, for example confidence intervals that include both important benefit and harm

Mortality Low More 87 69 18 fewer

Risk of Bias No serious concerns Imprecision Serious Indirectness Serious Inconsistency No serious concerns Publication bias No serious concerns Oxygen therapy may not decrease mortality
3-6 months

No important difference Functionally dependent Low More 560 549

Risk of Bias No serious concerns Imprecision Serious Indirectness Serious Inconsistency No serious concerns Publication bias No serious concerns Oxygen therapy may have little or no impact on becoming functionally dependent Functional dependancy is defined as a modified Rankin score greater than 2

No important difference Severe disability Low More 270 270

Risk of Bias No serious concerns Imprecision Serious Indirectness Serious Inconsistency No serious concerns Publication bias No serious concerns Oxygen therapy may have little or no impact on severe disability Severe disability is defined as a modified Rankin score greater than 4
See all outcomes

Comparison of benefits and harms - patients with myocardial infarction

Favours oxygen therapy Favours no oxygen therapy Evidence quality Events per 1000 people In hospital No important difference The panel found that this difference was not important for most patients, because the intervention effects were negligible and/or very imprecise, for example confidence intervals that include both important benefit and harm

No important difference Mortality Low More 55 49

Risk of Bias No serious concerns Imprecision Serious Indirectness Serious Inconsistency No serious concerns Publication bias No serious concerns Oxygen therapy may not decrease mortality

No important difference Chest pain requiring antianginal Low More 215 211

Risk of Bias No serious concerns Imprecision Serious Indirectness Serious Inconsistency No serious concerns Publication bias No serious concerns Oxygen therapy may have little or no impact on chest pain
6 months

Coronary revascularisation Low More 106 34 fewer 72

Risk of Bias No serious concerns Imprecision Serious Indirectness Serious Inconsistency No serious concerns Publication bias No serious concerns Oxygen therapy may increase coronary revascularisation procedures
6 months to 1 year

Recurrent myocardial infarction Moderate More 62 11 fewer 51

Risk of Bias No serious concerns Imprecision No serious concerns Indirectness Serious Inconsistency No serious concerns Publication bias No serious concerns Oxygen therapy probably does not reduce the risk of recurrent myocardial infarction
See all outcomes
The ideal oxygen saturation at which to start oxygen therapy is uncertain, but is probably 90% or lower Ideal levels Wearing a mask or nasal prongs can be uncomfortable. However, aside from terminally ill patients, almost all patients are likely to accept this discomfort for even a small reduction in chance of death Values and preferences Key practical issues Sometimes causes one or more of: claustrophobia, nasal or throat dryness, hoarseness, irritation Oxygen delivery devices may hinder patients’ freedom of movement, eating, drinking, and communication Oxygen therapy No practical issues No oxygen therapy

Recommendation 3 - lower limit (>92%)

or Oxygen therapy No oxygen therapy Provision of supplemental oxygen No provision of supplemental oxygen Applies to people with: or + Acute stroke Acute myocardialinfarction Oxygen saturation of greater than 92% on ambient air Oxygen therapy No oxygen therapy

We recommend not providing oxygen therapy Moredetails Strong All or nearly all informed people would likely want this option. Benefits outweigh harms for almost everyone. Weak Most people would likely want this option. Benefits outweigh harms for the majority, but not for everyone. Weak Most people would likely want this option. Benefits outweigh harms for the majority, but not for everyone. Strong All or nearly all informed people would likely want this option. Benefits outweigh harms for almost everyone.

Comparison of benefits and harms - patients with stroke

Favours oxygen therapy Favours no oxygen therapy Evidence quality Events per 1000 people In hospital No important difference The panel found that this difference was not important for most patients, because the intervention effects were negligible and/or very imprecise, for example confidence intervals that include both important benefit and harm

Mortality Moderate More 87 69 18 fewer

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Oxygen therapy probably does not decrease mortality
3-6 months

No important difference Functionally dependent Moderate More 560 549

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Oxygen therapy probably has little or no impact on becoming functionally dependent Functional dependancy is defined as a modified Rankin score greater than 2

No important difference Severe disability Moderate More 270 270

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Oxygen therapy probably has little or no impact on severe disability Severe disability is defined as a modified Rankin score greater than 4
See all outcomes

Comparison of benefits and harms - patients with myocardial infarction

Favours oxygen therapy Favours no oxygen therapy Evidence quality Events per 1000 people In hospital No important difference The panel found that this difference was not important for most patients, because the intervention effects were negligible and/or very imprecise, for example confidence intervals that include both important benefit and harm

No important difference Mortality Moderate More 55 49

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Oxygen therapy probably does not decrease mortality

No important difference Chest pain requiring antianginal Moderate More 215 211

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Oxygen therapy probably has little or no impact on chest pain
6 months

Coronary revascularisation Moderate More 106 34 fewer 72

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Oxygen therapy probably increases coronary revascularisation procedures
6 months to 1 year

Recurrent myocardial infarction High More 62 11 fewer 51

Risk of Bias No serious concerns Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Oxygen therapy does not reduce the risk of recurrent myocardial infarction
See all outcomes
The ideal oxygen saturation at which to start oxygen therapy is uncertain, but is likely below 93% Ideal levels Wearing a mask or nasal prongs can be uncomfortable. However, aside from terminally ill patients, almost all patients are likely to accept this discomfort for even a small reduction in chance of death Values and preferences Key practical issues Sometimes causes one or more of: claustrophobia, nasal or throat dryness, hoarseness, irritation Oxygen delivery devices may hinder patients’ freedom of movement, eating, drinking, and communication Oxygen therapy No practical issues No oxygen therapy

©BMJ Publishing Group Limited.

Disclaimer: This infographic is not a validated clinical decision aid. This information is provided without any representations, conditions or warranties that it is accurate or up to date. BMJ and its licensors assume no responsibility for any aspect of treatment administered with the aid of this information. Any reliance placed on this information is strictly at the user's own risk. For the full disclaimer wording see BMJ's terms and conditions: https://www.bmj.com/company/legal-information/

Find recommendations, evidence summaries and consultation decision aids for use in your practice
  1. Reed A C Siemieniuk, methods co-chair, general internist1,
  2. Derek K Chu, general internist2,
  3. Lisa Ha-Yeon Kim, clinical fellow2,
  4. Maria-Rosa Güell-Rous, senior pulmonology consultant3,
  5. Waleed Alhazzani, critical care clinician12,
  6. Paola M Soccal, pulmonologist45,
  7. Paul J Karanicolas, associate professor of surgery6,
  8. Pauline D Farhoumand, general internist7,
  9. Jillian L K Siemieniuk, registered nurse8,
  10. Imran Satia, respiratory physician2,
  11. Elvis M Irusen, professor of pulmonology and intensive care9,
  12. Marwan M Refaat, cardiologist10,
  13. J Stephen Mikita, patient partner11,
  14. Maureen Smith, patient partner12,
  15. Dian N Cohen, patient partner13,
  16. Per O Vandvik, general internist14,
  17. Thomas Agoritsas, general internist1715,
  18. Lyubov Lytvyn, patient partnership liaison1,
  19. Gordon H Guyatt, chair, distinguished professor12
  1. 1Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton L8S 4K1, Canada
  2. 2Department of Medicine, McMaster University, Hamilton L8S 4K1, Canada
  3. 3Departament de Pneumologia, Hospital de la Santa Creu I Sant Pau. Barcelona, Catalonia 08041, Spain
  4. 4Division of Pulmonary Medicine, Geneva University Hospitals, 1211 Geneva, Switzerland
  5. 5Faculty of Medicine, Geneva University, 1206 Geneva, Switzerland
  6. 6Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario M4N 3M5, Canada
  7. 7Division General Internal Medicine, University Hospitals of Geneva, 1205 Geneva, Switzerland
  8. 8Alberta Health Services, Calgary, Alberta T1Y 6J4, Canada
  9. 9Divisions of Pulmonology and Medical Intensive Care, Stellenbosch University, Cape Town 7505, South Africa
  10. 10Departments of Internal Medicine and Biochemistry & Molecular Genetics, American University of Beirut Faculty of Medicine and Medical Center, Beirut 1107 2020, Lebanon
  11. 11Salt Lake City, Utah 84106, USA
  12. 12Ottawa, Ontario K2P 1C8, Canada
  13. 13Hatley, Quebec J0B 4B0, Canada
  14. 14Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
  15. 15Division Clinical Epidemiology, University Hospitals of Geneva, 1205 Geneva, 1205, Switzerland
  1. Correspondence: R A C Siemieniuk reed.siemieniuk{at}medportal.ca

What you need to know

  • It is a longstanding cultural norm to provide supplemental oxygen to sick patients regardless of their blood oxygen saturation

  • A recent systematic review and meta-analysis has shown that too much supplemental oxygen increases mortality for medical patients in hospital

  • For patients receiving oxygen therapy, aim for peripheral capillary oxygen saturation (SpO2) of ≤96% (strong recommendation)

  • For patients with acute myocardial infarction or stroke, do not initiate oxygen therapy in patients with SpO2 ≥90% (for ≥93% strong recommendation, for 90-92% weak recommendation)

  • A target SpO2 range of 90-94% seems reasonable for most patients and 88-92% for patients at risk of hypercapnic respiratory failure; use the minimum amount of oxygen necessary

What is the best way to use oxygen therapy for patients with an acute medical illness? A systematic review published in the Lancet in April 2018 found that supplemental oxygen in inpatients with normal oxygen saturation increases mortality.1 Its authors concluded that oxygen should be administered conservatively, but they did not make specific recommendations on how to do it. An international expert panel used that review to inform this guideline. It aims to promptly and transparently translate potentially practice-changing evidence to usable recommendations for clinicians and patients.2 The panel used the GRADE framework and following standards for trustworthy guidelines.3

The panel asked;

  • In acutely ill patients, when should oxygen therapy be started? (What is the lower limit of peripheral capillary oxygen saturation (SpO2)?)

  • In acutely ill patients receiving oxygen therapy, how much oxygen should be given? (What is the upper limit of SpO2?)

The panel makes a strong recommendation for maintaining an oxygen saturation of no more than 96% in acutely ill medical patients (upper limit). The panel did not make a recommendation on when to start (the lower limit) for …

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