Choosing Wisely : ®

Things We Do
for No Reason™
Supplemental Oxygen for Patients without Hypoxemia

Based on Moss BJ, Sargsyan Z. Supplemental Oxygen for Patients without Hypoxemia. J
Hosp Med. 2020 Apr 1;14(4):242-244.

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Clinical Scenario
• 65-year-old woman with hypertension is hospitalized with
community-acquired pneumonia.

• Vital signs: Temperature 100.1F, heart rate 110, BP 110/60,

• Nurse places her on 3L/min of oxygen via nasal cannula, and her
saturation rises to 99%

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Why You Might Think This is Necessary
• Supplemental oxygen use without clear indications is common 1-2

• Presumed or theoretical benefit of additional oxygen delivery to

• It is easy to conflate dyspnea with hypoxemia and assume that

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Why This Is Unnecessary and Potentially Harmful:
Theory and Practice
• There is a difference between hypoxemia (low oxygen levels in blood)
and tissue hypoxia (e.g. from an occluded coronary artery).
Supplemental oxygen does not mitigate the latter.
• A variety of mechanisms cause dyspnea, most of which do not involve
hypoxemia
• In a normoxemic patient, increasing inspired fraction of oxygen does not
meaningfully increase oxygen-carrying capacity
• Providing supplemental oxygen to a patient who is not hypoxemic may
delay the recognition of cardiopulmonary decompensation by delaying
detection of hypoxemia
• Oxygen administration has direct and indirect costs, including those of
supplies, care coordination, and monitoring

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Why This Is Unnecessary and Potentially Harmful:
Evidence
• Supraphysiologic levels of dissolved oxygen can cause lung injury,
endothelial dysfunction, inflammatory activation, and systemic and coronary
vasoconstriction3-5
• Hyperoxia can worsen pulmonary shunting by reversing adaptive pulmonary
hypoxic vasoconstriction4
• In patients with COPD at risk for hypercarbia, oxygen titrated to a goal SpO2
outside 88-92% is associated with two-fold risk of mortality 6
• Multiple RCTs of supplemental oxygen in patients with myocardial infarction
have shown increased mortality when oxygen is administered in the absence
of hypoxemia5,7-9
• Trials of liberal oxygen use in other settings including critical illness, septic
shock, ischemic stroke, traumatic brain injury, and post-cardiac arrest have
also linked hyperoxia with increased mortality and adverse events. 10-11

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What You Should Do Instead / Recommendations
• Treat oxygen like any other drug and administer only after
assessment of indications, intended benefits, and possible harms
• Apply recent society guidelines in various clinical scenarios to
appropriately treat hypoxemia while avoiding hyperoxemia:
• In patients with MI, initiate oxygen only if SpO2 < 90% 9
• In patients at risk for hypercapnia (e.g. COPD), target SpO2 of 88-
92%6
• For most other acutely ill patients, initiate if SpO2 < 90-92% and
target SpO2 no higher than 94-96%12-13
• Supplemental oxygen may be indicated despite normoxemia in
patients with carbon monoxide poisoning, decompression injury,
gas embolism, cluster headache, sickle cell crisis, and
pneumothorax

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Conclusions
• Strong pathophysiologic and clinical evidence suggests that
supplemental oxygen in patients without hypoxemia is
unnecessary and can cause harm
• Individuals and institutions should revise practices and policies
that contribute to unnecessary use of supplemental oxygen

Case Scenario
• The patient’s nasal cannula was removed and reassurance
was provided about good oxygen levels on ambient air
• The physician shared reasoning with the patient’s nurse and
asked that oxygen levels continue to be monitored with vital
sign checks

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References
Subset of references from Moss BJ, Sargsyan Z. Supplemental Oxygen for Patients without Hypoxemia. J Hosp Med. 2020 Apr 1;14(4):242-
244.

1. Burls A, Emparanza JI, Quinn T, Cabello J. Oxygen use in acute myocardi- al infarction: an online survey of health professionals’ practice and beliefs. Emerg Med J. 2010;27(4):283-286.
https://doi.org/10.1136/emj.2009.077370.

2. Hale KE, Gavin C, O’Driscoll BR. Audit of oxygen use in emergency ambulanc- es and in a hospital emergency department. Emerg Med J. 2008;25(11):773- 776. https://doi.org/10.1136/emj.2008.059287.

3. Helmerhorst HJ, Schultz MJ, van der Voort PH, de Jonge E, van Wasterloo DJ. Bench-to-bedside review: the effects of hyperoxia during critical illness. Crit Care. 2015;19(1):284.
https://doi.org/10.1186/s13054-015-0996-4.

4. Downs JB. Has oxygen administration delayed appropriate respiratory care? Fallacies regarding oxygen therapy. Respir Care. 2003;48(6):611-620.

5. Rawles JM, Kenmure AC. Controlled trial of oxygen in uncomplicated myo- cardial infarction. Br Med J. 1976;1(6018):1121-1123. https://doi.org/10.1136/ bmj.1.6018.1121.

6. Austin MA, Willis KE, Blizzard L, Walters EH, Wood-Baker R. Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial.
BMJ. 2010;341:c5462. https://doi.org/10.2307/20800296.

7. Stub D, Smith K, Bernard S, et al. Air versus oxygen in ST-segment-eleva- tion myocardial infarction. Circulation. 2015;131(24):2143-2150. https://doi. org/10.1161/CIRCULATIONAHA.114.014494.

8. Hofman R. Witt N, Lagergvist B, et al. Oxygen therapy in ST-elevation myocar- dial infarction. Eur Heart J. 2018;39(29):2730-2739. https://doi.org/10.1093/ eurheartj/ehy326.

9. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the manage- ment of acute myocardial infarction in patients presenting with ST-segment elevation: the Task Force for the management of
acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018:39(2):119-177. https://doi.org/10.1093/eurheartj/ehx393.

10. Girardis M, Busani S, Damiani E, et al. Effect of conservative vs conventional oxygen therapy on mortality among patients in an intensive care unit. JAMA. 2016;316(15):1583-1589.
https://doi.org/10.1001/jama.2016.11993.

11. Asfar P, Schortgen F, Boisramé-Helms J, et al. Hyperoxia and hyperton- ic saline in patients with septic shock (HYPERS2S): a two-by-two factorial, multicentre, randomised, clinical trial. Lancet Respir
Med. 2017:5(3):180-190. https://doi.org/10.1016/S2213-2600(17)30046-2.

12. O’Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017;72(1):ii1-ii90. https://doi. org/10.1136/thoraxjnl-2016-209729.

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

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Citation
To cite this teaching tool:

Sargsyan Z; Moss B. Things We Do For No Reason: Supplemental Oxygen In Patients

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