Background:

 

Acute cardiogenic pulmonary edema (ACPE) is a common medical emergency presenting to the Emergency Department (ED) and Oxygen is commonly given to reverse hypoxaemia.[1] However, there is growing evidence to suggest the harm of over-oxygenation in a variety of critical conditions.[2-9] So far, there is little to no evidence of the effects of hyperoxaemia in ACPE. 

 

Objectives:

 

We investigated the effects of hyperoxemia on morbidity and mortality in ACPE.

 

Method:

 

We conducted a retrospective cohort study of patients presenting to a tertiary hospital ED with ACPE with an arterial blood gas (ABG) performed. Patients were classified into three categories according to their partial pressures of arterial Oxygen (PaO2) on the first ED ABG: namely hypoxemic (<75 mmHg), normoxemic (75-100 mmHg) and hyperoxemic (>100 mmHg). The primary outcome was the ED rates of mechanical (invasive and noninvasive) ventilation (MV) between the groups after correction for known risk factors.[11-15] Secondary outcomes included hospital length of stay and rates of intra-hospital mortality. 

 

Results:

 

We recruited 335 patients; 34.0% had hyperoxemia. 27.5% had normoxemia and 38.5% had hypoxemia. The adjusted odds ratios (OR) for MV of the hyperoxemic and hypoxemic groups were 0.98 (95% CI: 0.53–1.79) and 1.38 (95% CI 0.77–2.48) (reference: normoxemic group). Intubation rates for the groups were: hyperoxemic 12/114 (10.6%) vs normoxemic 6/92 (6.5%) vs hypoxemic 15/129 (11.6%) (P=0.43). Secondary outcome rates were comparable between the groups.

 

Conclusion:

 

Our study did not illustrate any statistically significant effects of hyperoxemia on our primary and secondary outcomes as compared to hypoxemia and normoxemia in ED patients with ACPE.

Tables:

References:

 

1. Gray A, Goodacre S, Newby DE, Masson M, Sampson F, Nicholl J; 3CPO Trialists. Noninvasive ventilation in acute cardiogenic pulmonary edema. N Engl J Med 2008; 359:142–151.

2. Damiani E, Adrario E, Girardis M, Romano R, Pelaia P, Singer M, Donati A. Arterial hyperoxia and mortality in critically ill patients: a systematic review and meta-analysis. Crit Care 2014; 18:711.

3. Helmerhorst HJ, Roos-Blom MJ, van Westerloo DJ, de Jonge E. Association between arterial hyperoxia and outcome in subsets of critical illness: a systematic review, meta-analysis, and meta-regression of cohort studies. Crit Care Med 2015; 43:1508–1519.

4. Hofmann R, James SK, Jernberg T, Lindahl B, Erlinge D, Witt N, et al.; DETO2X–SWEDEHEART Investigators. Oxygen therapy in suspected acute myocardial infarction. N Engl J Med 2017; 377:1240–1249.

5. Stub D, Smith K, Bernard S, Nehme Z, Stephenson M, Bray JE, et al.; AVOID Investigators. Air versus oxygen in ST-segment-elevation myocardial infarction. Circulation 2015; 131:2143–2150.

6. Janz DR, Hollenbeck RD, Pollock JS, McPherson JA, Rice TW. Hyperoxia is associated with increased mortality in patients treated with mild therapeutic hypothermia after sudden cardiac arrest. Crit Care Med 2012;40:3135–3139.

7. Wang CH, Chang WT, Huang CH, Tsai MS, Yu PH, Wang AY, et al. The effect of hyperoxia on survival following adult cardiac arrest: a systematic review and meta-analysis of observational studies. Resuscitation 2014; 85:1142–1148.

8. Austin MA, Wills 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.

9. Khoshnood A, Carlsson M, Akbarzadeh M, Bhiladvala P, Roijer A, Nordlund D, et al. Effect of oxygen therapy on myocardial salvage in ST elevation myocardial infarction: the randomized SOCCER trial. Eur J Emerg Med 2018; 25:78–84.

11. Masip J, P ez J, Merino M, Parejo S, Vecilla F, Riera C, et al. Risk factors for intubation as a guide for noninvasive ventilation in patients with severe acute cardiogenic pulmonary edema. Intensive Care Med 2003; 29:1921–1928.

12. Di Marco F, Tresoldi S, Maggiolini S, Bozzano A, Bellani G, Pesenti A, Fumagalli R. Risk factors for treatment failure in patients with severe acute cardiogenic pulmonary oedema. Anaesth Intensive Care 2008; 36:351–359.

13. Tavazzi L, Senni M, Metra M, Gorini M, Cacciatore G, Chinaglia A, et al.; IN-HF (Italian Network on Heart Failure) Outcome Investigators. Multicenter prospective observational study on acute and chronic heart failure: oneyear follow-up results of IN-HF (Italian Network on Heart Failure) outcome registry. Circ Heart Fail 2013; 6:473–481.

14. Hawkins NM, Virani S, Ceconi C. Heart failure and chronic obstructive pulmonary disease: the challenges facing physicians and health services. Eur Heart J 2013; 34:2795–2803.

15. Hawkins NM, Petrie MC, Jhund PS, Chalmers GW, Dunn FG, McMurray JJ. Heart failure and chronic obstructive pulmonary disease: diagnostic pitfalls and epidemiology. Eur J Heart Fail 2009; 11:130–139.