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Nasal high-flow preoxygenation for endotracheal intubation in the critically ill patient: a randomized clinical trial
PurposePreoxygenation with high-flow therapy by nasal cannulae (HFNC) is now widespread in the intensive care unit (ICU). However, no large randomized study has assessed its relevance in non-severely hypoxemic patients. In a randomized controlled trial (PROTRACH study), we aimed to evaluate preoxygenation with HFNC vs. standard bag-valve mask oxygenation (SMO) in non-severely hypoxemic patients during rapid sequence intubation (RSI) in the ICU.MethodsRandomized controlled trial including non-severely hypoxemic patients requiring intubation in the ICU. Patients received preoxygenation by HFNC or SMO during RSI. HFNC was maintained throughout the intubation procedure whereas SMO was removed to perform laryngoscopy. The primary outcome was the lowest pulse oximetry (SpO2) throughout the intubation procedure. Secondary outcomes included drop in SpO2, adverse events related to intubation, and outcome in the ICU.ResultsA total of 192 patients were randomized. In the intent-to-treat analysis, 184 patients (HFNC n = 95; SMO n = 89), the median [IQR] lowest SpO2 was 100% [97; 100] for HFNC and 99% [95; 100] for the SMO group (P = 0.30). Mild desaturation below 95% was more frequent with SMO (23%) than with HFNC (12%) (RR 0.51, 95% CI 0.26–0.99, P = 0.045). There were fewer adverse events in the HFNC group (6%) than in the SMO group (19%) (RR 0.31, 95% CI 0.13–0.76, P = 0.007), including fewer severe adverse events, respectively 6 (6%) and 14 (16%) with HFNC and SMO (RR 0.38, 95% CI 0.15–0.95, P = 0.03).ConclusionsCompared with SMO, preoxygenation with HFNC in the ICU did not improve the lowest SpO2 during intubation in the non-severely hypoxemic patients but led to a reduction in intubation-related adverse events.Trial registrationClinical trial Submission: 7 March 2016. Registry name: Benefits of high-flow nasal cannulae oxygen for preoxygenation during intubation in non-severely hypoxemic patients: the PROTRACH study. Clinicaltrials.gov identifier: NCT02700321. Eudra CT: 2015-A00145-44. CPP: 15/13-975 (Comité de protection des personnes de Rennes). URL registry: https://clinicaltrials.gov/ct2/show/record/NCT02700321.
Journal Article
Lower or Higher Oxygenation Targets for Acute Hypoxemic Respiratory Failure
Even though supplemental oxygen is used for the treatment of patients with hypoxemic respiratory failure, the most effective oxygenation targets are not known. In this randomized trial, a lower oxygenation target did not result in lower mortality than a higher target.
Journal Article
Liberal or Conservative Oxygen Therapy for Acute Respiratory Distress Syndrome
Patients with acute respiratory distress syndrome received conservative oxygen therapy or liberal oxygen therapy for 7 days. The trial was prematurely stopped because of futility and safety concerns. Mortality at day 28 was 34.3% in the conservative-oxygen group and 26.5% in the liberal-oxygen group. Five mesenteric ischemic events occurred, all in the conservative-oxygen group.
Journal Article
Optimised oxygenation improves functional capacity during daily activities in patients with COPD on long-term oxygen therapy: a randomised crossover trial
BackgroundMinimising hypoxaemia during submaximal walking tests has a positive effect on exercise capacity and dyspnoea in patients with chronic obstructive pulmonary disease (COPD) on long-term oxygen therapy (LTOT). However, the impact of optimising oxygenation during everyday tasks remains unexplored. Therefore, we investigated the effects of maintaining a target saturation on activities of daily living (ADL) using automated oxygen titration compared with conventional fixed oxygen flow.MethodsIn a double-blinded, randomised crossover trial, patients with COPD on LTOT performed two GlittreADL tests to assess the functional capacity of everyday activities using (1) their fixed oxygen dose and (2) an adjusted flow from 0 to 8 L/min targeting a peripheral oxygen saturation (SpO2) of 90–94%. A closed-loop device automatically titrated the oxygen based on information from a Bluetooth wrist pulse oximeter.Results31 patients (mean±SD age: 72.8±5.9 years, forced expiratory volume in 1 s of % predicted: 36.7±12.7) were included. The patients reduced the time to perform the ADL test by median (IQR) 38 (12–73) s, p<0.001, using automated titration compared with the fixed oxygen flow. The oxygen flow in the automated arm more than tripled to 5.4 (4.1–6.8) versus 1.6 (1.1–2.1) L/min (fixed) during the test, p<0.001, while the time spent within SpO2-target was increased from 19% to 49%, p=0.002. Correspondingly, the patients experienced less dyspnoea (BorgCR10); 5 (3–7) versus 6 (4–8), p<0.001, in favour of the automated oxygen titration.ConclusionsImproving oxygenation and extending the time spent within target saturation reduced dyspnoea and improved functional capacity in ADL in patients with COPD on LTOT.Trial registration numberNCT05553847.
Journal Article
Conservative Oxygen Therapy during Mechanical Ventilation in the ICU
In this study, patients who were undergoing mechanical ventilation received conservative oxygen therapy (i.e., a fraction of inspired oxygen set at 0.21) or usual oxygen therapy with no specific limit, with a lower limit of 90% for oxygen saturation. The number of ventilator-free days did not differ significantly between the two groups.
Journal Article