Oxygen Saturation Targets – Covid Guidelines India

This recommendation applies to acute COVID-19 in adults. Some of our recommendations vary according to the severity of COVID-19 illness. Definitions of the categories are based on the World Health Organization (WHO) criteria and can be viewed by clicking the plus (+) signs below.

RECOMMENDATION: In people with COVID-19, the group recommends respiratory support measures targeting a peripheral oxygen saturation (SpO₂) of 94-98%, and not a lower saturation target as there is insufficient evidence and potential harm (Conditional recommendation, very low certainty evidence).

DATE OF RECOMMENDATION: 14th February 2022

GOOD PRACTICE STATEMENTS RELATED TO THE RECOMMENDATION

Patients receiving respiratory support measures must have their SpO₂ monitored regularly as oxygen toxicity is a risk with any person on supplementary oxygen.

The group acknowledged that some hospitals and clinicians may set a lower SpO₂ target when oxygen supplies are short, but care should be taken to not set a target lower than 90% for patients without underlying risk of hypercapnic respiratory failure (e.g. those with chronic obstructive pulmonary disease & obesity hypoventilation syndrome).

Justification

There is a paucity of direct evidence for safe SpO₂targets in patients with COVID-19. In brief the group considered evidence from one systematic review and four individual randomised trials comparing higher vs. lower SpO₂ targets in patients with a variety of causes of hypoxic respiratory failure. One of the trials included some patients with COVID-19, for which a post hoc subgroup analysis was conducted¹. The four trials did not address the PICO question pre-defined by the group, and varied amongst each other in terms of participant characteristics (including causes of their need for oxygen or respiratory support therapy), interventions & comparator target ranges, and outcomes. They also varied substantially in terms of the methods used to monitor SpO₂, including frequency of monitoring, and invasive vs. non-invasive options. Furthermore, the COVID-19 subgroup analysed separately in one of the trials was too small and infrequently monitored to be considered as direct evidence¹.

Adverse event measurement and reporting was limited and varied between trials. One trial reported a significantly higher proportion of patients being diagnosed with mesenteric ischaemia in the group with the lower SpO₂ target⁹. The trial used a lower target than that defined by the group (88-92% vs. 90-94%), and this is a life-threatening event plausibly caused by hypoxia. This raises safety concerns about routine use of lower SpO₂ targets. Conversely, concerns about oxygen toxicity in other conditions was also noted.

Evidence Summary

Date of latest search: 13^th October 2021.

Date of completion & presentation to Expert Working Group: 29^th October 2021.

Date of planned review: 29^th April 2022.

Evidence synthesis team: Jefferson Daniel J, Avinash A Nair, Richard Kirubakaran, Priscilla Rupali and Bhagteshwar Singh.

Background

Supplemental oxygen is the key intervention for severely and critically unwell COVID-19 patients. Oxygen is often administered liberally to acutely ill adults, but the evidence of benefit vs. risk of achieving high oxygen saturations in the blood is unclear, though in some conditions risk of harm has been demonstrated. The two essential questions that needed an answer were the SpO₂ cut-off point for initiation of oxygen therapy and the ideal target range of SpO₂ that should be maintained while on oxygen and other respiratory support therapy. If a patient can be successfully treated at lower targets without complications, unnecessary over-oxygenation and oxygen wastage could be minimised.

During the peak of the second wave of the SARS CoV-2 pandemic, India faced a severe oxygen shortage^2-3. The government rapidly increased oxygen supply to various states⁴.

To preserve oxygen reserves and avoid wastage, various measures were looked at, such as:

Timing of initiation of oxygen therapy,
Target peripheral oxygen saturation (SpO₂) range with the most clinical benefit,
Lowest safe target oxygenation range,
Timing of intubation and ventilation to achieve the lowest oxygen use

In COVID-19, World Health Organization (WHO) recommends that the target SpO₂ should be ≥ 90%, and supplemental oxygen should be initiated below this cut-off. While an upper limit was not prescribed, it was understood that the patient should have a SpO₂ of 90% or above at all times⁵. The US National Institutes of Health, British Thoracic Society, Italian Thoracic Society and the ICMR Covid-19 National Taskforce (India) recommend a SpO₂ target of 92% to 96%^6-8. This is based on the IOTA systematic review and LOCO₂ randomized control trial, both based on non-COVID patients^9,10. While the IOTA systematic review includes a high-quality meta-analysis, the population and interventions included in the analysis were diverse. In IOTA, substantial weight was given to trials that included patients with myocardial infarction, neurological disorders, trauma and surgery. Most studies included for analysis defined the interventions (conservative/lower SpO₂ target vs liberal/higher SpO₂ targets) based on a pre-fixed standard fraction of inhaled oxygen (FiO₂) delivered to the patient, rather than titration of FiO₂ to arrive at a target SpO₂ range.

Methods

For studies on this topic, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Epistemonikos, and the COVID‐19‐specific resource covid19.recmap.org published up to 13^th October 2021.

Our population, pre-defined by the Expert Working Group, was inpatients with confirmed or suspected COVID-19 with specific sub-populations: Pre-existing COPD, Obesity, Co-existing cardiac failure (acute/chronic) and Age >65 years.

The intervention was defined as active titration of oxygen delivery or respiratory support by measuring saturation at-least every 6 hours to target a SpO₂ 90-94%.

The comparison was defined as active titration of oxygen delivery or respiratory support by measuring saturation at-least every 6 hours to target a SpO₂ 95-100%.

We planned to extract data for the following outcomes, predefined by the Expert Working Group:

Primary outcome:

• All-cause Mortality

• Need for ventilation (IMV or NIV)

Secondary Outcomes:

• Time to clinical improvement (WHO ordinal scale or other definitions)

• Length of stay in hospital

• Duration of days free from invasive ventilation

• Length of stay in critical care

Adverse events:

1. All

2. Serious

3. Hypoxemia-related events:

1. 1. Mesenteric ischemia
  2. Myocardial infarction/ischemia

4. Others as specified by trials/reviews

We found the non-COVID IOTA review, five non-COVID RCTs, with one of them performing a post-hoc subgroup analysis of COVID-19 patients.

Two reviewers independently assessed the eligibility of search results. Since all RCTs were non-COVID and the COVID subgroup analysis from the HOT-ICU trial¹³ was small and underpowered, we did not perform meta-analysis, and described the findings narratively.

Comments on the non-COVID RCTs.

• While all these were ICU based trials, only CLOSE 2016, LOCO2 and ICU ROX trials included mechanically ventilated patients at recruitment. OXYGEN ICU 2016 and the HOT ICU 2021 trials included patients in the ICU irrespective of their need for ventilation.

• The population varied across the trials. The OXYGEN ICU 2016 and CLOSE 2016 trials recruited only 35% of patients with medical causes of respiratory failure, and the rest had surgical causes. ICU ROX 2020 did not mention the nature of the underlying illness and instead provided details on where the patients were brought to ICU from, for example,the emergency ward and operation theatre. 57% of the HOT ICU 2021 trial patients had pneumonia, while the rest had non-pulmonary causes.

• Trials varied in their reporting of the syndrome necessitating oxygen supplementation, such as respiratory failure and acute respiratory distress syndrome (ARDS), and their causes. Most studies had recruited patients with type 1 respiratory failure; while some had ARDS, others were respiratory failure due to other causes. The following were the proportion of patients with documented ARDS in these trials: OXYGEN ICU 2016 (did not report), CLOSE 2016 (33 - 35%), ICU ROX 2020 (67 - 71%), HOT ICU 2021 (12 - 13%), LOCO2 2020 (100%); OXYGEN ICU 2016 (did not report)

• There was indirectness of evidence due to the differences in SpO₂ targets in each arm across the various RCTs. None of the trials was close to our predefined definition of intervention (conservative;SpO₂ 90-94%) and comparison (liberal;95-100%).

• Some studies monitored partial pressure of oxygen from blood gas analysis while other studies used a peripheral SpO₂ monitor and some used both. It is well known that cold peripheries, peripheral vascular compromise, abnormal haemoglobin, shock and vasoconstriction can cause differences in correlation between SpO₂ and PaO₂ at a particular point, which limits comparability between trials using SpO₂ and those using PaO₂.

• Implemented/resultant SpO₂ varied from the target in some trials. However, as the “intervention” is a package of actions to achieve a target, the effect of this is unclear on the directness of the evidence.

• Monitoring of the patients to pick up deviations from the intended interventions was not uniform across studies. While the LOCO2 2020 trial used six-hourly blood gas analysis, HOT ICU 2021 performed blood gas analysis twice-daily.

HOT ICU COVID-19 subgroup analysis.

The HOT ICU 2021 trial was recruiting patients until the latter half of 2020. They had a subgroup of confirmed COVID-19 PCR-positive patients. The authors performed a posthoc analysis of the COVID positive subgroup and published it separately. There was no difference in mortality between the arms with conservative saturation target group (PaO₂ 60mmHg) compared to the liberal saturation (PaO₂ 90mmHg) target group. However, the conservative saturation target arm had a significantly lower percentage of life support-free days than the liberal arm. This significant difference was not present when the whole HOT ICU 2021 trial data (including the COVID-19 and non-COVID-19 participants) were analysed together. Here, life support was defined as the use of invasive or non-invasive mechanical ventilation, or continuous positive airway pressure, infusion of vasopressors or inotropic agents, or any form of renal replacement therapy.

HOT ICU post-hoc COVID subgroup analysis.

This subgroup had a sample size of around 100 and was not sufficiently powered to describe the outcomes meaningfully. The oxygenation target was primarily based on twice-daily monitoring of arterial partial pressure of oxygen. Intermittent SpO₂ monitoring was done as per the discretion of the treating doctor to adjust the FiO₂ to reach the target PaO₂ levels. The twelve-hour gap in ABG monitoring could have delayed the adjustment needed in the deviated PaO₂ to attain the target range.

• Mortality was around 41% in both arms and was generally higher than other RCTs, however this may be explained by the mortality risk of COVID-19 ARDS earlier in the pandemic. Also, the mortality described is only available for 90 days. Whereas clinically, a one-month mortality would be more useful

• Invasive mechanical ventilation: At recruitment, 44% of the conservative arm and 55% of the liberal arm were already intubated. Around 83% of conservative target arm patients and 97% of liberal target arm group required invasive mechanical ventilation by the end of the study.

• Requirement for intubation (new): 39% of the conservative arm and 41% of the liberal arm needed intubation for the first time after trial recruitment.

Summary:

We did not consider the IOTA systematic review in the evidence contributing directly to this recommendation as the population and definition of interventions were very different from that in our PICO.

The non-COVID RCTs also provided only indirect evidence. One safety concern with lower SpO₂ targets emerged from one trial, with mesenteric ischaemia being more common in the group with the lower SpO₂ target, though this target (88-92%) allowed lower SpO₂ than that considered in our PICO (90-94%). The HOT ICU trial was a post hoc analysis with 109 patients and the data is not powered adequately to make meaningful recommendations.

Results

We critically looked at the five non-COVID RCTs and the post hoc subgroup analysis on COVID-19 patients. The definition of the conservative oxygen arm and the liberal oxygen arm was different across the studies (Table 2). The interventions to maintain the desired SpO₂ target were also different for each arm and varied across the studies. Table 2 summarizes these essential differences.

1. Intensive care unit (ICU) Mortality

The Oxygen ICU Trial 2016 reported that patients in the arm with a conservative SpO₂ target of 94-98% had lower ICU mortality compared to a more liberal target of 97% - 100% SpO₂. The CLOSE 2016 trial and the LOCO2 trial also reported ICU mortality, which did not significantly differ between the two arms.

2. 90-day Mortality

The LOCO2 trial 2020 showed that a conservative SpO₂ target of 88-92% had higher 90-day mortality than a liberal target of > 97%. CLOSE 2016, ICU ROX 2020 trial and Oxygen ICU 2021 also reported 90-day mortality, which did not significantly differ between the two arms.

3. Length of stay in hospital and ICU

Only OXYGEN ICU 2016 and CLOSE 2016 trials reported length of stay in hospital and length of stay in ICU. Both these outcomes were not significantly different between the two arms.

4. Invasive Mechanical Ventilation-free days

The CLOSE 2016 and the ICU ROX 2020 trials reported the number of invasive mechanical ventilation-free days. Neither trial reported a significant difference between the two arms.

5. Adverse Events

The LOCO2 trial 2020 was prematurely stopped due to mesenteric ischaemia in the conservative (lower) oxygen target arm; 5.1% (1.7%–11.4%) vs 0. The prevalence of arrhythmias, seizures and cerebrovascular events (reported to be stroke) were also higher in the conservative oxygen therapy arm. The HOT ICU 2021 trial also reported mesenteric ischaemia, arrhythmias, seizures and strokes, but they were not significantly different between the two arms.

Summary of Characteristics of included studies

Table 1: List of RCTs included in evidence synthesis.

ARDS, acute respiratory distress syndrome; FiO₂, fraction of inspired oxygen; ICU, intensive care unit; IMV, invasive mechanical ventilation.

Table 2: Summary of interventions and saturation targets of the RCTs.

Evidence to Decision

The evidence was deemed to be too indirect to populate an ‘evidence to decision’ template for this intervention, but the group applied ‘evidence to decision’ framework principles to the available evidence and the Indian healthcare context to provide a recommendation. Other existing guidelines and the group’s own expertise were considered to formulate the consensus good practice statements.

Implementation Considerations

As mentioned in the Good Practice Statements, most critical care situations will require an oxygen saturation target of 92-96% to ensure adequate tissue oxygenation and prevent oxygen toxicity. In some subgroups like those with chronic obstructive pulmonary disease or obesity hypoventilation syndromes a lower saturation target may be necessitated. Some guidelines including WHO advise targets lower than 94-98%, keeping in mind possible the global oxygen shortage. On synthesis of available evidence, increased adverse events were only seen in the trial with a substantially lower SpO₂ target of 88-92%. The group acknowledged that a lower SpO₂ target may be applied temporarily in a given facility constrained by the availability of oxygen. However, a target range should not include SpO₂ less than 90%, as this is the lowest advised by any of the guidelines reviewed by the group, and as informed by the group’s own expertise. Any lower target must be reviewed regularly (see Monitoring and Evaluation section), and clinicians should be encouraged to assess patients for hypoxia related events and ensure individual safety regardless of this target.

Regarding monitoring, while measuring SpO₂ using a fingertip probe is quick, easy, and more widely accessible than invasive measurements; various factors may influence the SpO₂ reading, including peripheral vasoconstriction due to any cause, colouring of fingers or nails, the equipment and the method used. Therefore, measurements may need to be re-checked to determine accuracy and a dynamic trend rather than one static reading should inform management decisions. This is especially important when SpO₂ readings are not consistent with the clinical picture.

Subgroup Considerations

The SpO₂ target range provided in the recommendation, as with all of our recommendations, is for non pregnant adults, and should be applied to individual patients after clinical consideration of whether it is applicable in their situation. Target SpO₂ ranges vary for some subgroups of people for physiological reasons, none of whom were specifically studied as subgroups in the trials, and most trials excluded some or all of them:

• Pregnancy: Pregnant women require higher targets than non-pregnant adults, with several guidelines recommending maintenance of SpO₂ of ≥ 94-95% in women with COVID-19.

• Children: There is a lack of evidence regarding SpO₂ targets in children, and while targets are often the same as those for adults, a clinician familiar with managing children should assess and decide the appropriate target for each child.

• Conditions predisposing to hypercapnic respiratory failure: SpO₂ targets are often lower in chronic obstructive pulmonary disease (COPD), obesity hypoventilation syndrome, and with various causes of respiratory depression such as neuromuscular disease and acute intoxication with some drugs, due to the risk of reducing ‘hypoxic drive’ leading to CO₂ retention. Additionally, older adults may have lower baseline SpO₂, so the target SpO₂ range may need to take that into consideration based on a primary clinical assessment.

Monitoring And Evaluation

Despite evidence of harm with very high or very low SpO₂ across a broad range of conditions, the incidence of adverse events at different SpO₂ targets in patients with COVID-19 is not well established. The group recommends a target range which avoid extremes and provides a clinician or hospital the option on deciding on an alternative target range in situations of short oxygen supply keeping individual safety of patient paramount. These patients should be monitored closely for adverse events concerning hypoxia and/or oxygen toxicity.

Research Priorities

As found in the evidence review for this recommendation, there is a paucity of trials comparing SpO₂ targets in patients with COVID-19, and there is an urgent need to conduct new or report results of ongoing trials. Outside of COVID-19, key subgroups as mentioned in the subgroup considerations section are not recruited in most trials, so future trials should attempt to include these special populations. Additionally, pre-COVID-19 trials included patients with a variety of causes, and ensuring a well powered subgroup of patients with key causes of ARDS, such as pneumonia, may provide more direct evidence for COVID-19 and potential future respiratory infection epidemics.

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Citation

Covid Management Guidelines India Group - Respiratory Therapy Working Group. Oxygen Saturation targets. Covid Guidelines India; Published online on February 14th, 2022; URL :- Oxygen Saturation Targets – Covid Guidelines India (indiacovidguidelines.org) ( ).