Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine.
Department of Medicine, School of Medicine.
Ann Am Thorac Soc. 2021 Aug;18(8):1369-1379. doi: 10.1513/AnnalsATS.202007-802OC.
Mechanically ventilated patients in the intensive care unit (ICU) are often managed to maximize oxygenation, yet hyperoxemia may be deleterious to some. Little is known about how ICU providers weigh tradeoffs between hypoxemia and hyperoxemia when managing acute respiratory failure. To define ICU providers' mental models for managing oxygenation for patients with acute respiratory failure and identify barriers and facilitators to conservative oxygen therapy. In two large U.S. tertiary care hospitals, we performed semistructured interviews with a purposive sample of ICU nurses, respiratory therapists, and physicians. We assessed perceptions of oxygenation management, hyperoxemia, and conservative oxygen therapies through interviews, which we audio recorded and transcribed verbatim. We analyzed transcripts for representative themes using an iterative thematic-analysis approach. We interviewed 10 nurses, 10 respiratory therapists, 4 fellows, and 5 attending physicians before reaching thematic saturation. Major themes included perceptions of hyperoxemia, attitudes toward conservative oxygen therapy, and aspects of titrated-oxygen-therapy implementation. Many providers did not recognize the term "hyperoxemia," whereas others described a poor understanding; several stated they never encounter hyperoxemia clinically. Concerns about hyperoxemia varied: some providers believed that typical ventilation strategies emphasizing progressive lowering of the fraction of inspired oxygen mitigated worries about excess oxygen administration, whereas others maintained that hyperoxemia is harmful only to patients with chronic lung disease. Almost all interviewees expressed familiarity with lower oxygen saturations in chronic obstructive pulmonary disease. Cited barriers to conservative oxygen therapy included concerns about hypoxemia, particularly among nurses and respiratory therapists; perceptions that hyperoxemia is not harmful; and a lack of clear evidence supporting conservative oxygen therapy. Interviewees suggested that interprofessional education and convincing clinical trial evidence could facilitate uptake of conservative oxygenation. This study describes attitudes toward hyperoxemia and conservative oxygen therapy. These preferences and uncertain benefits and risks of conservative oxygen therapy should be considered during future implementation efforts. Successful oxygen therapy implementation most likely will require ) improving awareness of hyperoxemia's effects, ) normalizing lower saturations in patients without chronic lung disease, ) addressing ingrained beliefs regarding oxygen management and oxygen's safety, and ) using interprofessional education to obtain buy-in across providers and inform the ICU team.
重症监护病房（ICU）中接受机械通气的患者通常会接受治疗以最大程度地提高氧合作用，但高氧血症可能对某些患者有害。对于 ICU 医护人员在管理急性呼吸衰竭时如何权衡低氧血症和高氧血症之间的利弊，我们知之甚少。本研究旨在确定 ICU 医护人员管理急性呼吸衰竭患者氧合的思维模型，并确定保守氧疗的障碍和促进因素。我们在美国 2 家大型三级保健医院中，对 ICU 护士、呼吸治疗师和医师进行了有针对性的样本半结构式访谈。我们通过访谈评估了对氧合管理、高氧血症和保守氧疗的看法，并对访谈进行了音频记录和逐字转录。我们使用迭代主题分析方法对转录本进行了代表性主题分析。在达到主题饱和之前，我们采访了 10 名护士、10 名呼吸治疗师、4 名研究员和 5 名主治医生。主要主题包括对高氧血症的看法、对保守氧疗的态度以及滴定氧疗实施的各个方面。许多提供者没有意识到“高氧血症”这个术语，而其他人则表示他们对此知之甚少；有几个人表示他们在临床上从未遇到过高氧血症。对高氧血症的担忧各不相同：一些提供者认为强调逐步降低吸入氧分数的典型通气策略减轻了对过度供氧的担忧，而另一些人则认为高氧血症仅对慢性肺部疾病患者有害。几乎所有接受采访者都熟悉慢性阻塞性肺疾病中的低氧饱和度。保守氧疗的障碍包括对低氧血症的担忧，特别是在护士和呼吸治疗师中；对高氧血症无害的看法；以及缺乏支持保守氧疗的明确证据。受访者建议，跨专业教育和令人信服的临床试验证据可以促进保守氧合的采用。本研究描述了对高氧血症和保守氧疗的态度。在未来的实施工作中，应考虑这些偏好以及保守氧疗的不确定益处和风险。成功实施氧疗很可能需要）提高对高氧血症影响的认识，）使没有慢性肺部疾病的患者的饱和度正常化，）解决有关氧管理和氧安全性的固有信念，以及）使用跨专业教育在提供者之间获得认可并为 ICU 团队提供信息。
