1. Beal, Judy A. DNSc, RN, FAAN

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Supplemental oxygen is a cornerstone of treatment to prevent and treat hypoxemia in critically ill patients. Although its use has strong research and clinical evidence and in most cases is viewed as beneficial, recent concerns have been raised about detrimental effects of hyperoxia. Most of the research about oxygen toxicity in children has been focused on preterm babies who are well known to be at high risk to develop hyperoxia-induced illness. Very little is known about hyperoxia in critically ill children. Therefore, clinical guidance for pediatric patients relies on expert opinion, however, in a recent study Lilien et al. (2022) reported on association of arterial hyperoxia with outcomes of critically ill children.


Most studies examined the detrimental effects of induced hyperoxia in critically ill adults. Damiani et al. (2014) conducted a meta-analysis of 17 studies with 221,316 adults diagnosed with postcardiac arrest, stroke, and traumatic brain injury. They found an association between hyperoxia and increased mortality in these patients. Helmerhorst et al. (2015) reported similar findings. In their meta-analysis of 24 studies published between 2008 and 2015, hyperoxia was associated with poor hospital outcomes in critically ill patients over 18 years of age with the diagnoses of cardiac arrest, traumatic brain injury, stroke, postcardiac surgery, and any mechanical ventilation (Helmerhorst et al., 2015). Authors of both studies concluded that though their findings are of concern, more research was warranted due to limitations of study heterogeneity, lack of randomized trials, and a lack of a standard definition of hyperoxia in study demographics (Damiani et al., 2014; Helmerhorst et al., 2015).


With little information about hyperoxia in hospitalized children, Lilien et al. (2022) undertook a meta-analysis of observational studies and clinical trials that examined hyperoxia and outcomes in children admitted to pediatric intensive care units. A systematic review of four databases was conducted and 16 studies with 27,555 were included (15 observational studies and 1 clinical randomized trial). Populations studied included children with postcardiac arrest, traumatic brain injury, extracorporeal membrane oxygenation, and general critical care diagnoses. As with the two previous meta-analysis in adults (Damiani et al., 2014; Helmerhorst et al., 2015), definitions and assessments of hyperoxia varied among the 16 studies. Other limitations included lack of randomized clinical trials, small sample sizes, lack of statistical significance, lack of correction for severity of illness, study design heterogeneity, and the need to pool data. Despite these limitations, as with the adult-focused studies, these authors concluded that supplemental oxygen leading to hyperoxia may be harmful above a certain dose and is associated with increased mortality. The limitations of their study do not allow for an assumption of causation. Based on their analysis, Lilien et al. concluded that clinicians in the pediatric setting administering supplemental oxygen to critically ill children must be cautious, and that further research is warranted to confirm or dispute the association of hyperoxia to increased mortality and to examine secondary outcomes. I encourage all pediatric nurses involved in care that may include oxygen administration to hospitalized critically ill children to review the analysis by Lilien et al. Their systematic review and meta-analysis questions the routine practice of high-dose oxygen leading to hyperoxia for critically ill children. Overzealous use of oxygen, leading to hyperoxia may be harmful for critically ill pediatric patients when compared with patients with normoxia, but more data are needed (Lilien et al., 2022).




Damiani E., Adrario E., Girardis M., Romano R., Pelaia P., Singer M., Donati A. (2014). Arterial hyperoxia and mortality in critically ill patients: A systematic review and meta-analysis. Critical Care, 18(6), 711.[Context Link]


Helmerhorst H. J. F., Roos-Blom M. J., van Westerloo D. J., de Jonge E. (2015). Association between arterial hyperoxia and outcome in subsets of critical illness: A systematic review, meta-analysis, and meta-regression of cohort studies. Critical Care Medicine, 43(7), 1508-1519.[Context Link]


Lilien T. A., Groeneveld N. S., Van Etten-Jamaludin F., Peters M. J., Buysse C. M. P., Ralston S. L., van Woensel J. B. M., Bos L. D. J., Bem R. A. (2022). Association of arterial hyperoxia with outcomes in critically ill children: A systematic review and meta-analysis. JAMA Network Open, 5(1), e2142105.[Context Link]