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PILOT RCT – Do Oxygen Targets Matter in Critically Ill Patients?

January 4, 2023

Written by Laura Murphy

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Among adult patients receiving mechanical ventilation, there was no significant difference in ventilator-free days or 28-day mortality between groups in which a lower (88-92%), intermediate (92-96%), or higher SpO2 target (96-100%) was used.

Why does this matter?
To date, randomized controlled trials examining oxygenation targets have had differing results. Furthermore, observational research has proposed a U-shaped relationship between oxygenation and outcomes (suggesting intermediate oxygenation targets may be beneficial). How do oxygen targets impact mechanically ventilated patients?

Did this PILOT get off the ground?
The Pragmatic Investigation of Optimal Oxygen Targets (PILOT) trial was pragmatic, cluster-randomized, cluster-crossover trial conducted at a single center in both the emergency department and medical intensive care unit. Patients receiving mechanical ventilation were assigned to low (88-92%), intermediate (92-96%), or high (96-100%) oxygenation targets. Primary outcomes were number of ventilator-free days through day 28 with secondary outcome of death by day 28.

Prior to this, trials comparing intermediate oxygenation targets with high or low targets were lacking. This was a large trial including 2,541 enrolled patients, and enrollment occurred immediately on receipt of mechanical ventilation, either in the ED or ICU. Baseline characteristics were similar in the three groups; importantly, other interventions such as positive end-expiratory pressure, choice of sedation, and ventilator weaning were similar between the groups as well (according to institutional protocols). While this was a single-center trial, which could limit generalizability, the study design increased internal validity by ensuring fidelity of intervention and collection of granular data to oxygen targets, FiO2, and incidence of hypoxemia.

The bottom line: In conjunction with several other trials, this trial suggests that choice of oxygenation target within 90-98% does not affect clinical outcomes for critically ill adults.

Oxygen-Saturation Targets for Critically Ill Adults Receiving Mechanical Ventilation. N Engl J Med. 2022 Nov 10;387(19):1759-1769. doi: 10.1056/NEJMoa2208415. Epub 2022 Oct 24.

What are your thoughts?