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HOT-COVID RCT – Lower O2 Target in Hypoxemic COVID-19 Patients

April 29, 2024

Written by Samuel Rouleau

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The HOT-COVID RCT found that hypoxemic COVID-19 patients in the ICU benefitted from a lower oxygenation target (PaO2 60 mm Hg) by having more days without life support than those who had a higher oxygenation target (PaO2 goal 90 mm Hg).

Don’t try to run up the oxygen levels on your COVID patients, drop it like it’s “HOT”!
This multisite RCT included 726 adult ICU patients with COVID-19 and severe hypoxemia. The primary outcome consisted of days alive without life support (non-invasive or invasive mechanical ventilation, vasopressors, renal replacement therapy) in 90 days. Secondary outcomes were: 90-day all-cause mortality, serious adverse events, days alive and outside of the hospital within 90 days.

The lower oxygenation group (n=365) and the higher oxygenation group (n=361) exhibited similar characteristics with comparable demographics, comorbidities, frequency of ARDS, proportion of intubated patients, and ventilator settings. For the primary outcome, the lower oxygenation group had more days without life support, with a mean difference of 5.8 days (95%CI 0.2 to 11.5, p = 0.04). The difference between the two groups was primarily impacted by mechanical ventilation. There was no meaningful difference in 90-day all-cause mortality between the lower and higher oxygenation groups. The lower oxygenation group had more days out of the hospital with a mean difference of 5.1 days (95%CI -1.2 to 11.4, p = 0.03).

How will this change my practice?
This well-done study will lead me to pursue a lower oxygenation target in COVID-19 patients with severe hypoxemia.

  • The subgroup of patients who had the most benefit from a lower oxygenation target was those with shock (18 and 19 patients in each treatment group). The subgroup size is too small to make a firm conclusion but hints at the possibility of increased damage from hyperoxia/oxygen radicals in the presence of shock and disrupted cellular metabolism.
  • This trial is different due to its focus on a specific pathophysiologic process (COVID-19) and cannot be extrapolated beyond COVID-19 patients currently. Multiple trials have looked at oxygenation targets across patients with heterogeneous pathophysiological processes and found no meaningful difference in outcomes.

Lower vs Higher Oxygenation Target and Days Alive Without Life Support in COVID-19: The HOT-COVID Randomized Clinical Trial. JAMA. Published online March 19, 2024. doi:10.1001/jama.2024.2934

What are your thoughts?