Intraoperative FiO2 and risk of impaired postoperative oxygenation in lung resection: A propensity score-weighted analysis

Alex Choi; Hao Deng; Mitchell Fuller; Jamie L Sparling; Min Zhu; Brooks Udelsman; Gyorgy Frendl; Marcos F Vidal Melo; Alexander Nagrebetsky

doi:10.1016/j.jclinane.2024.111739

Intraoperative FiO₂ and risk of impaired postoperative oxygenation in lung resection: A propensity score-weighted analysis

J Clin Anesth. 2025 Jan 3:101:111739. doi: 10.1016/j.jclinane.2024.111739. Online ahead of print.

Authors

Alex Choi¹, Hao Deng², Mitchell Fuller³, Jamie L Sparling², Min Zhu², Brooks Udelsman⁴, Gyorgy Frendl⁵, Marcos F Vidal Melo⁶, Alexander Nagrebetsky⁷

Affiliations

¹ Duke University School of Medicine, 40 Duke Medicine Circle, Durham, NC 27710, USA.
² Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
³ Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, 03756, USA.
⁴ Division of Thoracic Surgery, Keck School of Medicine of University of Southern California 1,450 San Pablo St, Los Angeles, CA 90033, USA.
⁵ Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
⁶ Department of Anesthesiology, Columbia University Irving Medical Center, 630 W 168th St New York, NY 10032, USA.
⁷ Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA. Electronic address: anagrebetsky@mgh.harvard.edu.

PMID: 39754911
DOI: 10.1016/j.jclinane.2024.111739

Abstract

Study objective: To assess whether, in a lung resection cohort with a low probability of confounding by indication, higher FiO₂ is associated with an increased risk of impaired postoperative oxygenation - a clinical manifestation of lung injury/dysfunction.

Design: Pre-specified registry-based retrospective cohort study.

Setting: Two large academic hospitals in the United States.

Patients: 2936 lung resection patients with an overall good intraoperative oxygenation (median intraoperative SpO₂ ≥ 95 %).

Measurements: We compared patients with a higher (≥0.8) and lower (<0.8) median intraoperative FiO₂ after propensity score-weighting for 75 perioperative variables based on a causal inference framework. The primary outcome of impaired oxygenation was defined as at least one of the following within seven postoperative days: (1) SpO₂ < 92 %; (2) imputed PaO₂/FiO₂ < 300 mmHg [(1) or (2) at least twice within 24 h]; (3) intensive oxygen therapy (mechanical ventilation or > 50 % oxygen or high-flow oxygen).

Main results: Among the 2936 included patients, 2171 (73.8 %) received median intraoperative FiO₂ ≥ 0.8. Impaired postoperative oxygenation occurred in 1627 (74.9 %) and 422 (55.2 %) patients in the higher and lower FiO₂ groups, respectively. In a propensity score-weighted analysis, higher intraoperative FiO₂ was associated with an 84 % increase in the likelihood of impaired postoperative oxygenation (OR 1.84; 95 % CI 1.60 to 2.12; P < 0.001).

Conclusions: Despite plausible harm from hyperoxia, high intraoperative FiO₂ is extremely common during lung resection. Nearly three-quarters of lung resection patients with acceptable oxygenation received median intraoperative FiO₂ ≥ 0.8. Such higher FiO₂ was associated with an increased risk of impaired postoperative oxygenation - a clinically relevant manifestation of lung injury or dysfunction. This observation supports the administration of a lower (< 0.8) intraoperative FiO₂ and its further assessment in clinical trials.

Keywords: Fraction of inspired oxygen; Lung injury; Lung resection; Lung-protective ventilation; One-lung ventilation; Oxygen toxicity; Postoperative pulmonary complications.