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Oxygen therapy in acute hypoxemic respiratory failure: guidelines from the SRLF-SFMU consensus conference

SRLF/SFMU · 2024 · France

Source and licence

Authors
Julie Helms, Pierre Catoire, Laure Abensur Vuillaume et al.
Title
Oxygen therapy in acute hypoxemic respiratory failure: guidelines from the SRLF-SFMU consensus conference
Journal
Annals of Intensive Care, 2024
DOI
10.1186/s13613-024-01367-2
Licence
CC BY 4.0
Changes
Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC11377397

Licence statement of the original publication

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This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.

Open the original publication →Full text on Europe PMC

Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Question 1: What are the criteria for initiating oxygen therapy in patients with acute hypoxemic respiratory failure?

  • Recommendation 1AThe panel suggests initiating oxygen therapy in the event of acute hypoxemic respiratory failurepanel opinion, strong agreement

Question 2: In patients with acute hypoxemic respiratory failure, what are the targets of oxygen saturation?

  • Oxygen flow or FiO 2 should probably be adjusted according to pulse oximetry values, to achieve: • SpO 2 ranging from 94 to 98% for patients with no risk of oxygen-induced hypercapnia (GRADE 2 + , moderate quality of evidence, low agreement). • SpO 2 ranging from 88 to 92% for patients at risk of oxygen-induced hypercapniaGRADE 2 + , moderate quality of evidence, strong agreement

Question 3: In patients with acute hypoxemic respiratory failure, what is the role of blood gas analysis?

  • Recommendation 3APatients with acute hypoxemic respiratory failure should probably not be routinely monitored by blood gas analysisGRADE 2-, moderate quality of evidence, strong agreement
  • Recommendation 3BThe panel suggests using venous blood gas analysis to rule out hypercapnia for the evaluation and monitoring of acute hypoxemic respiratory failurepanel opinion, strong agreement
  • The panel suggests that arterial blood gas analysis should be performed when there is a doubt about the reliability of SpO2, when it is not measurable, or when PvCO2 is elevated, so as to confirm and quantify hypercapniapanel opinion, strong agreement
  • The panel suggests that arterial blood gas analysis should be performed in cases of pathological hemoglobin, suspicion or presence of methemoglobin or CO intoxication, or when there is a non-respiratory indication for arterial blood gas analysispanel opinion, strong agreement

Question 4: In patients with acute hypoxemic respiratory failure, when should an arterial catheter be inserted?

  • Recommendation 4The panel suggests invasive blood gas monitoring in patients for whom repeated arterial sampling is indicatedpanel opinion, strong agreement

Question 5: Should standard oxygen therapy, high-flow nasal cannula oxygen therapy (HFNC) or continuous positive airway pressure (CPAP) be preferred in patients with acute hypoxemic respiratory failure?

  • Recommendation 5BHFNC should probably be used rather than standard oxygen therapy in patients with hypoxemic ARF, with an oxygen flow rate > 6L/min to achieve SpO2 > 92% or a PaO2/Fi O 2 ratio < 200GRADE 2 + , moderate quality of evidence, strong agreement

Question 6: What are the indications for non-invasive ventilation (NIV) in patients with acute hypoxemic respiratory failure?

  • In the absence of intubation criteria, high-flow nasal cannula oxygen therapy (HFNC) should probably be used rather than NIV in patients with de novo acute hypoxemic respiratory failureGRADE 2 + , moderate quality of evidence, strong agreement

Question 7: What are the indications for invasive mechanical ventilation in patients with acute hypoxemic respiratory failure?

  • The panel suggests that in acute hypoxemic respiratory failure, the presence of any of the following criteria requires intubation (panel opinion, strong agreement): • Cardiac or respiratory arrest due to hypoxemia • Persistent hypoxemia despite maximal oxygenation strategy, with PaO2/FiO2 < 60 mm Hg and/or SpO2 < 88%.
  • The panel suggests that in acute hypoxemic respiratory failure, the presence of one or more of the following criteria should lead to consideration of intubation (panel opinion, strong agreement): • Shock requiring vasopressor • Clinical signs of respiratory distress • Appearance or worsening of vigilance disorders • Worsening hypoxemia despite maximal oxygenation strategy • Persistent hypoxemia despite maximal oxygenation strategy, with Pa O2/FiO2 < 100 mm Hg or SpO2 < 92%. • Respiratory or mixed acidosis with pH < 7.30 • Tachypnea with respiratory rate > 30 or worsening respiratory rate • Bronchial congestion or copious secretions • Recurrent desaturation episodes with SpO2 < 86% • Agitation • Intolerance to oxygenation modality

Question 8: In patients with acute hypoxemic respiratory failure, should awake prone position be used?

  • Recommendation 8AThe panel makes no recommendation concerning awake prone position in acute hypoxemic respiratory failure not related to COVID-19insufficient quality of evidence, strong agreement
  • In acute hypoxemic respiratory failure related to COVID-19, awake prone position should probably be used to reduce the need for intubation in patients requiring high-flow oxygen therapyGRADE 2 + , moderate quality of evidence, strong agreement

Question 9: In patients with acute hypoxemic respiratory failure, what is the role of physiotherapy?

  • The panel suggests physiotherapy to promote lung recruitment in clinically stable patients with acute hypoxemic respiratory failure requiring ICU admissionpanel opinion, strong agreement

Question 10: In patients with acute hypoxemic respiratory failure, which criteria necessarily lead to ICU admission?

  • The panel suggests that patients receiving conventional oxygen therapy and showing clinical signs of respiratory distress should be managed in an ICUpanel opinion, strong agreement
  • Recommendation 10BThe panel suggests that patients receiving HFNC, CPAP or NIV should be managed in an ICUpanel opinion strong agreement

Question 11: Which oxygenation device should be preferred for patients for whom a do-not-intubate decision has been made?

  • Recommendation 11The panel makes no recommendation regarding the preferred oxygenation device for patients for whom a do-not-intubate decision has been madeinsufficient quality of evidence, strong agreement

Abstract

Introduction: Although largely used, the place of oxygen therapy and its devices in patients with acute hypoxemic respiratory failure (ARF) deserves to be clarified. The French Intensive Care Society (Société de Réanimation de Langue Française, SRLF) and the French Emergency Medicine Society (Société Française de Médecine d’Urgence, SFMU) organized a consensus conference on oxygen therapy in ARF (excluding acute cardiogenic pulmonary oedema and hypercapnic exacerbation of chronic obstructive diseases) in December 2023.

Methods: A committee without any conflict of interest (CoI) with the subject defined 7 generic questions and drew up a list of sub questions according to the population, intervention, comparison and outcomes (PICO) model. An independent work group reviewed the literature using predefined keywords. The quality of the data was assessed using the GRADE methodology. Fifteen experts in the field from both societies proposed their own answers in a public session and answered questions from the jury (a panel of 16 critical-care and emergency medicine physicians, nurses and physiotherapists without any CoI) and the public. The jury then met alone for 48 h to write its recommendations.

Results: The jury provided 22 statements answering 11 questions: in patients with ARF (1) What are the criteria for initiating oxygen therapy? (2) What are the targets of oxygen saturation? (3) What is the role of blood gas analysis? (4) When should an arterial catheter be inserted? (5) Should standard oxygen therapy, high-flow nasal cannula oxygen therapy (HFNC) or continuous positive airway pressure (CPAP) be preferred? (6) What are the indications for non-invasive ventilation (NIV)? (7) What are the indications for invasive mechanical ventilation? (8) Should awake prone position be used? (9) What is the role of physiotherapy? (10) Which criteria necessarily lead to ICU admission? (11) Which oxygenation device should be preferred for patients for whom a do-not-intubate decision has been made?

Conclusion: These recommendations should optimize the use of oxygen during ARF.

Supplementary Information: The online version contains supplementary material available at 10.1186/s13613-024-01367-2.

Contents of the original publication

The section headings of the original.

  • Introduction and background
  • Pathophysiology key points
  • Definition of oxygen therapy methods and devices
  • Impact of the COVID-19 outbreak on oxygen therapy management
  • Methods
  • Section 1: definitions, scores, oxygen therapy techniques and devices
  • 1: Definitions of acute respiratory failure and respiratory distress
  • 2. Oxygenation scores and indices
  • 3. Oxygen therapy techniques and devices
  • Section 2: Indications for oxygen therapy, targets and monitoring methods
  • Question 1: What are the criteria for initiating oxygen therapy in patients with acute hypoxemic respiratory failure?
  • Question 2: In patients with acute hypoxemic respiratory failure, what are the targets of oxygen saturation?
  • Question 3: In patients with acute hypoxemic respiratory failure, what is the role of blood gas analysis?
  • Question 4: In patients with acute hypoxemic respiratory failure, when should an arterial catheter be inserted?
  • Section 3: Choice of oxygen therapy modality
  • Question 5: Should standard oxygen therapy, high-flow nasal cannula oxygen therapy (HFNC) or continuous positive airway pressure (CPAP) be preferred in patients with acute hypoxemic respiratory failure?
  • Section 4: Indications for non-invasive and invasive mechanical ventilation
  • Question 6: What are the indications for non-invasive ventilation (NIV) in patients with acute hypoxemic respiratory failure?
  • Question 7: What are the indications for invasive mechanical ventilation in patients with acute hypoxemic respiratory failure?
  • Section 5: The role of adjuvant therapies: awake prone position and physiotherapy.
  • Question 8: In patients with acute hypoxemic respiratory failure, should awake prone position be used?
  • Question 9: In patients with acute hypoxemic respiratory failure, what is the role of physiotherapy?
  • Section 6: organizational measures
  • Question 10: In patients with acute hypoxemic respiratory failure, which criteria necessarily lead to ICU admission?
  • Section 7: Ethical considerations
  • Question 11: Which oxygenation device should be preferred for patients for whom a do-not-intubate decision has been made?

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