Incomplete Guideline Search

Letters to the Editor Clinical Practice Guideline: Recommendations on the In-Hospital Treatment of Patients with COVID-19 by Prof. Dr. med. Stefan Kluge, Dr. med. Jakob J. Malin, Dr. med. Falk Fichtner, Prof. Dr. med. Oliver J. Müller, Prof. Dr. med. Nicole Skoetz, and Prof. Dr. med. Christian Karagiannidis, on behalf of the Guideline Development Group, in issue 50/2021

We have noted the update of this German S3 guideline with interest (1). We welcome the update of the limit values ​​for initiating oxygen (O₂) therapy at pulse oximetry oxygen saturation (SpO₂) levels of < 92% and < 88%, respectively. To our regret, no upper limit of the SpO₂ level is included in the recommendations. The S3 guideline on oxygen therapy in acute medicine (2), published in 6/2021, takes an evidence-based position on O₂ therapy in COVID-19, yet unfortunately it seems not to have been considered in the guideline search. The lack of benefit from hyperoxemia (i.e. SpO₂ > 96%) as a goal of oxygen therapy has been demonstrated by numerous randomized controlled studies and meta-analyses. SpO₂ values ​​of > 96% on O₂ therapy should be avoided in patients with COVID-19 too. It has been shown that, when an upper SpO₂ limit of 96% is used, 37% of patients breathed room air in the intensive care unit, as compared to 9% of patients without this upper SpO₂ limit (3). We consider this to be relevant in the context of scarce resources during the pandemic.

In patients with respiratory failure, hyperoxemia under O₂ therapy can lead to a delay in the recognition of a clinical deterioration (4).

We also recommend extending the SpO₂ lower limit under O₂ therapy of 88% to other patient groups at risk of hypercapnia, in addition to patients with chronic obstructive pulmonary diseases.

Beside this, it remains unclear to the reader, based on Figure 1 and the text, how the treatment should proceed in the presence of either hypoxemia without tachypnea (respiratory rate over 30/min) or tachypnea without hypoxemia (SpO₂ < 92% or < 88%, respectively).

DOI: 10.3238/arztebl.m2022.0141

Prof. Dr. med. Jens Gottlieb, Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany, Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), Hannover, Germany [e-mail]

Prof. Dr. med. Heinrich Worth, Facharztforum Fürth, Germany

Prof. Dr. med. Thomas Volk, Department of Anaesthesiology, Intensive Care, and Pain Therapy, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Saarland, Germany

Prof. Dr. med. Thomas Fühner, Department of Respiratory and Critical Care Medicine, KRH Klinikum Siloah, Hannover, Germany

Conflict of interest statement:

Prof. Gottlieb is coordinator of the S3 Guideline Sauerstoff in der Akuttherapie beim Erwachsenen (Oxygen for Acute Therapy of Adults).

Prof. Worth is chairman of the pneumology section of the German Society for Internal Medicine (Deutschen Gesellschaft für Innere Medizin).

The remaining authors declare that no conflict of interest exists.

References

1. Kluge S, Malin JJ, Fichtner F, et al.: Clinical practice guideline: Recommendations on the in-hospital treatment of patients with COVID-19. Dtsch Arztebl Int 2021; 118: 865–71

2. Gottlieb J, Capetian P, Hamsen U, et al.: German S3 guideline – oxygen therapy in the acute care of adult patients. Pneumologie 2022; 76: 159–216

3. Mackle D, Bellomo R, Bailey M, et al.: Conservative oxygen therapy during mechanical ventilation in the ICU. N Engl J Med 2020; 382: 989–98

4. Beasley R, Aldington S, Robinson G: Is it time to change the approach to oxygen therapy in the breathless patient? Thorax 2007; 62: 840–1