Letter to the Editor
Pulmonary toxicity by oxygen and COVID-19
Toxicidad pulmonar por oxígeno y COVID-19
A. León-Jiménez, E. Vázquez-Gandullo
, F. Montoro-Ballesteros
Corresponding author
Unidad de Gestión Clínica de Neumología, Alergología y Cirugía Torácica, Servicio de Neumología, Hospital Universitario Puerta del Mar, Cádiz, Spain
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(B) Bar chart showing the respiratory admissions. Comparisons are made by fundamental cause and excluding patients with hematological malignancies. The “Miscellaneous” group comprises those patients in which no single fundamental cause of admission could be specified. Mention is made of the patients with diabetic ketoacidosis in view of the notorious increase in cases observed.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. García-Salido, I. Leoz-Gordillo, M.Á. García-Teresa, M.I. Iglesias-Bouzas, A. Martínez de Azagra-Garde, M. Nieto-Moro" "autores" => array:6 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "García-Salido" ] 1 => array:2 [ "nombre" => "I." "apellidos" => "Leoz-Gordillo" ] 2 => array:2 [ "nombre" => "M.Á." "apellidos" => "García-Teresa" ] 3 => array:2 [ "nombre" => "M.I." "apellidos" => "Iglesias-Bouzas" ] 4 => array:2 [ "nombre" => "A." "apellidos" => "Martínez de Azagra-Garde" ] 5 => array:2 [ "nombre" => "M." "apellidos" => "Nieto-Moro" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0210569121001686" "doi" => "10.1016/j.medin.2021.06.002" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569121001686?idApp=WMIE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572722000753?idApp=WMIE" "url" => "/21735727/0000004600000006/v1_202206091533/S2173572722000753/v1_202206091533/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Pulmonary toxicity by oxygen and COVID-19" "tieneTextoCompleto" => true "saludo" => "To the Editor," "paginas" => array:1 [ 0 => array:1 [ "paginaInicial" => "353" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A. León-Jiménez, E. Vázquez-Gandullo, F. Montoro-Ballesteros" "autores" => array:3 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "León-Jiménez" ] 1 => array:4 [ "nombre" => "E." "apellidos" => "Vázquez-Gandullo" "email" => array:1 [ 0 => "evavgandullo@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:2 [ "nombre" => "F." "apellidos" => "Montoro-Ballesteros" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Gestión Clínica de Neumología, Alergología y Cirugía Torácica, Servicio de Neumología, Hospital Universitario Puerta del Mar, Cádiz, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Toxicidad pulmonar por oxígeno y COVID-19" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pulmonary toxicity by oxygen has been known for over a century. Exposure to a fraction of inspired oxygen (FiO<span class="elsevierStyleInf">2</span>) of 0.7 causes progressive pulmonary lesion and the intensity of the lesions is associated with the concentration and duration of hyperoxia.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Lesion manifests just a few hours after the administration of oxygen in high concentrations causing an increased alveolar-capillary patency and a complex cellular response including epithelial, endothelial, proinflammatory cells, and platelets that induce the destruction of alveolocapillary membranes with increased air spaces, vascular obstruction due to microthrombi, and cellular infiltration that eventually leads to the loss of alveolar architecture and, in the long run, to pulmonary fibrosis. All oxygen-induced lesions are similar to those due to acute respiratory distress syndrome (ARDS). Also, in patients with established ARDS, hyperoxia can worsen clinical results.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Finally, many of the pathological characteristics reported in hyperoxia occur also in ARDS due to COVID-19 since it has been reported that in these patients’ lungs increased air spaces following the destruction of alveolar septa, alveolar swelling, capillary thrombosis, perivascular infiltrates, and fibrosis have been found.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The appearance of COVID19 has challenged respiratory support, and the need for applying elevated fractions of inspired oxygen has been a constant in many patients whether through high-flow nasal oxygen (HFNO) therapy or concomitantly to ventilation systems. However, the high mortality rates reported in cases of ARDS—an average of 39%—is indicative that, at least in some cases, the application of elevated concentrations of oxygen is worsening or triggering COVID-19<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>-related ARDS-like lesions. It could even cause a vicious circle that would create the need to increase the concentration of oxygen gradually in the air breathed in thus causing greater pulmonary impairment.</p><p id="par0015" class="elsevierStylePara elsevierViewall">This possibility—together with data obtained by other authors<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> that most patients with moderate-to-severe acute respiratory failure due to COVID-19, and even cases with radiological findings and compatible gas exchange with ARDS recovered with CPAP and FiO<span class="elsevierStyleInf">2</span> between 0.4 and 0.6, should, in own opinion, make us reconsider or detail the current strategy of respiratory support. Therefore, following the plan established by current recommendations,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> although the next step towards conventional oxygen therapy can still be HFNO when FiO<span class="elsevierStyleInf">2</span> > 0.6 would be needed respiratory support like CPAP should be attempted to recruit more alveolar units before increasing FiO<span class="elsevierStyleInf">2</span> to levels that can be toxic to an already damaged lung. Even under certain safety and monitoring conditions, the saturation target currently established at around 95% in the aforementioned current recommendations could be reduced down to 92% to stop FiO<span class="elsevierStyleInf">2</span> from going > 0.6.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: León-Jiménez A, Vázquez-Gandullo E, Montoro-Ballesteros F. Toxicidad pulmonar por oxígeno y COVID-19. Med Intensiva. 2022;46:353.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Should Oxygen Therapy Be Tightly Regulated to Minimize Hyperoxia in Critically Ill Patients?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R.H. Kallet" 1 => "R.D. Branson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4187/respcare.04933" "Revista" => array:6 [ "tituloSerie" => "Respir Care" "fecha" => "2016" "volumen" => "61" "paginaInicial" => "801" "paginaFinal" => "817" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27235315" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Oxygen exposure resulting in arterial oxygen tensions above the protocol goal was associated with worse clinical outcomes in acute respiratory distress syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "N.R. Aggarwal" 1 => "R.G. Brower" 2 => "D.N. Hager" 3 => "B.T. Thompson" 4 => "G. Netzer" 5 => "C. Shanholtz" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Crit Care Med" "fecha" => "2018" "volumen" => "46" "paginaInicial" => "517" "paginaFinal" => "524" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hyperoxia and modulation of pulmonary vascular and immune responses in COVID-19" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D. Hanidziar" 1 => "S.C. Robson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1152/ajplung.00304.2020" "Revista" => array:6 [ "tituloSerie" => "Am J Physiol Lung Cell Mol Physiol" "fecha" => "2021" "volumen" => "320" "paginaInicial" => "L12" "paginaFinal" => "L16" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33050737" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Continuous positive airway pressure in COVID-19 patients with moderate-to-severe respiratory failure" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "Galliera CPAP-Covid-19 study group; Collaborators of the Galliera CPAP-COVID-19 study group are" "etal" => true "autores" => array:6 [ 0 => "C. Brusasco" 1 => "F. Corradi" 2 => "A. di Domenico" 3 => "F. Raggi" 4 => "G. Timossi" 5 => "G. Santori" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Eur Respir J" "fecha" => "2021" "volumen" => "57" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Indication of high-flow oxygen therapy in patients with SARS-CoV-2 pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. Belenguer-Muncharaz" 1 => "H. Hernández-Garcés" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.medin.2020.11.001" "Revista" => array:2 [ "tituloSerie" => "Med Intensiva" "fecha" => "2020" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735727/0000004600000006/v1_202206091533/S2173572722000777/v1_202206091533/en/main.assets" "Apartado" => array:4 [ "identificador" => "64604" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735727/0000004600000006/v1_202206091533/S2173572722000777/v1_202206091533/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572722000777?idApp=WMIE" ]
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