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This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.

This landmark nurse-led study has challenged the accepted practice for providing oxygen to children in intensive care in a way that could have a global impact.

Professor Marian Knight, Scientific Director for NIHR Infrastructure

A groundbreaking nurse-led NIHR study explored the oxygen levels of critically ill children in intensive care. The study found that with reduced oxygen targets:

  • 50 more children would survive in the UK each year
  • children spent less time on life-saving machines and required fewer drugs
  • the NHS could save £20 million per year.

This is the first trial evidence to support the opinion-based recommendation of lower oxygen levels for children on ventilators in intensive care.

How much oxygen do children in intensive care need?

In the UK, around 20,000 children are admitted to intensive care each year. Most (75%) will receive oxygen through a ventilator (a machine that supports breathing).

Clinicians monitor how much oxygen the patient has in their blood. Many hospitals aim to give almost as much oxygen as people’s blood can carry (more than 94% saturation). However, some studies suggest that this could be harmful for some children. Providing less oxygen (88 – 92% of the blood’s capacity) may be better. Some recommendations exist, but the optimum oxygen level has not been tested.

This was the first trial to assess the best level of oxygen for children on ventilators in intensive care.

A landmark trial

This was the largest randomised controlled trial to be conducted in intensive care units for children. 15 of the 28 units in England and Scotland took part.

The study included children (newborn – 16 years) admitted to intensive care and needed a ventilator. In all 1,872 children took part; half (939) received a high level of oxygen (more than 94% of the blood’s capacity) and half (933) received less oxygen (88 – 92% of the blood’s capacity).

The study found that, 30 days after starting on a ventilator, children in the low oxygen group:

  • were more (6%) likely to have a good outcome (a composite of survival and fewer days spent on life-saving machines or drugs)
  • had similar levels of adverse events (3%) to those in the high oxygen group (4%)
  • had fewer serious adverse events (12 compared with 17), for example, complications that were life-threatening or led to permanent disability.

These benefits of lower oxygen levels were small but significant.

The costs of care were lower in the low oxygen group (£32,479) compared with the high oxygen group (£34,725). The researchers estimate that, if units across the country change to giving lower oxygen levels to children, it would save the NHS £20 million per year.

Why is this important?

The findings suggest that, if oxygen targets for children in intensive care were reduced across the NHS, 50 more children would survive every year. In total, children would spend 6,000 fewer days in intensive care.

Lower oxygen targets could be particularly beneficial in countries where resources are scarce, the researchers say, or at times of crisis (such as during a pandemic).

What’s next?

Many of the sites that took part in the study now use lower levels of oxygen for children in intensive care. The results are being considered for inclusion in the Surviving Sepsis for Children guidelines.

The research team is conducting further research on long-term outcomes for these children, and the value for money of each approach. They will consider children’s ethnicity because oximeters (which measure oxygen saturation) may give different readings according to skin colour.

The researchers did not analyse whether children with specific conditions fared better or worse depending on the oxygen levels they were given. They say further research is needed to identify which children are most likely to benefit from lower oxygen levels.

You may be interested to read

This is a summary of: Peters MJ, and others. Conservative versus liberal oxygenation targets in critically ill children (Oxy-PICU): a UK multicentre, open, parallel-group, randomised clinical trial. The Lancet 2023; 403: 355-364.

A lecture at Critical Care Reviews 2023 about this study.

A podcast about the study from PICPod.

Bliss, a charity for premature and sick babies, provides information and support.

The NIHR issued a press release about the study.

Funding: The trial was funded by the NIHR Health Technology Assessment programme.

Conflicts of Interest: One author has received fees from a pharmaceutical company; full disclosures are on the original research paper.

Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.

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