Variability of indices of hypoxemia in adult respiratory distress syndrome

Objective: To determine the usefulness of indices of hyperemia in assessing patients with the adult respiratory distress syndrome (ARDS). Design: Retrospective analysis of previously published data that describe the distributions of ventilation and pulmonary blood flow in ARDS. Setting: University research laboratory. Patients: Sixteen patients with ARDS. Interventions: The FIO2 was varied between 0.21 and 1.0 in a computer model of gas exchange, based on a 50 compartment model of ventilation/perfusion inhomogeneity plus true shunt and deadspace. The indices of hypoxemia that were calculated as a function of inspired oxygen concentration included Pao(2)/Flo(2), arterial/alveolar ratio (Pao(2)/alveolar Po-2), the alveolar-arterial Po-2 difference (P[A-a]o(2)), respiratory index (P[A-a]o(2)/Pao(2)), and venous admixture. Measurements and Main Results: The Pao(2)/FIO2 ratio in patients with moderate shunts (<30%) varied considerably with alteration in FIO2. At both extremes of FIO2, the Pao(2)/FIO2 in these patients was substantially greater than at intermediate FIO2. Patients with larger shunts (>30%) had greater Pao(2)/FIO2, ratios at low FIO2, but the Pao(2)/FIO2, ratios decreased to relatively stable values at FIO2 values of >0.5. In all patients, Pao(2)/FIO2, remained relatively stable at FIO2 values of greater than or equal to 0.5 and Pao(2) values of less than or equal to 100 torr (less than or equal to 13.3 kPa). Other Po-2-based indices exhibited less stability as Flo(2) was varied. If hypoxemia resulted from true shunting, venous admixture was found to be stable at all FIO2 values. However, approximately one half of patients had clinically important hypoxemia resulting from mismatching of ventilation and blood flow. In these patients, venous admixture varied substantially with change in FIO2, and the degree of variation was proportional to the fraction of cardiac output perfusing gas exchange units with ventilation/perfusion ratios of <0.1. Conclusions: All indices of hypoxemia are affected by changes in Flo(2) in patients with ARDS. Pao(2)FIO(2), ratio exhibits the most stability at FIO2 values of greater than or equal to 0.5 and Pao(2) values of less than or equal to 100 torr (less than or equal to 13.3 kPa), and is a useful estimation of the degree of gas exchange abnormality under usual clinical conditions. Venous admixture varies substantially with alteration of FIO2 in patients who have clinically important ventilation/perfusion abnormalities. Under these circumstances, venous admixture is a poor indicator of the efficiency of pulmonary oxygen exchange, even if venous admixture is calculated from measured arterial and venous oxygen content values. Estimated venous admixture, based on an assumed arterial-venous oxygen content difference, is even more unreliable.