Arterial Blood Gas and Pulse Oximetry in Initial Management of Patients with Community-acquired Pneumonia

Authors

  • Kenneth P. Levin MD,

    1. Received from the Division of General Internal Medicine, Department of Medicine (KPL, BHH, WNK, MJF) and the Department of Anesthesiology and Critical Care Medicine, Center for Research on Health Care (AR), University of Pittsburgh, Pittsburgh, Pa; the VA Pittsburgh Center for Health Services Research (MJF), Pittsburgh, Pa; the General Internal Medicine Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Mass (DES, CMC); and the Department of Medicine, University of Alberta, Edmonton, Alberta, Canada (TJM).
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  • Barbara H. Hanusa PhD,

    1. Received from the Division of General Internal Medicine, Department of Medicine (KPL, BHH, WNK, MJF) and the Department of Anesthesiology and Critical Care Medicine, Center for Research on Health Care (AR), University of Pittsburgh, Pittsburgh, Pa; the VA Pittsburgh Center for Health Services Research (MJF), Pittsburgh, Pa; the General Internal Medicine Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Mass (DES, CMC); and the Department of Medicine, University of Alberta, Edmonton, Alberta, Canada (TJM).
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  • Armando Rotondi PhD,

    1. Received from the Division of General Internal Medicine, Department of Medicine (KPL, BHH, WNK, MJF) and the Department of Anesthesiology and Critical Care Medicine, Center for Research on Health Care (AR), University of Pittsburgh, Pittsburgh, Pa; the VA Pittsburgh Center for Health Services Research (MJF), Pittsburgh, Pa; the General Internal Medicine Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Mass (DES, CMC); and the Department of Medicine, University of Alberta, Edmonton, Alberta, Canada (TJM).
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  • Daniel E. Singer MD,

    1. Received from the Division of General Internal Medicine, Department of Medicine (KPL, BHH, WNK, MJF) and the Department of Anesthesiology and Critical Care Medicine, Center for Research on Health Care (AR), University of Pittsburgh, Pittsburgh, Pa; the VA Pittsburgh Center for Health Services Research (MJF), Pittsburgh, Pa; the General Internal Medicine Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Mass (DES, CMC); and the Department of Medicine, University of Alberta, Edmonton, Alberta, Canada (TJM).
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  • Christopher M. Coley MD,

    1. Received from the Division of General Internal Medicine, Department of Medicine (KPL, BHH, WNK, MJF) and the Department of Anesthesiology and Critical Care Medicine, Center for Research on Health Care (AR), University of Pittsburgh, Pittsburgh, Pa; the VA Pittsburgh Center for Health Services Research (MJF), Pittsburgh, Pa; the General Internal Medicine Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Mass (DES, CMC); and the Department of Medicine, University of Alberta, Edmonton, Alberta, Canada (TJM).
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  • Thomas J. Marrie MD,

    1. Received from the Division of General Internal Medicine, Department of Medicine (KPL, BHH, WNK, MJF) and the Department of Anesthesiology and Critical Care Medicine, Center for Research on Health Care (AR), University of Pittsburgh, Pittsburgh, Pa; the VA Pittsburgh Center for Health Services Research (MJF), Pittsburgh, Pa; the General Internal Medicine Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Mass (DES, CMC); and the Department of Medicine, University of Alberta, Edmonton, Alberta, Canada (TJM).
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  • Wishwa N. Kapoor MD, MPH,

    1. Received from the Division of General Internal Medicine, Department of Medicine (KPL, BHH, WNK, MJF) and the Department of Anesthesiology and Critical Care Medicine, Center for Research on Health Care (AR), University of Pittsburgh, Pittsburgh, Pa; the VA Pittsburgh Center for Health Services Research (MJF), Pittsburgh, Pa; the General Internal Medicine Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Mass (DES, CMC); and the Department of Medicine, University of Alberta, Edmonton, Alberta, Canada (TJM).
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  • Michael J. Fine MD, MSc

    Corresponding author
    1. Received from the Division of General Internal Medicine, Department of Medicine (KPL, BHH, WNK, MJF) and the Department of Anesthesiology and Critical Care Medicine, Center for Research on Health Care (AR), University of Pittsburgh, Pittsburgh, Pa; the VA Pittsburgh Center for Health Services Research (MJF), Pittsburgh, Pa; the General Internal Medicine Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Mass (DES, CMC); and the Department of Medicine, University of Alberta, Edmonton, Alberta, Canada (TJM).
      Address correspondence and reprint requests to Dr. Fine: VA Pittsburgh Medical Center (130-U), University Drive C, 11th Floor, 11E127, Pittsburgh, PA 15240 (e-mail: finemj@msx.upmc.edu).
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Address correspondence and reprint requests to Dr. Fine: VA Pittsburgh Medical Center (130-U), University Drive C, 11th Floor, 11E127, Pittsburgh, PA 15240 (e-mail: finemj@msx.upmc.edu).

Abstract

OBJECTIVE: To identify the factors associated with the use of arterial blood gas (ABG) and pulse oximetry (PO) in the initial management of patients with community-acquired pneumonia (CAP) and arterial hypoxemia at presentation.

PARTICIPANTS: A total of 944 outpatients and 1,332 inpatients with clinical and radiographic evidence of CAP prospectively enrolled from 5 study sites in the United States and Canada.

ANALYSES: Separate multivariate logistic regression analyses were used to 1) compare measurement of ABG and PO within 48 hours of presentation across sites while controlling for patient differences, and 2) identify factors associated with arterial hypoxemia (PaO2 <60 mm Hg or SaO2 <90% for non–African Americans and <92% for African Americans) while breathing room air.

RESULTS: Range of ABG use by site was from 0% to 6.4% (P = .06) for outpatients and from 49.2% to 77.3% for inpatients (P < .001), while PO use ranged from 9.4% to 57.8% for outpatients (P < .001) and from 47.9% to 85.1% for inpatients (P < .001). Differences among sites remained after controlling for patient demographic characteristics, comorbidity, and illness severity. In patients with 1 or more measurements of oxygenation at presentation, hypoxemia was independently associated with 6 risk factors: age >30 years (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.7 to 5.9), chronic obstructive pulmonary disease (OR, 1.9; 95% CI, 1.4 to 2.6), congestive heart failure (OR, 1.5; 95% CI, 1.0 to 2.1), respiratory rate >24 per minute (OR, 2.3; 95% CI, 1.8 to 3.0), altered mental status (OR, 1.6; 95% CI, 1.1 to 2.3), and chest radiographic infiltrate involving >1 lobe (OR, 2.2; 95% CI, 1.7 to 2.9). The prevalence of hypoxemia among those tested ranged from 13% for inpatients with no risk factors to 54.6% for inpatients with ≥3 risk factors. Of the 210 outpatients who had ≥2 of these risk factors, only 64 (30.5%) had either an ABG or PO performed. In the 48 outpatients tested without supplemental O2 with ≥2 risk factors 8.3% were hypoxemic.

CONCLUSIONS: In the initial management of CAP, use of ABG and PO varied widely across sites. Increasing the assessment of arterial oxygenation among patients with CAP is likely to increase the detection of arterial hypoxemia, particularly among outpatients.

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