Patients with respiratory failure are usually mechanically ventilated, mostly with fraction of inspired oxygen (FiO2) > 0.21. Minimizing FiO2 is increasingly an accepted standard. In underserved nations and disasters, salvageable patients requiring mechanical ventilation may outstrip oxygen supplies.

The hypothesis of the present study was that mechanical ventilation with FiO2 = 0.21 is feasible. This assumption was tested in an Acute Respiratory Distress Syndrome (ARDS) model in pigs.

Seventeen pigs were anesthetized, intubated, and mechanically ventilated with FiO2 = 0.4 and Positive End Expiratory Pressure (PEEP) of 5cmH2O. Acute Respiratory Distress Syndrome was induced by intravenous (IV) oleic acid (OA) infusion, and FiO2 was reduced to 0.21 after 45 minutes of stable moderate ARDS. If peripheral capillary oxygen saturation (SpO2) decreased below 80%, PEEP was increased gradually until maximum 20cmH2O, then inspiratory time elevated from one second to 1.4 seconds.

Animals developed moderate ARDS (mean partial pressure of oxygen [PaO2]/FiO2 = 162.8, peak and mean inspiratory pressures doubled, and lung compliance decreased). The SpO2 decreased to <80% rapidly after FiO2 was decreased to 0.21. In 14/17 animals, increasing PEEP sufficed to maintain SpO2 > 80%. Only in 3/17 animals, elevation of FiO2 to 0.25 after PEEP reached 20cmH2O was needed to maintain SpO2 > 80%. Animals remained hemodynamically stable until euthanasia one hour later.

In a pig model of moderate ARDS, mechanical ventilation with room air was feasible in 14/17 animals by elevating PEEP. These results in animal model support the potential feasibility of lowering FiO2 to 0.21 in some ARDS patients. The present study was conceived to address the ethical and practical paradigm of mechanical ventilation in disasters and underserved areas, which assumes that oxygen is mandatory in respiratory failure and is therefore a rate-limiting factor in care capacity allocation. Further studies are needed before paradigm changes are considered.