REVIEW

CURRENT
OPINION Acute life-threatening hypoxemia during
mechanical ventilation
Thomas Piraino a,b and Eddy Fan c,d

Purpose of review
To describe current evidence-based practice in the management of acute life-threatening hypoxemia in
mechanically ventilated patients and some of the methods used to individualize the care of the patient.
Recent findings
Patients with acute life-threatening hypoxemia will often meet criteria for severe ARDS, for which there are
only a few treatment strategies that have been shown to improve survival outcomes. Recent findings have
increased our knowledge of the physiological effects of spontaneous breathing and the application of
PEEP. Additionally, the use of advanced bedside monitoring has a promising future in the management of
hypoxemic patients to fine-tune the ventilator and to evaluate the individual patient response to therapy.
Summary
Treating the patient with acute life-threatening hypoxemia during mechanical ventilation should begin with
an evidence-based approach, with the goal of improving oxygenation and minimizing the harmful effects
of mechanical ventilation. The use of advanced monitoring and the application of simple maneuvers at the
bedside may assist clinicians to better individualize treatment and improve clinical outcomes.
Keywords
acute hypoxemia, lung-protective ventilation, mechanical ventilation, severe acute respiratory distress syndrome

INTRODUCTION the prevalence, and also difficult for deciding inclu-

Managing acute and life-threatening hypoxemia in
the patient receiving mechanical ventilation can be
a challenging task for the bedside clinician. Early
recognition and identifying the underlying cause is
extremely important for deciding the right strategy
to treat the patient. Severe hypoxemia sustained for
even a short period can be life-threatening, and may
also result in long-term morbidity [1].
This review will summarize the initial approach
to the ventilated patient with acute life-threatening
hypoxemia, current evidence-based management of
these patients, and some novel methods that are
being developed based on our growing knowledge of
the factors contributing to ventilator-induced lung
injury (VILI).
DEFINITION
The severity of hypoxemia referenced in the current
literature considers the absolute level of PaO2 and
commonly, also the PaO2/FiO2 ratio. Unfortunately,
there is no commonly accepted definition of life-
threatening or refractory hypoxemia. This makes
epidemiology of the subject difficult for determining
sion criteria for studies. Many studies of patients in
hypoxemic respiratory failure secondary to acute
respiratory distress syndrome (ARDS) have used
PaO2/FiO2 rather than the PaO2 level as the hypox-
emic component for inclusion (other ARDS criteria
must also be met for inclusion). The Berlin Definition
of ARDS classifies severe ARDS as a PaO2/FiO2 that is
less than 100 mmHg, with a mortality of close to 50%
[2]. In a posthoc analysis of patients with a PaO2/FiO2
less than 100 mmHg, however, those with higher
compliance (>20 ml/cmH2O) and lower corrected
minute ventilation (<13 l/min) had significantly
a
Department of Anesthesia, McMaster University, Hamilton, bDepartment
of Respiratory Therapy, St. Michael’s Hospital, cDivision of Respirology,
Toronto General Hospital, University Health Network and Sinai Health
System and dInterdepartmental Division of Critical Care Medicine and the
Institute of Health Policy, Management and Evaluation, University of
Toronto, Toronto, Ontario, Canada
Correspondence to Eddy Fan, MD, PhD, Division of Respirology, Toronto
General Hospital, University Health Network and Sinai Health System,
585 University Avenue, PMB 11-123, Toronto, ON M5G 2N2, Canada.
Tel: +1 416 340-5483; fax: +1 647 776-3148; e-mail: eddy.fan@uhn.ca
Curr Opin Crit Care 2017, 23:541–548
DOI:10.1097/MCC.0000000000000459

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Emergencies in critical care
KEY POINTS
 Early recognition and patient assessment is key to
managing patients with acute life-
threatening hypoxemia.
 Currently, there is no widely accepted definition for life-
threatening hypoxemia.
 The starting point for ventilatory support should be
evidence-based management for patients with ARDS.
 Strategies as higher PEEP, neuromuscular blocking
agents, and prone positioning should be considered
early in the management of these patients.
 Additional strategies such as esophageal pressure
monitoring, and electrical impedance tomography may
improve the individual management of these patients,
particularly in challenging cases.
lower mortality [2]. This implies that the true severity
of hypoxemia is likely related to multiple physiologi-
cal variables, and proper management may need to be
tailored to these differences.
The term ‘life-threatening’ can also be mislead-
ing. Reduction of ICU or hospital mortality seems
like the primary goal for outcomes, but the long-
term recovery and functional outcomes should also
be considered [3,4]. Although many studies of ARDS
have used a low PaO2 limit of 55 mmHg, a
PaO2 < 60 mmHg should be avoided to minimize
any long-term cognitive effects of hypoxemia
[1,5,6]. For this reason, a patient with a PaO2 of
60 mmHg and a FiO2 of 1.0 (PaO2/FiO2 60 mmHg)
would classify as life-threatening. Clinical decisions
for rescue or salvage therapy, however, should occur
prior to patients requiring FiO2 levels of 1.0 to allow
some buffer for preparing equipment, or transfer-
ring to an external facility. For this reason, and for
the purpose of this review, we will choose a thresh-
old PaO2/FiO2 of 80 mmHg as a recommended
threshold for early consideration of certain thera-
pies. We will also consider that the initial ventila-
tion strategies to manage these patients should
reflect evidence-based guidelines for ventilating
patients with ARDS, with the addition of evidence-
based adjunctive therapies for patients with PaO2/
FiO2 level of less than 150 mmHg (i.e. prone position-
ing and neuromuscular blocking agents) [7,8] (Fig. 1).
CAUSES OF ACUTE LIFE-THREATENING
HYPOXEMIA
The underlying cause of acute hypoxemia during
mechanical ventilation is a result of the mismatch
between ventilation and perfusion. The cause could
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include an obstructed endotracheal tube, atelectasis,
alveolar consolidation, or intracardiac or intrapul-
monary shunt. The complexity of the underlying
cause generally reflects the complexity in properly
managing or improving oxygenation. All of the
strategies used to manage these patients will have
the goal of improving distribution of alveolar venti-
lation, and to optimize pulmonary perfusion. It is
often challenging, however, to improve oxygen-
ation while preventing or minimizing VILI, particu-
larly in patients with severe ARDS.
INITIAL STEPS FOR MANAGING ACUTE
LIFE-THREATENING HYPOXEMIA
The clinician managing the patient with acute hyp-
oxemia must have a simple and effective strategy of
applying basic troubleshooting skills before making
significant ventilator adjustments. Monitoring the
patient in real-time with pulse oximetry helps to
recognize severe hypoxemic events whenever they
happen. Limitations, however, exist in patients with
hypotension and this may prevent accurate pulse
oximetry values. The use of point-of-care testing for
arterial blood gas analysis can assist in the rapid
determination of the magnitude of a hypoxemic
event. The overall patient assessment, however,
should include some basic laboratory investigations,
as well as a chest X-ray (CXR). Finally, as the major-
ity of patients with life-threatening hypoxemia will
meet criteria for the Berlin Definition of ARDS [2],
the initial ventilation strategy should be based on a
general lung-protective approach using tidal vol-
ume of 6 ml/kg of predicted body weight (PBW), a
higher positive end-expiratory pressure (PEEP), and
keeping the inspiratory plateau pressure less than
&&
30 cmH2O [9 ].
AIRWAY ASSESSMENT
Ensuring an airway is patent and free of secretions
and obstruction is among the initial assessments
usually performed by a clinician attempting to
determine the cause of acute severe hypoxemia.
The ability to monitor flow graphics with all modern
ventilators helps to rule out airway obstruction, and
the shape of the expiratory waveform can also help
to determine if there are issues with airway secre-
tions that need immediate attention. Airway emer-
gencies are not common in the ICU [10], but do
require immediate attention and quick resolution
to avoid any serious adverse events. The patient’s
response to endotracheal suctioning, bronchos-
copy, position changes, endotracheal tube migra-
tion, obstruction, or accidental dislodgment, could
all cause acute hypoxemia. Having constant
Volume 23  Number 6  December 2017
 Acute life-threatening hypoxemia Piraino and Fan

FIGURE 1. A sample clinical algorithm for life-threatening hypoxemia in the mechanically ventilated patient. ACP, acute cor
pulmonale; ECMO, extracorporeal membrane oxygenation; HFOV, high frequency oscillatory ventilation; IBW, ideal body
weight; IPV, inhaled pulmonary vasodilators; PFO, patent foramen ovale; RM, recruitment maneuver.

monitoring of values such as end-tidal CO2, suffi-
cient healthcare staff, and clinicians skilled at per-
forming endotracheal intubation, should minimize
any negative outcomes related to these issues.
SUPPLEMENTAL OXYGEN
Supplemental oxygen is one of the immediate steps
in managing acute hypoxemia with the goal of
stabilizing the patient while the underlying cause
is investigated and management strategies are
applied. Once the patient is stabilized, supplemental
oxygen can be titrated to achieve modest physio-
logical goals. A recent study demonstrated that a
conservative approach for providing supplemental
oxygen with a target PaO2 of 70–100 mmHg or SpO2
94–98% had a survival benefit compared to a liberal
approach allowing PaO2 less than 150 mmHg and
SpO2 97–100% [11]. In this study, the median FiO2
level was less than 0.40 in both groups. Patients
with life-threatening hypoxemia unfortunately will
likely require higher FiO2 levels to achieve PaO2
within the range of 70–100 mmHg, placing them
at higher risk of the negative effects of high FiO2
[12,13]. Using FiO2 levels of 1.0 has been shown to
worsen gas exchange through absorption atelectasis
[12]. This can be, however, prevented through the
use of higher levels of PEEP [13]. Titrating supple-
mental oxygen to target a PaO2 of 60–80 mmHg for
hypoxemic patients requiring high levels of FiO2
can help avoid some of these concerns regarding
over oxygenation.
EVIDENCE-BASED MANAGEMENT
The current evidence-based guidelines for managing
ARDS patients should be applied to the patient with
acute life-threatening hypoxemia. The following sec-
tion will provide the rationale regarding evidence-
based strategies for managing life-threatening

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Emergencies in critical care

hypoxemia. A potential therapeutic approach to life-
threatening hypoxemia in the mechanically venti-
lated patient is summarized in the Fig. 1.
POSITIVE END-EXPIRATORY PRESSURE
The current evidence-based practice is to use higher
levels of PEEP in patients with a moderate-to-severe
ARDS [14]. In the Large Observational Study to
Understand the Global Impact of Severe Acute
Respiratory Failure (LUNG SAFE) study, however,
PEEP was more commonly set lower than the cur-
rent evidence-based recommendation, and was con-
sidered a modifiable factor, which could improve
&&
patient outcomes [15 ,16].
In a secondary analysis of the Lung Open Venti-
lation Study (LOVS) and Expiratory Pressure
(ExPress) study, the oxygenation response to chang-
ing PEEP was a predictor of survival. Patients who
experienced an increase in PaO2/FiO2 after an
increase in baseline PEEP level had a lower risk of
death [16,17]. This may have been related to the
recruitability of the lung where higher PEEP is
needed to maintain recruitment.
There is a growing consensus that the setting of
PEEP needs to be individualized in patients with
&&
ARDS [9 ]. The best method, however, to individu-
alize PEEP has been a source of constant debate. A
study by Chiumello et al. [18] compared various PEEP
selection methods and found the high PEEP/FiO2
table (from the LOVS trial) [6] selected the PEEP level
that best represented the recruitability of the lung.
Using techniques, such as esophageal pressure
measurements, to estimate transpulmonary pres-
&&
sure (Ptp) [19 ], stress index [20], and electrical
&
impedance tomography (EIT) [21 ] to individualize
PEEP are promising techniques that not only have
been used to optimize PEEP, but also can be used in
the assessment of overdistension. These techniques,
however, require more clinical data to determine
superiority to the simplicity of a high PEEP/FiO2
table and minimizing plateau pressure for patients
with moderate-to-severe ARDS (Table 1).
The major clinical challenge to setting PEEP in
the patient with life-threatening hypoxemia, or
severe ARDS is preventing atelectrauma, while min-
imizing overdistension of other areas of the lung.
The many causes of acute hypoxemia make a gener-
alized approach for all patients difficult, particularly
whenever there is heterogeneous distribution of
ventilation, differences in lung recruitability, or
elevated chest wall elastance. Although avoiding
plateau pressure more than 30 cmH2O is generally
recommended, clinicians should also consider
the change in respiratory system driving pressure
(DP ¼ plateau pressure  PEEP) that occurs after the
adjustment of PEEP. In a recent study by Amato et al.
[23], DP greater than 14 was associated with higher
risk of mortality [22]. The level of DP also correlates
well to lung stress in ARDS patients. If DP increases
after an increase in PEEP, this could reflect over-
distension within the lungs, and PEEP should be
decreased. In patients with high chest wall ela-
stance, however, DP may reflect the contribution
of the chest wall rather than the lungs. In these
patients, the use of esophageal pressure measure-
ments could be used to monitor and attempt to limit
the transpulmonary driving pressure (DPtp ¼ Ptp
plateau  Ptp PEEP) to less than 10 cmH2O [24 ].
&&
Although DP may be a simple parameter to monitor,

Table 1. Methods to set individualized positive end-expiratory pressure and minimize overdistension

Method Description Clinical use

Esophageal pressure measurements
Stress index
Electrical impedance tomography
An esophageal balloon catheter is placed
into the lower third of the esophagus.
Esophageal pressure can be used to
estimate pleural pressure, Ptp, and
measure chest wall and lung elastance.
During constant flow (volume assist-control)
ventilation, the pressure–time curve can
provide useful information related to tidal
recruitment within the lung.
Electrodes placed around the thorax allow
impedance measurements to display real-
time changes to ventilation distribution.
PEEP can be set to maintain a Ptp of more than
0 cmH2O or to minimize the stress on the lung
using either a Ptp plateau or elastance-derived
method (Ptp ¼ plateau  EL/ERS).
A downward curvature (like a shark fin) indicates
tidal recruitment (stress index <0.9) and that
PEEP could be increased. An upward curvature
indicates there is no tidal recruitment, and
possible overdistension (stress index >1.1). A
straight pressure–time curve indicates optimal
PEEP (stress index 0.9–1.1)
Data collected during incremental or decremental
PEEP titration while monitoring lung impedance
can be analyzed to determine the balance
between collapse and overdistension within the
lung using regional compliance information.

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the potential efficacy of strategies targeting DP needs
to be evaluated in clinical trials.
RECRUITMENT MANEUVERS
The importance of recruitment maneuvers is sup-
ported in the subgroup of patients with life-threat-
&&
ening hypoxemia [9 ,25]. Future studies should
focus on the proper timing and frequency of
performing recruitment maneuvers. Currently, the
recommended technique for recruiting the lung is
moving away from the sustained inflation maneu-
ver to a stepwise incremental PEEP adjustment with
&&
a fixed DP [26 ,27]. The factor most likely related to
the success of recruitment maneuvers is to have the
appropriate setting of PEEP after the maneuver to
ensure recruited alveoli are kept open.
As already stated, the major concern after select-
ing PEEP is the possibility of overdistension that may
affect the already opened regions of the lung. One of
the more common methods to select PEEP after a
stepwise recruitment maneuver is the decremental
PEEP titration. Various measurements can be moni-
tored during this maneuver to assist in selecting the
appropriate PEEP level including compliance, dead-
space fraction, and oxygenation. Other methods that
can be used to determine both lung recruitment and
individualize PEEP at the bedside include lung ultra-
sound and electrical impedence tomography (EIT,
&
discussed in another section) [21 ,28,29].
OTHER STRATEGIES FOR MANAGING
LIFE-THREATENING HYPOXEMIA
Neuromuscular blocking agents
The use of deep sedation and neuromuscular block-
ing agents (NMBAs) in the management of severe
ARDS is supported by a single randomized con-
trolled trial (RCT) [8]. According to findings of the
LUNG SAFE study, however, the use of NMBAs in
severe ARDS patients remains low (37.8%) [16]. The
use of NMBAs should be considered as a primary
therapy strategy in patients presenting with life-
threatening hypoxemia not only to reduce oxygen
demand, but also to minimize potentially harmful
inspiratory effort. Animal studies using EIT and
transpulmonary pressure have demonstrated that
spontaneous breathing even during volume-con-
trolled ventilation (thought to control volume-
related injury and maintain transpulmonary pres-
sure) can lead to pendelluft, and greater tidal infla-
tion, tidal recruitment, and higher regional lung
&&
stress in the dorsal lung regions [30,31 ]. This con-
cept of patient self-inflicted lung injury (P-SILI)
should be considered in the context of lung-
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Acute life-threatening hypoxemia Piraino and Fan
&&
protective ventilation [32 ]. The use of NMBAs to
prevent high inspiratory effort in patients with
acute respiratory failure has not been tested in a
clinical trial. Physiological data supporting the
potential contribution of patient effort in worsening
lung injury, however, should be considered in future
studies.
Prone positioning
The use of prone positioning has been shown to
improve outcomes in ARDS patients with PaO2/FiO2
less than 150 mmHg [7,33]. The goal of prone posi-
tioning is to improve the gas to tissue ratio within the
lungs, and patients with life-threatening hypoxemia
may have poor distribution of ventilation to the
dependent regions. Placing patients into the prone
position alters the gas to tissue ratio by increasing
ventilation to dependent lung regions, which can
cause alveolar recruitment and a more homogeneous
distribution of ventilation. The perfusion of the lung is
not altered by placing patients in the prone position,
so any improvement in ventilation will decrease intra-
pulmonary shunting [34,35]. Despite the benefits of
prone positioning, the use of this strategy in clinical
practice is still low as reported by the LUNG SAFE study
(16.3% of patients with severe ARDS PaO2/FiO2 less
than 100 mmHg) [16]. Some of the hesitation for
clinical sites to implement a prone position strategy
may be because of the potential risk of complications.
In centers with significant experience with prone
positioning, however, there appears to be no increased
risk to the patient [7]. Given the significant improve-
ment in patient outcomes with prone positioning,
centers that are less experienced should develop
implementation strategies to facilitate the increased
use of this intervention in appropriate ARDS patients.
Inhaled pulmonary vasodilators
The use of inhaled pulmonary vasodilators (IPVs)
has been shown to improve oxygenation, but with
no survival benefit in patient with ARDS [36]. The
use of IPVs for treating right ventricular (RV) failure
[37] or known pulmonary hypertension [38] cou-
pled with severe hypoxemia could be considered,
but only as a temporary strategy to allow the time to
consider the next step in patient management. In
severe ARDS patients, IPVs could facilitate the well
tolerated transfer to a center with expertise in lung-
protective strategies [39].
Extracorporeal life support
The goal of extracorporeal life support (ECLS) in
patients with respiratory failure is to provide
www.co-criticalcare.com 545
Emergencies in critical care
oxygenation and CO2 elimination so the lungs have
sufficient time to recover, without causing further
VILI. The method of ECLS, most commonly used for
the treatment of severe hypoxemia, is venovenous
extracorporeal membrane oxygenation (VV ECMO)
[40]. Whenever patients present with severe refrac-
tory hypoxemia that is unresponsive to the above-
mentioned strategies, appropriate candidates should
be considered for ECMO.
Unconventional modes of ventilation
The two most common modes considered for
improving severe hypoxemia by increasing mean
airway pressure are high-frequency oscillatory ven-
tilation (HFOV) and airway pressure release ventila-
tion (APRV) [41]. Only one of these modes has been
rigorously tested against the use of higher levels of
PEEP in a multicenter RCT, which resulted in higher
mortality in patients treated with HFOV compared
to conventional ventilation and high PEEP [5]. In a
secondary analysis, however, HFOV could still be
considered for refractory hypoxemia with a PaO2/
FiO2 less than 64 mmHg [42]. The use of APRV in
severely hypoxemic patients has not been tested in a
multicenter RCT, and therefore has not been proven
to provide benefit over any of the previously
mentioned strategies.
THE CARDIOPULMONARY RELATIONSHIP
It is important to understand the intricate relation-
ship between the heart and lungs. Cardiac output
with or without positive pressure can affect oxygen-
ation and oxygen delivery. Proper fluid resuscitation
is important to minimize the effects of positive
pressure ventilation; however, a conservative fluid
maintenance strategy should also be considered to
minimize effects on the lungs and the need for
prolonged ventilation [43].
Although the use of lung-protective ventilation
has reduced the hemodynamic effects of positive
pressure ventilation, acute cor pulmonale (ACP) has
&
been reported with a prevalence of 20–25% [44 ,45].
Risk factors for ACP include pneumonia as the cause
of ARDS, DP at least 18 cmH2O, PaO2/FiO2 less than
150 mmHg, and PaCO2 at least 48 mmHg, whereas
the use of prone positioning reduced the risk of ACP
&
[44 ]. Therefore, in patients with multiple risk fac-
tors for ACP, a ‘RV protective strategy’ should be
considered that includes ensuring a plateau pressure
less than 30 cmH2O, DP less than 18 cmH2O, PaCO2
less than 48 mmHg, and that prone positioning is
used whenever PaO2/FiO2 is less than 150 mmHg
&
[44 ]. Additionally, a right-to-left cardiac shunt via a
patent foramen ovale has been reported with a
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prevalence of 20%. Although patients were found
with a patent foramen oval (PFO) at baseline, some
patients developed a PFO only after an increase in
PEEP, suggesting a potential risk for applying high
PEEP in select patients [46]. Patients that appear
unresponsive to PEEP should have echocardiogra-
phy performed to confirm or rule-out these possible
contributing factors.
ADVANCED MONITORING
Esophageal pressure monitoring
Esophageal pressure is used as a surrogate of pleural
pressure and can provide additional information
related to the mechanical properties of the respira-
tory system. Esophageal pressure allows the clinician
to distinguish between the relative contributions of
the lung and chest wall to overall respiratory system
compliance in the difficult to ventilate and oxygen-
ate patient. Ventilatory strategies based on values
derived from esophageal manometry have been asso-
ciated with improvements in respiratory system com-
pliance, oxygenation, and has led to the avoidance of
ECMO [47,48]. There is constant debate, however, in
the literature over the appropriate way to use the
esophageal pressure. The debate is based on the rea-
soning that an esophageal catheter placed in the
lower third of the esophagus likely underestimates
the pleural pressure in the nondependent lung
regions, particularly in patients with severe hetero-
geneous lung disease with nonrecruitable lung
&&
regions [19 ]. Despite its limitations, successfully
implementing these measurements at the bedside
can impact the patient-care plan and individualize
mechanical ventilation [49].
Lung ultrasound
The use of lung ultrasound is a valuable noninvasive
bedside monitoring technique that can provide
information by assessing different regions with
the ultrasound probe. Lung ultrasound can be used
to identify various causes of acute hypoxemia such
as pleural effusions, pulmonary edema, pulmonary
consolidation, and pneumothorax. Additionally,
ultrasound can be used to identify improvements
in lung aeration after adjusting PEEP and during
lung recruitment maneuvers [29,50]. Unfortu-
nately, lung ultrasound cannot assess regional over-
distension, and therefore should not be used as the
only method to set PEEP [29].
Electrical impedance tomography
Electrical impedance tomography is a radiation-free
imaging technique that uses multiple electrodes
Volume 23  Number 6  December 2017

placed around the thorax that measure the imped-
ance of volume change both globally and within
different regions of the lung, in real-time, and with-
out adjustment of the belt position. It has been used
for titration of PEEP, lung recruitment, viewing the
effects of strong spontaneous effort (causing pen-
delluft), and the assessment of regional overdisten-
& &
sion [21 ,28,51,52,53 ]. The ability to noninvasively
visualize ventilation distribution at the bedside, and
to set ventilator parameters that balance effects of
regional collapse and regional overdistension, gives
EIT a unique advantage as a bedside monitoring
tool. The real-time analysis and interpretation of
information, and adding visualization of perfusion
at the bedside, however, would make these devices
& 4. Cabrini L, Landoni G, Bocchino S, et al. Long-term survival rate in patients
even more ideal for the bedside clinician [53 ].
CONCLUSION
Although, there is evidence to support the use of
lung-protective ventilation and adjunctive thera-
pies in the management of patients with acute
life-threatening hypoxemia, there is also the emerg-
ing concept of personalizing the approach for each
patient. In the current literature, this encompasses
understanding the patient’s full respiratory
mechanics separated into the lung and chest wall
using esophageal pressure measurements, or the
bedside visualization of regional difference within
the lung using lung ultrasound or EIT. Although,
there are currently only a few strategies for improv-
ing outcomes in these patients (NMBAs, prone posi-
tioning, and low tidal volume), future randomized
trials should aim to include patients based on the
individualized assessment of the patient’s response
to PEEP, and lung recruitability [49,54]. This indi-
vidualized approach could help to provide the right
approach for the right patient, and could be used to
better select patients for inclusion into studies using
ECMO. Finally, other emerging nonventilatory
strategies, such as therapeutic hypothermia, should
be further studied in this high-risk patient popula-
tion [55].
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
T.P. has received speaking and consultation fees from
Philips, Drager, and Mallinckrodt. Dr E.F. has received
consultation fees from MC3 Cardiopulmonary, and is
supported by a New Investigator Award from the
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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Acute life-threatening hypoxemia Piraino and Fan
Canadian Institutes of Health Research. None of the
sponsors had any role in the drafting or revisions of
the manuscript.
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Volume 23  Number 6  December 2017