CHEST Original Research

CRITICAL CARE MEDICINE

Comparison of the SpO2/FIO2 Ratio and

the PaO2/FIO2 Ratio in Patients With
Acute Lung Injury or ARDS*
Todd W. Rice, MD, MSc; Arthur P. Wheeler, MD, FCCP;
Gordon R. Bernard, MD, FCCP; Douglas L. Hayden, MA;
David A. Schoenfeld, PhD; and Lorraine B. Ware, MD, FCCP; for the National
Institutes of Health, National Heart, Lung, and Blood Institute ARDS Network

Background: The diagnostic criteria for acute lung injury (ALI) and ARDS utilize the PaO2/
fraction of inspired oxygen (FIO2) [P/F] ratio measured by arterial blood gas analysis to assess the
degree of hypoxemia. We hypothesized that the pulse oximetric saturation (SpO2)/FIO2 (S/F) ratio
can be substituted for the P/F ratio in assessing the oxygenation criterion of ALI.
Methods: Corresponding measurements of SpO2 (values < 97%) and PaO2 from patients enrolled
in the ARDS Network trial of a lower tidal volume ventilator strategy (n ⴝ 672) were compared
to determine the relationship between S/F and P/F. S/F threshold values correlating with P/F
ratios of 200 (ARDS) and 300 (ALI) were determined. Similar measurements from patients
enrolled in the ARDS Network trial of lower vs higher positive end-expiratory pressure (n ⴝ 402)
were utilized for validation.
Results: In the derivation data set (2,613 measurements), the relationship between S/F and P/F
was described by the following equation: S/F ⴝ 64 ⴙ 0.84 ⴛ (P/F) [p < 0.0001; r ⴝ 0.89). An S/F
ratio of 235 corresponded with a P/F ratio of 200, while an S/F ratio of 315 corresponded with a
P/F ratio of 300. The validation database (2,031 measurements) produced a similar linear
relationship. The S/F ratio threshold values of 235 and 315 resulted in 85% sensitivity with 85%
specificity and 91% sensitivity with 56% specificity, respectively, for P/F ratios of 200 and 300.
Conclusion: S/F ratios correlate with P/F ratios. S/F ratios of 235 and 315 correlate with P/F ratios
of 200 and 300, respectively, for diagnosing and following up patients with ALI and ARDS.
(CHEST 2007; 132:410 – 417)

Key words: acute lung injury; ARDS; definition; Pao2/fraction of inspired oxygen ratio

Abbreviations: AECC ⫽ American European Consensus Conference; ALI ⫽ acute lung injury; AUC ⫽ area under the
curve; CI ⫽ confidence interval; Fio2 ⫽ fraction of inspired oxygen; PBW ⫽ predicted body weight; PEEP ⫽ positive
end-expiratory pressure; P/F ⫽ Pao2/fraction of inspired oxygen; ROC ⫽ receiver operator characteristic; S/F ⫽ pulse
oximetric saturation/fraction of inspired oxygen; Spo2 ⫽ pulse oximetric saturation

A cute lung injury (ALI) and the ARDS are devas-

tating clinical syndromes with high morbidity
and mortality.1,2 Acute hypoxic respiratory failure, as
defined by the Pao2/fraction of inspired oxygen
(Fio2) ratio (or P/F ratio) is one of the criteria for
ALI/ARDS that was developed by an American
European Consensus Conference (AECC) in 1994.3
A P/F ratio ⱕ 300 and ⱕ 200, respectively, are
utilized to define ALI and ARDS.3
Despite the straightforward nature of the AECC
definition of ALI and ARDS, the requirement for
arterial blood gas sampling may contribute to the
underdiagnosis of these syndromes.4 Concerns about
anemia, excessive blood draws, and a movement to
minimally invasive approaches have led to fewer arte-
rial blood gas measurements in critically ill patients.5–7
In healthy subjects, changes in Pao2 correlate well with
changes in pulse oximetric saturation (Spo2) for oxygen
saturation in the range of 80 to 100%.8 –10 However,
studies in critically ill patients, especially those with
ALI/ARDS, are lacking. Furthermore, threshold values
for Spo2/Fio2 (S/F) ratios could be used as noninvasive

410 Original Research

criteria for diagnosing ALI/ARDS. In this study, we
sought to derive and validate the relationship between
S/F and P/F ratios in critically ill patients with ALI/
ARDS. We hypothesize that the continuously available
S/F ratio can be used as a surrogate for the P/F ratio in
the diagnosis of ALI/ARDS. The use of the S/F ratio
may better facilitate the screening and rapid identifica-
tion of patients with ALI/ARDS while avoiding the
blood use and cost for blood gas determinations.
Materials and Methods
Derivation Data Set
Corresponding measurements of Spo2 and Pao2 from patients
enrolled in the National Heart, Lung, and Blood Institute ARDS
Network trial11 comparing tidal volumes of 6 mL/Kg predicted
body weight (PBW) with those of 12 mL/kg were utilized to
establish the relationship between S/F and P/F ratios. Each
ARDS Network site received approval from local institutional
review boards to conduct the studies. The inclusion and exclusion
criteria for the ARDS Network tidal volume study11 have been
reported elsewhere. All patients underwent measurements of
Spo2 and Pao2 with documentation of inhaled concentrations of
oxygen at study enrollment and as clinically indicated prior to
study day 28 or achieving unassisted breathing. Research person-
nel were instructed to document Spo2 values at the time of
arterial blood gas sampling. In rare cases when this was not
possible, the Pao2 measurement closest to the Spo2 value was
utilized. The following measures were employed to improve the
accuracy of the Spo2 measurements: optimal position and clean-
liness of the sensor; satisfactory waveforms; no position changes
or endobronchial suctioning for at least 10 min prior to the
measurement; and no invasive procedures or ventilator changes
for at least 30 min prior to the measurement.12 Spo2 was
observed for a minimum of 1 min before the value was recorded.
Because the P/F ratio cutoffs used to diagnosis ALI/ARDS differ
at lower barometric pressures, patients who were enrolled in the
study at centers located ⬎ 1,000 m in altitude (eg, Salt Lake City
and Denver) were excluded from the data sets. Measurements
*From the Division of Allergy, Pulmonary, and Critical Care
Medicine (Drs. Rice, Wheeler, Bernard, and Ware), Department
of Medicine, Vanderbilt University School of Medicine, Nash-
ville, TN; ARDS Network Clinical Coordinating Center (Mr.
Hayden and Dr. Schoenfeld), Massachusetts General Hospital,
Boston, MA.
This research was funded by National Institutes of Health grants
N01-HR-46054 (to Drs. Rice, Wheeler, and Bernard), N01-HR-
46064 (to Mr. Hayden and Dr. Schoenfeld), HL07123 (to Dr.
Rice), HL70521 (to Dr. Ware), and HL81332 (to Dr. Ware) from
the National Heart, Lung, and Blood Institute.
The authors have reported to the ACCP that no significant
conflicts of interest exist with any companies/organizations whose
products or services may be discussed in this article.
Manuscript received March 20, 2007; revision accepted May 2,
2007.
Reproduction of this article is prohibited without written permission
from the American College of Chest Physicians (www.chestjournal.
org/misc/reprints.shtml).
Correspondence to: Todd W. Rice, MD, MSc, Division of Allergy,
Pulmonary, and Critical Care Medicine, T-1218 MCN, Nashville,
TN 37232-2650; e-mail: todd.rice@vanderbilt.edu
DOI: 10.1378/chest.07-0617
www.chestjournal.org
with Spo2 values of ⬎ 97% were also excluded from analysis
because the oxyhemoglobin dissociation curve is flat above these
levels.
Analysis of the Derivation Data Set
A scatterplot of S/F vs P/F ratios was utilized to determine the
linear relationship between the two measurements. Generalized
estimating equations13 were then utilized to quantify the best
regression line. The equation for this regression line was em-
ployed to determine threshold values for S/F ratios that correlate
with P/F ratios of 300 and 200, respectively, for ALI and ARDS.
The S/F ratio divided by the P/F ratio was plotted against Fio2,
positive end-expiratory pressure (PEEP), and Spo2 to assess the
effect that each had on the relationship. Linear mixed-effect
modeling was undertaken to determine the effect that PEEP
exerted on the S/F threshold values for defining either ALI or
ARDS, as defined by the P/F ratio oxygenation criterion. Arterial
pH and Paco2 might also affect the relationship between S/F and
P/F ratios but were not included in the model because both
require arterial blood sampling. In these situations, the availabil-
ity of the P/F ratio would obviate the need for a noninvasive
measurement defining ALI. An interaction term was included in
the model to assess the effect modification by PEEP on the
relationship between the P/F and S/F ratios. Receiver operator
characteristic (ROC) curves were plotted to assess the degree of
discrimination between S/F and P/F ratios and to slightly adjust
the S/F ratio threshold values for both ALI and ARDS to
optimize the sensitivity and specificity.
Validation Data Set
The relationship of S/F vs P/F ratio was externally validated
using similarly matched data for S/F and P/F ratios from patients
enrolled in another ARDS Network trial comparing lower vs
higher PEEP.14 This study utilized inclusion and exclusion
criteria that were similar to those of the derivation data set
study.14 Arterial blood gas measurements and Spo2 data were
collected at similar time points using methods that were similar to
those of the derivation data set.
Analysis of the Validation Data Set
Generalized estimating equations13 was utilized to quantify the
relationship between S/F and P/F ratios in the validation data set.
ROC curves were plotted to determine the sensitivity and
specificity of the threshold values derived from the derivation
data set for both ALI and ARDS, with the area under the curve
(AUC) calculated to assess the degree of discrimination between
S/F and P/F ratios.
Statistical Analysis
Normally distributed continuous variables are expressed as the
means and SD. Nonnormally distributed continuous variables are
reported as the median and interquartile range. The correlation
between P/F and S/F ratios was analyzed using Spearman
correlation analysis. Linear regression modeling was utilized to
compare the relationship between P/F and S/F ratios with
adjustment for levels of PEEP as a potential confounder and
effect modifier. A fixed effect with parametric compound sym-
metry structure was utilized to account for multiple measure-
ments obtained from the same patient. PEEP, P/F ratio, and the
interaction term PEEP*P/F were included in the model as
continuous variables. Statistical software packages (SPSS, version
14.0; SPSS; Chicago, IL; and SAS, version 9.1; SAS Institute Inc;
CHEST / 132 / 2 / AUGUST, 2007 411
Cary, NC) were utilized to perform analyses, graph scatterplots Table 1—Baseline Demographics of the Patients
and ROC curves, and calculate the AUC of the ROC. Likelihood Enrolled in the Studies for Both Data Sets
ratios were calculated using appropriate software (Confidence
Interval Analysis, version 2.1.0) [available at: www.medschool. Derivation Validation
soton.ac.uk/cia]. Two thousand bootstrap samples were com- Data Set Data Set
puted by resampling patients with replacement to determine Variables (n ⫽ 672) (n ⫽ 402)
95% CI for the likelihood ratios.
Age, yr 50.8 ⫾ 17.5 50.9 ⫾ 17.4
Female sex 41 44
Etiology of ALI
Results Pneumonia 34 41
Sepsis 26 22
Of the 861 patients enrolled in the study compar- Trauma 10 9
ing tidal volumes of 6 and 12 mL/kg PBW, 189 were Aspiration 16 16
Baseline P/F ratio 132 ⫾ 61 152 ⫾ 66
enrolled at sites located at ⬎ 1,000 m in altitude (Fig Minute ventilation, L/min 12.9 ⫾ 4.1 11.7 ⫾ 3.5
1). The remaining 672 patients provided 3,384 Pao2 APACHE III score 85 ⫾ 29 93 ⫾ 31
and Spo2 measurements at known Fio2 values. Spo2 Nonpulmonary organ 1.6 ⫾ 0.8 1.0 ⫾ 0.9
exceeded 97% in 711 patients, leaving 2,673 data failures, No.
points for analysis in the derivation data set. Of the *Values are given as the mean ⫾ SD or %. APACHE ⫽ acute
549 patients who were enrolled in the trial compar- physiology and chronic health evaluation.43
ing high and low PEEP, 146 were enrolled at centers
that were at altitudes of ⬎ 1,000 m, and 1 patient
had no matched measurements for Spo2 and Pao2. Table 1. The respiratory parameters from the time of
The remaining 402 patients provided 2,031 measure- the measurements for both data sets are depicted in
ments with Spo2 values of ⱕ 97% for the validation Table 2. In the derivation data set, the minimum
data set (Fig 1). Spo2 measurement was 56%, with 94% of the mea-
Patients enrolled in both studies had similar base- surements being between 88% and 97%. Likewise,
line demographics, which have been previously de- the minimum Spo2 measurement in the validation
tailed elsewhere11,14 and are briefly summarized in data set was 62%, with 95% of the measurements

Figure 1. Flow diagram for the data points utilized in the derivation and validation data sets. The
derivation set was derived from the ARDS Network trial11 of 6 vs 12 mL/kg tidal volume ventilation.
The validation set was derived from the ARDS Network trial14 of higher vs lower PEEP.

412 Original Research

being between 88% and 97%. The majority of P/F
ratio measurements met the AECC oxygenation
criterion for ARDS (P/F ratio ⱕ 200) in both the
derivation data set (2,130 of 2,673 measurements;
79.7%) and the validation data set (1,475 of 2,031
measurements; 72.6%), while 96.9% of measure-
ments for the derivation data set (2,590 of 2,673
measurements) and 96.1% of measurements for the
validation data set (n ⫽ 1952/2031) met the criterion
for ALI (P/F ratio ⱕ 300).
Derivation Data Set
S/F and P/F ratios demonstrated a linear correla-
tion. This relationship, which did not differ between
the two tidal volume strategies (ie, 6 vs 12 mL/kg
PBW) is described by the following regression equa-
tion: S/F ⫽ 64 ⫹ 0.84 ⫻ (P/F) [95% CI, S/F ⫽
(58 ⫺ 70) ⫹ (0.79 ⫺ 0.88) ⫻ P/F] (p ⬍ 0.0001;
r ⫽ 0.89) [Fig 2]. The relationship between S/F and
P/F ratios did not change across varying levels of Fio2
(Fig 3, top, A) or PEEP (Fig 3, middle, B). Since the
Fio2 delivered to patients was protocol-driven with a
goal Spo2 between 88% and 92%, the inverse of the
Fio2 correlates similarly with P/F ratio (r ⫽ 0.83) [Fig
3, bottom, C]. ROC curves (Fig 4) demonstrated that
S/F ratios had excellent ability to discriminate between
patients with and without ARDS (ie, P/F ratio ⱕ 200;
AUC ⫽ 0.929) and ALI (P/F ⱕ 300; AUC ⫽ 0.920).
Linear mixed-effect analysis of the derivation data
set demonstrated that PEEP had a significant effect on
S/F ratios (p ⬍ 0.001) and slightly modified the effect
of the P/F ratio on S/F ratios (p ⫽ 0.001) as
described by the following equation: S/F ⫽ 129 ⫹
0.72 ⫻ (P/F) ⫺ 4.0 ⫻ (PEEP) ⫺ 0.008 ⫻ (PEEP) ⫻
(P/F) [95% CI: S/F ⫽ (121 ⫺ 137) ⫹ (0.68 ⫺ 0.76)
⫻ P/F ⫺ (3.3 ⫺ 4.7) ⫻ PEEP ⫺ (0.004 ⫺ 0.013) ⫻
(PEEP) ⫻ (P/F)] (p ⬍ 0.001; r ⫽ 0.87). The linear re-
gression equation utilized in conjunction with the
mixed-effect model and ROC curves predicted that S/F
ratios of 235 and 315 would correspond with P/F ratios
of 200 (ARDS) and 300 (ALI), respectively.
Table 2—Respiratory Parameters at the Time of the Corresponding S/F and P/F Ratio Measurements in Both
Data Sets*
Derivation Data Set Measurements
Variables
S/F ratio
P/F ratio
Tidal volume, mL/kg PBW
Total respiratory rate, breaths/min
Minute ventilation, L/min
PEEP, cm H2O
Paco2, mm Hg
Arterial pH
*Values are given as the mean ⫾ SD (median; interquartile range 关for variables that are not normally distributed兴).
www.chestjournal.org
Validation Data Set
S/F and P/F ratios demonstrated a similar linear
relationship in the validation data set, described by
the following equation: S/F ⫽ 68 ⫹ 0.84 ⫻ (P/F)
[95% CI, S/F ⫽ (60 ⫺ 77) ⫹ (0.78 ⫺ 0.89) ⫻ P/F]
(p ⬍ 0.0001; r ⫽ 0.82) [Fig 5]. S/F ratios also dem-
onstrated discriminatory ability for P/F ratio values
of both 200 and 300 in the validation data set as
shown by AUC values of 0.928 and 0.878, respec-
tively, for ROC curves. The S/F ratio threshold of
235 from the derivation data set accurately identified
1,257 of the 1,475 cases of ARDS in the validation
data set (P/F ratio ⱕ 200), yielding a sensitivity of
85%. The same threshold value also correctly dis-
criminated 472 of the 556 cases in which the P/F
ratio was ⬎ 200, for a specificity of 85%. The positive
and negative likelihood ratios for the S/F ratio value
of 235 discriminating P/F ratio values of ⱕ 200 (ie,
the oxygenation criterion for ARDS in the AECC
definition) were 5.64 (95% CI, 4.69 to 7.08) and 0.17
(95% CI, 0.15 to 0.20), respectively. Similarly, the
S/F threshold of 315 demonstrated 91% sensitivity
(accurately identifying 1,778 of the 1,952 cases) for
discriminating ALI (P/F ratio ⱕ 300) with 56%
specificity (correctly discriminating 44 of the 79
cases in which the P/F ratio was ⬎ 300). The positive
and negative likelihood ratios for the S/F ratio of 315
for ALI (P/F ratio ⱕ 300) were 2.06 (95% CI, 1.64 to
2.76) and 0.16 (95% CI, 0.12 to 0.21), respectively.
Discussion
We hypothesized that the continuously available
S/F ratio can serve as a surrogate for P/F ratio in the
diagnostic criteria for ALI/ARDS. Using data from
patients with ALI and ARDS who were enrolled in
two large clinical trials,11,14 we found that S/F ratio
correlates well with a simultaneously obtained P/F
ratio. The correlation improves slightly if PEEP is
included in the regression model. S/F ratios of 235
Validation Data Set Measurements
(n ⫽ 2,673) (n ⫽ 2,031)
194 ⫾ 65 (188; 137–235) 208 ⫾ 69 (194; 155–242.5)
155 ⫾ 66 (146; 106–190) 166 ⫾ 68 (157.5; 115–207.5)
9.0 ⫾ 2.9 6.4 ⫾ 1.7
23.3 ⫾ 8.7 28.1 ⫾ 7.7
13.2 ⫾ 4.2 (12.7; 10.4–15.5) 12.1 ⫾ 3.5 (11.8; 9.6–14.1)
8.7 ⫾ 3.9 10.7 ⫾ 4.6
40.4 ⫾ 10.7 (39; 33–45.8) 42.9 ⫾ 13.0 (41; 35–47)
7.39 ⫾ 0.07 7.38 ⫾ 0.08
CHEST / 132 / 2 / AUGUST, 2007 413

Figure 2. S/F ratio vs P/F ratio scatterplot for the derivation data
set. The line represents the best fit linear relationship (S/F
ratio ⫽ 64 ⫹ 0.84 ⫻ [P/F]) [p ⬍ 0.0001; r ⫽ 0.89].
and 315, were found to correspond to P/F ratios of
200 and 300, respectively, which are the oxygenation
criteria defining ARDS and ALI, respectively.3
These threshold S/F ratios demonstrated excellent
sensitivity and good specificity in predicting the
corresponding P/F ratios in a validation data set. To
our knowledge, these findings represent the first
large study of the relationship between Spo2 and
Pao2 in critically ill patients.
The noninvasive and continuously available Spo2
is standard monitoring in most ICUs.15 Although
Spo2 reliably predicts Pao2 measured by blood gas
analysis in healthy subjects,8,9,15–17 patient race,
oximeter location, and disease states, like low cardiac
output or methemoglobinemia, may reduce the ac-
curacy.8,10,16,18 Despite the ubiquity of Spo2, Pao2 is
the accepted “gold standard” for determining arterial
oxygenation. The measurement of Pao2 may also
significantly vary in patients over short periods of
time despite constant Fio2 due to factors such as
positioning, agitation, and endotracheal suction-
ing.19,20 Institutions, in an effort to contain costs,
conserve blood, and reduce inappropriate use,5–7
have vastly reduced the number of arterial blood gas
samples obtained in mechanically ventilated pa-
tients.21
The sensitivity and specificity of the threshold S/F
ratios of 235 and 315 derived in this study suggest
that they are appropriate surrogates for P/F ratios of
200 and 300. The use of the S/F ratio in the
diagnostic definitions for ALI/ARDS has several
potential clinical applications. First, the use of these
414
values will allow the recognition of patients who
likely have ALI/ARDS but have not undergone
arterial blood gas sampling, facilitating early enroll-
ment into clinical trials and early diagnosis and
treatment in clinical practice. Second, the S/F ratio
threshold of 315 can be utilized as a continuously
available screening tool to identify which patients
should undergo arterial blood gas analysis to deter-
mine whether they meet the oxygenation criterion
for ALI. For example, a ventilated patient receiving
30% Fio2 with 94% Spo2 (S/F ratio 313) who meets
the other criteria for ALI has a high likelihood of also
meeting the P/F ratio oxygenation criterion.
Utilizing S/F ratios to facilitate the clinical diag-
nosis of ALI/ARDS should help to address the
underdiagnosis of these syndromes. A volume-lim-
ited and pressure-limited ventilation strategy is the
only therapeutic intervention that has been shown to
significantly reduce mortality in patients with ALI.11
Despite being inexpensive and easy to use, this
intervention has not been widely adopted.22–26 One
explanation may be that ALI and ARDS are often not
recognized,4,26 likely contributing to the failure to
implement treatment strategies such as lung-protec-
tive ventilation and conservative fluid manage-
ment.11,27
S/F ratios may be useful in other important clinical
applications. Many organ failure scores, such as lung
injury score,28 sequential organ failure assessment,29
simplified acute physiology score II,30 or multiorgan
dysfunction score,31 utilize P/F ratios to quantify
hypoxemia. In instances in which these scores are
calculated frequently, the respiratory component is
often omitted due to the lack of repeated arterial
blood gas analyses. Using S/F ratio as a surrogate
measure of hypoxemia would allow these scores to be
calculated in the absence of arterial blood gas sam-
pling. It should be noted, however, that, except for
the lung injury score, these scoring systems are often
used for widely heterogeneous groups of critically ill
patients and not just those with ALI/ARDS requiring
mechanical ventilation. Since a diagnosis of ALI or
ARDS was required for enrollment in both of the
trials utilized in our analysis, ⬎ 95% of the measure-
ments in both the derivation and validation data sets
met the oxygenation criteria for ALI. The relatively
few patients with a P/F ratio of ⬎ 300 in our data sets
and the exclusion of patients enrolled at sites located
at altitudes of ⬎ 1,000 m renders extrapolation of
our results to these populations uncertain. Further-
more, the majority of the patients were nonsurgical,
with medical conditions causing ALI/ARDS. Our
results should be prospectively validated in other
patient populations, including patients not requiring
mechanical ventilation and patients without lung
Original Research

Figure 3. Relationship of S/F vs P/F ratio across varying levels
of (top, A) Fio2 (r ⫽ 0.14), (middle, B) PEEP (r ⫽ 0.18), and
(bottom, C) P/F vs 1/F ratio (P/F ⫽ ⫺13 ⫹ 81.2/Fio2; r ⫽ 0.83)
for the derivation data set. The line in all panels represents the
best-fit linear relationship.
www.chestjournal.org
Figure 4. ROC curves for (top, A) S/F vs P/F ratios of ⱕ 200 and
(bottom, B) S/F vs P/F ratios of ⱕ 300 for the derivation data set.
injury, to ensure that they remain accurate in these
heterogeneous populations.
There are some additional limitations of this study.
First, although the vast majority of the Spo2 and
Pao2 measurements were made simultaneously, the
protocols allowed separation by a few hours, which
could contribute to discrepancies between measure-
CHEST / 132 / 2 / AUGUST, 2007 415

Figure 5. S/F vs P/F ratio scatterplot for the validation data set.
The line in both panels represents the best-fit linear relationship
(S/F ⫽ 68 ⫹ 0.84 ⫻ [P/F]) [p ⬍ 0.0001; r ⫽ 0.82].
ments. Despite this, S/F and P/F ratios remained
highly correlated. Second, measurements made with
an Spo2 of ⬎ 97% were excluded from analysis. At
these saturations, the slope of the relationship be-
tween Spo2 and Pao2 becomes almost zero, and
large changes in Pao2 may result in little or no
change in Spo2. We believe that this limitation is
acceptable because routine ICU care titrates Fio2 to
maintain saturations of 92 to 95%.16 Finally, numer-
ous studies have reported low specificity and sensi-
tivity of the AECC definitions for ALI and
ARDS,4,32–38 with many studies criticizing the defi-
nition of hypoxemia.38 – 42 Our proposal to utilize S/F
ratio as a surrogate is not meant to alleviate these
concerns. The S/F ratio thresholds determined in
this study were based on P/F ratios proposed by the
AECC.3 Although using an S/F ratio will allow the
degree of hypoxemia to be assessed noninvasively,
the optimal definition of hypoxemia for the diagnosis
of ALI/ARDS and whether measurements should be
obtained on standardized PEEP and ventilator set-
tings remains controversial.4,39 – 42 Furthermore, S/F
ratio does not allow the evaluation of acid-base status
or Paco2 levels, two other potentially important
clinical reasons for performing blood gas analysis.
In summary, we have derived and validated
threshold values for S/F ratio that can be used as
surrogates to diagnose ALI/ARDS when a P/F ratio
is unavailable. Utilizing the noninvasive and contin-
uously available S/F ratio may facilitate an earlier
diagnosis of ALI/ARDS, allowing the application of
416
appropriate therapies such as lung-protective venti-
lation and conservative fluid management strategies.
Future studies are needed to validate the relation-
ship between S/F and P/F ratio in more heteroge-
neous populations of critically ill patients.
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