E 6 Oxygen Therapy

This equipment is mainly important for breathing problems as in Breathing problems of a neonate and young infants. When oxygen is needed and how to deliver oxygen as well as when to stop it, is described in How to deliver Oxygen to a NYI.

Subsection of this chapter:

1. Clinical Problem
2. Assessment
3. Management
4. Infection Prevention
5. Complications
6. Care & Maintenance
7. Troubleshooting & Repair

NEST360°. Newborn Essential Solutions and Technologies-Education – Clinical Modules: Oxygen Therapy. (June 2020). License: CC BY-NC-SA 4.0.

Clinical Problem

Oxygen sources may be used to provide supplemental oxygen directly to patients, shared between patients by using a flow splitter or used with other treatment devices such as continuous positive airway pressure devices.

Supplemental oxygen is indicated for sick children, especially those with hypoxia. Hypoxia is defined as an oxygen saturation (SpO2) < 90%. See how to deliver oxygen for more information.

• Respiratory distress syndrome
• Transient tachypnoea of the newborn
• Birth asphyxia
• Meconium aspiration
• Pneumonia
• Pneumothorax
• Partial airway obstruction
• Neonatal anaemia
• Neonatal sepsis with respiratory distress
• Congenital anomalies (e.g., some types of congenital heart disease, diaphragmatic hernia)
• Persistent pulmonary hypertension of the newborn
• Seizures
• Chronic lung disease

Whilst nearly all sick infants may benefit from oxygen therapy, any concentration of oxygen administered without appropriate monitoring of peripheral blood oxygen saturation can cause harm.¹ Carefully select between those that would benefit from oxygen delivered directly to a patient (e.g., via nasal prongs) and those that would benefit from supplemental oxygen delivered with pressure via CPAP. Monitor carefully and discontinue oxygen as soon as it becomes unnecessary.

Assessment

Hypoxia contributes to both morbidity and mortality. Oxygen therapy may be used to improve body tissue oxygenation, measured by SpO₂ levels and also to provide symptomatic relief.

Oxygen therapy may be delivered using oxygen concentrators , oxygen flow splitters, walled oxygen, and oxygen cylinders. Oxygen flow rates vary based on intended use and mode of delivery:

• Resuscitation with bag and mask ventilation: 10 L/min¹ (Alert 2.1)
• Flowmeter stand (Splitter): 1 – 2 L/min per oxygen port
• Prongs: up to 2 L/min
• Mask: from 3 L/min to 10 L/min
• CPAP: from 1 L/min to 6 L/min

Neonatal patients should reach SpO₂ levels of 90 – 95% (Alert 2.1) by 15 minutes after birth. (Alert 2.2) If oxygen is needed it is recommended to give between 0.5-1 L/min.² Whilst on oxygen, regular monitoring should be conducted using a pulse oximeter to ensure that this saturation range is maintained for the duration of treatment. Ideally, patients suffering from severe respiratory distress should have continuous pulse oximetry monitoring throughout care.²

Management

Management of oxygen therapy covers how to use the device in a variety of settings, including patient preparation & commencement, care whilst on oxygen therapy & removal of the patient from the therapy. See the modules on oxygen concentrators , oxygen cylinders and oxygen flow splitters, for device specific recommendations.

PREPARING A PATIENT

1. Assess the condition of the baby. Ensure all clinical management measures are taken of which oxygen delivery is only one. Check the ABC and assess:
• Airway: suction if secretions are present
• Breathing:
• Respiratory rate: is it >60b/min
• SpO²: peripheral blood oxygen saturation level, is it <90%
• Work of breathing: e.g., grunting, fast breathing, chest indrawing
Chest auscultation
• Circulation:
• Perfusion: cool limbs and prolonged capillary refill time (>3 sec)
• Heart sounds
• Seizures
• Temperature
2. If CPAP is available assess whether the patient would benefit more from bubble CPAP than from oxygen alone. If so, prepare the patient for bubble CPAP.

STARTING A PATIENT

1. Collect:
• Appropriately sized nasal prongs (should fit loosely in the nostrils)
• Tape
• Cotton wool
2. Check that the end of the prong tubing is secured to the oxygen port on the concentrator, flow has been set and that oxygen is coming out of the nasal prongs.
3. Insert the nasal prongs and secure in place on both cheeks with tape. Adjust loop adjustment slider to hold nasal prongs looped above the ears in place securely. Protect the sides of the nose and cheek where the tubing could rub and injure the skin. (3.1)
4. Consider labelling nasal prongs to more easily determine which patients are being treated with which oxygen ports. This will make it easier for future staff to adjust oxygen levels & prevent incorrect changes from being made to the patient’s treatment due to port misidentification. (3.2)

CARING FOR A PATIENT

1. After starting on oxygen, monitor saturations using continuous pulse oximetry. Titrate oxygen up and down until normal saturation limits (SpO₂ 90 – 95)^3–6 are reached. If patient requires more than 2 L/min of oxygen, nasal prongs should be changed to either CPAP or facemask (3.7) oxygen depending on the underlying clinical condition. (Alert 3.2)
2. Monitor according to clinical condition, or in accordance to local policy:
• Vital signs, including oxygen saturation, respiratory rate, heart rate, blood pressure and temperature
• Work of breathing (see above)
• Nostril patency
3. Administer nasal saline drops to prevent mucosal drying, every four hours or more frequently depending on need.

REMOVING A PATIENT

1. Once patients can maintain normal oxygen saturations and are clinically stable, the oxygen flow rate should be reduced based on clinical response:
• Reduce oxygen flow by 0.25 L/min, rechecking saturations and clinical condition after 15 minutes.
• If saturations and clinical condition remain stable, continue reducing oxygen flow by increments of 0.25 L/min, rechecking saturations 15 minutes after each reduction and then every 4 hours or as clinically indicated.
• If saturations drop below 90% or the patient clinically deteriorates, increase the oxygen until normal saturations are obtained and the patient clinically improves.
2. Once saturations are consistently above 90 - 95% at 0.25 L/min and the patient is clinically stable, remove patient from oxygen by gently removing the tape and taking the prongs out of the patient’s nostrils. Recheck the saturations after 15 minutes:
• If saturations have dropped or there is a clinical deterioration, recommence oxygen.
• If saturations and clinical condition are stable, remove patient from oxygen.

Infection Prevention

Routine and adequate cleaning of medical devices is critical to prevent hospital-acquired infections in newborn care units. If devices and equipment are not disinfected or reprocessed promptly or adequately between patients, they may pose a significant infection risk.

GENERAL INFECTION PREVENTION

1. Clean hands with soap and water or alcohol before and after placing a patient on oxygen or handling any tubing that will be used on a patient.
2. Ensure that all patient-related tubing and consumables (including prongs and humidifier bottles) are new or have been cleaned thoroughly before use. Any patient-related tubing must be cleaned before it is used to place another patient on oxygen. The Reprocessing Respiratory Tubing Algorithm details reprocessing tubing for reuse.
3. Tubing should be hung to dry after disinfection and should not touch the floor or other unsanitary surfaces whilst drying. (4.2) It should be clearly labelled as having been cleaned.
4. All patient-related cleaned and new consumables should be stored in a clean, dry location. Tubing should be stored in loose rolls, preventing sharp bends or kinks which will decrease the lifetime of the tubing.

DISINFECTION AFTER USE

1. Remove end of prong tubing from oxygen port. If reusing, immediately begin hospital protocol for disinfection of tubing. Delay in initiating cleaning of reused medical devices can lead to the need for more intensive cleaning procedures to remove pathogens. If not reusing, discard appropriately. (Alert 4.1)
2. If using a humidifier in the oxygen circuit, change water after each patient or daily, if being used on the same patient.²

REPROCESSING TUBING

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Complications

Introduction of equipment in newborn care units poses clinical and device complications for patients. Awareness of potential complications is critical to maximise patient safety.

CLINICAL COMPLICATIONS

1. Hypoxia: if the nasal prongs become dislodged or blocked, the oxygen concentrator malfunctions or is turned off there is a risk that the baby will not receive enough oxygen. Hypoxia can cause:
• Damage to the brain (e.g. periventricular leukomalacia – damage to the white matter of the brain)
• Multi-organ failure
• Death

Reference Alert 2.2 for a full discussion of oxygen saturation level targets and recommendations.
2. Hyperoxia: if the peripheral blood oxygen saturations (SpO₂) are not monitored appropriately or the flow rate is inadvertently changed there is a risk that the baby will receive too much oxygen. Whilst oxygen can be lifesaving, peripheral blood oxygen saturations (SpO₂) above 95% on oxygen therapy can cause morbidities in premature babies, including:
• Retinopathy of prematurity: in premature babies, high blood oxygen levels can result in development of abnormal blood vessels on the retina, causing potential visual impairment or even blindness.
• Chronic lung disease: prolonged use (although sometimes unavoidable) of oxygen in premature babies causes lung fibrosis through inflammatory processes.
3. Nasal blockage: the nasal prongs and nostrils can become blocked with mucus which may result in increased respiratory distress and hypoxia.
4. Necrotic septum: incorrectly sized or applied nasal prongs may result in pressure on the nasal septum with resultant necrosis (tissue breakdown). Nasal septum should be checked twice daily.
5. Nasal prongs: prongs may become displaced, critically affecting the amount of oxygen received by the patient. All health workers, including the parents/guardians involved in the infant’s care should be aware of and watch out for this.

DEVICE COMPLICATIONS

Inadequate oxygen concentrations: all forms of delivered oxygen therapy are subject to issues with oxygen concentration. This may result in inadequate levels of oxygen to treat respiratory distress directly or through another device (e.g., CPAP).

Care & Maintenance

Power source, location and preventive maintenance will vary by oxygen therapy type. See the modules on oxygen concentrators , oxygen cylinders and oxygen flow splitters for device specific recommendations relating to power source, ward location and pertinent user preventive maintenance.

Troubleshooting & Repair

Typical failures and repair mechanisms will vary by oxygen therapy type. See the modules on oxygen concentrators , oxygen cylinders and oxygen flow splitters for device specific recommendations.

References