How to Deliver Oxygen to a NYI (Chapter 6)

Learning Objectives

After completion of this chapter the participant should be able to:

• Explain when oxygen is needed.
• Describe how to deliver oxygen therapy. Check the equipment section for more information:
  • Oxygen therapy
  • CPAP
  • Pulse oximeter
  • Oxygen concentrator
  • Oxygen cylinder
  • Oxygen splitter
• Explain when to stop oxygen therapy

The NYI requires oxygen, if oxygen saturation is less than 90%.

Normal oxygen saturations (SpO₂) for neonatal patients should be:

• 90%-100% if not on oxygen
• 90%-95% on oxygen

NB neonatal patients should reach oxygen saturations of 90 – 95% by 15 minutes after birth.

If there is severe respiratory distress, SpO₂ readings are less than 90% or there is central cyanosis the patient should be commenced on supplemental oxygen therapy.

Delivery Methods of Oxygen

The source of oxygen is generally the oxygen concentrator but may also be an oxygen cylinder. Oxygen is administered preferably by nasal prongs, but if unavailable nasal catheters can be used. If higher amounts of oxygen are required face masks can be used.

A baby with cyanosis or severe respiratory distress should be allowed to take a comfortable position of his choice and should be given oxygen immediately via nasal prongs or catheter. Escalate the oxygen therapy in a stepwise fashion depending on need and availability.

If the baby’s breathing difficulty does not improve on prongs or catheter oxygen, despite increasing the flow:

Place the YI on oxygen at a high flow rate (4 litres/min) via face mask if possible or if this is unavailable, or if the breathing difficulties persist, then place the baby on bCPAP.

Monitoring and ongoing care of the patient:

(Teach the mother to help her baby by also looking out for the following problems):

• Displacement of the prongs or catheter.
• The concentrator malfunctioning or being accidentally switched off.
• Nursing staff need to check 4 hourly the position and patency of upper airway.
• The airways may become blocked with mucus.
• The abdomen may become distended with air.
• Respiratory distress may increase.
• Check oxygen saturations using pulse oximeter as clinical signs alone cannot be reliably predict hypoxia (aim at 90-95% oxygen saturation).
• Apply nasal drops at least every 4 hours.
• Keep warm.
• Feed regularly.
• Prevent infection.

Stepwise escalation of oxygen therapy according to the YI condition

If breathing difficulty is so severe that the baby has central cyanosis even with high flow oxygen or bCPAP, or the work of breathing increases despite increased oxygen delivery, rule out a pneumothorax clinically or with a chest x-ray. Discuss with senior or colleague.

When and How to Stop Oxygen Therapy

Once patients can maintain normal oxygen saturations and are clinically stable, the oxygen flow rate should be reduced in a stepwise manner, based on clinical response:

• Reduce oxygen flow by 0.5 L/min, rechecking oxygen saturations and clinical condition after 15 minutes.
• If oxygen saturations and clinical condition remain stable, continue reducing oxygen flow by 0.5 L/min, rechecking saturations 15 minutes after each reduction.
• If oxygen saturations drop below 90% or the patient clinically deteriorates, increase the oxygen until normal oxygen saturations are obtained and the patient clinically improves.

Once oxygen saturations are consistently above 95% at 0.5 L/min and the patient is clinically stable, remove oxygen from the patient by gently removing the tape and taking the prongs out of the patient’s nostrils.

Recheck the saturations after 15 minutes.

• If oxygen saturations have dropped or there is a clinical deterioration, recommence oxygen.
• If oxygen saturations and clinical condition are stable, the patient no longer requires oxygen.

Where pulse oximetry is not available, the duration of oxygen therapy is guided by clinical signs. If oxygen saturations are not available, the oxygen can be stopped if the baby does not have respiratory distress,(i.e., no increased work of breathing, no increased respiratory rate, and baby not tiring), but keep under review and recommence if the respiratory distress increases after stopping the oxygen.

Avoid prolonged SpO₂ > 96% in premature infants as it can cause damage to the eyes (retinopathy of prematurity) leading to blindness, and can cause damage to the brain and the lungs. Premature infants should have oxygen saturations kept within 90-94% when given supplementary oxygen or CPAP.

Sources and delivery methods of oxygen

See supplement on oxygen concentrator module.

• The source of oxygen is generally the oxygen concentrator. These usually deliver 5 -10 litres of oxygen per minute and there is a gauge for adjusting the concentration of oxygen. The filter at the back of the concentrator should be cleaned every week to keep them working well. Sufficient oxygen should be given to keep oxygen saturations above 90%.

• Nasal prongs:Prongs come in different sizes. Nasal prongs are preferred over nasal tube or catheter for delivering oxygen to young infants. Place them just inside the nostrils and secure with a piece of tape on the cheeks near the nose.

  Take care that the nostrils are kept clear of mucus, which could block the flow of oxygen.

  A flow rate of 0.5-1 litres/min will deliver 30-35% oxygen concentration in the inspired air

  Aim for oxygen saturations >92%.

• Nasal tube or catheter: Use 8 French size catheter. Determine the distance the tube should be passed by measuring the distance from the side of the nostril to the inner margin of the eyebrow.

  Gently insert the catheter into the nostril. A flow rate of 0.5-1 litres/min in infants will deliver 30-35% oxygen.

  Aim for oxygen saturations >90%.

• A simple face mask will deliver 40-60% oxygen in an emergency and if the infant is very distressed.

  A minimum of 4 litres of oxygen per minute is needed to prevent rebreathing of expired air.

  A face mask with a reservoir attached will deliver 100% oxygen. It may be used for resuscitation.

  The problem with this method is that it may require one concentrator per NYI, which may be challenging if several NYIs require oxygen at the same time.

  Aim for oxygen saturations >90%.

E 6 Oxygen Therapy

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 continous 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 oxygen therapy for more information.