E 4 Oxygen Cylinder

This equipment is mainly important for breathing problems as in Breathing problems of a neonate and young infants.

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

Possible causes of hypoxia are outlined in Oxygen Therapy: Clinical Problem.

Assessment

Hypoxia contributes to both morbidity and mortality. Oxygen cylinders (2.1) deliver oxygen concentration of up to 99.5% and may be used as backup to oxygen concentrators in case of power outage or as a primary source of oxygen, particularly in a walled oxygen system.

Oxygen cylinders are usually made of a steel or aluminium alloy and are distinguished from other cylinders by having a black body with white shoulders and top. The capacity of oxygen is rated in litres which indicates the amount of oxygen the tank can store. Cylinder sizing follows an alphabetical system. Each letter corresponds to the capacity in litres of that particular cylinder.

Unlike oxygen concentrators, oxygen cylinders do not concentrate their own oxygen from ambient air, they are durable storage vessels for oxygen. Cylinders must be filled with oxygen under high pressure. At the oxygen generation plant, the oxygen cylinder is filled with oxygen up to a pressure of about 137-200 bar. Once a cylinder’s stop valve is in an open position, the pressure in the cylinder pushes the oxygen out. It passes through the stop valve to the pressure gauge and then the flow regulator. From the flow regulator the oxygen can then be delivered to a patient through a flow splitter, CPAP, or other oxygen delivery device. Oxygen cylinders are especially useful when high flow oxygen is required or as back up to concentrators when the power source fails.

Since neonates require low flows, flow meters with precision of at least 0.1 L/min should be utilised. There are special ultra-low flowmeters available for use with neonates with precision adjustments of 0.02-0.03 L/min which, especially in settings which do not utilise blenders, can be particularly useful to provide necessary oxygen to neonates and minimising hyperoxia. However, ultra-low flowmeters are not always available and great care must be taken when adjusting the oxygen flow through a standard flowmeter to monitor saturations and avoid hyperoxia which does not allow for very low flow titrations.

Neonatal patients should reach SpO₂ levels of 90 – 95% by 15 minutes after birth. (Alert 2.1)^1,3–6. 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 an oxygen concentrator covers how to use the device in a variety of settings, including set up for a patient, patient preparation & commencement, care whilst on the device & removal of the patient from the device.

SETTING UP FOR A PATIENT

1. Clean hands with soap and water or 70% alcohol before and after placing a patient on oxygen or handling any tubing that will be used on a patient.
2. Make sure the oxygen cylinder is in an upright position and is secured to a wall or stable object.
3. Assemble the pressure regulator and the flowmeter and connect them to the cylinder using the pin index connector. The flowmeter must be upright (vertical to the floor) to be read correctly. Tighten all connections and make sure there are no leaks.
4. Open the on/off valve and the pressure regulator assembly. Check the amount of oxygen in the cylinder by reading the pressure gauge.
5. Connect the oxygen delivery device. Adjust the flowrate required with the flowmeter regulator.
6. Assess whether your patient requires humidified flow. If oxygen needs are greater than 4 L/min, connect a humidifier.^2,11
7. Test that oxygen flow has begun by listening for a hissing sound at the patient end of the delivery device (e.g., nasal prongs). This can also be tested by submerging the nasal prongs in clean water and checking for bubbles (3.4), also known as the Bubble Test.¹¹

REMOVING A PATIENT

Once patients are clinically ready to be removed from the oxygen cylinder therapy as defined in Oxygen Therapy: Assessment, follow steps to remove the patient from oxygen. Close the flowmeter on the cylinder.

Infection Prevention

Routine and adequate cleaning of medical devices is critical to prevent hospitalacquired 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 70% alcohol before and after placing a patient on oxygen or handling any tubing that will be used on a patient.
2. The housing of the oxygen cylinder should be cleaned according to ward guidelines for disinfecting surfaces, or by wiping down with soapy water.
3. Ensure the stop valve is tightly shut in between patients and whist being stored.

DISINFECTION AFTER USE

1. Close the flowmeter on the cylinder. If reusing tubing, immediately remove and begin hospital protocol for disinfection as outlined in Oxygen Therapy: Infection Prevention.
2. Clean the flowmeter, gauge and dials using 70% alcohol after every use.

Complications

Irresponsible use of high pressurised oxygen cylinders could easily result in a disaster, serious injury or death for patients or staff on the ward. Strict adherence to safety protocol, maintenance and proper use is critical when using oxygen cylinders.

DEVICE COMPLICATIONS

• Fire: oxygen is an agent of combustion, meaning fire will burn more readily in its presence. Never use grease or oil to lubricate parts of the oxygen cylinder.
• Pressurised gas: oxygen cylinders are filled at very high pressures and must be chained to secure in place. Accidently tipping over a high-pressurised oxygen cylinder can easily dislodge the cap, creating a high-speed projectile. This projectile moves with sufficient speed and strength to break through cement walls. This poses an extreme danger to surrounding patients, health staff and hospital infrastructure.
• Cylinder empty: the stop valve on the cylinder must be turned off tightly when the cylinder is not in use. It is not uncommon for the valve to be left partially open and the cylinder will slowly empty.
• Cylinder unstable: the cylinder is very heavy and if not secured in an upright position can fall over and cause serious injury to a baby or member of staff. If it falls the flowmeter or pressure gauge may also be damaged.

Care & Maintenance

Users are responsible for basic first-line care and maintenance to ensure equipment lasts to their potential lifetime.

POWER SOURCE

Not powered.

WARD LOCATION

Oxygen cylinders should always be kept well-secured and safe from tipping or dropping, ideally along a wall with securing chains anchored into the wall. Oxygen cylinders should not be placed precariously, tilted or located without securing chains in the middle of walking areas.

Store in well ventilated, clean and dry conditions. Oxygen cylinders should be well labelled and easily distinguishable from other cylinders. Keep away from contaminants like oil and grease and sources of heat or ignition. Always use a secure trolley when transporting cylinders.

USER PREVENTIVE MAINTENANCE

Set up the oxygen cylinder for use. Open the flow meter & allow the oxygen cylinder to release oxygen for 1 minute every week if not in use.

Troubleshooting & Repair

Although users are not responsible for repairing their devices, there are steps that may be taken to troubleshoot first-line errors that may occur before contacting maintenance or engineering support.

References

1. Textbook of Neonatal Resuscitation (NRP), 7th Ed. (American Academy of Pediatrics, 2016).
2. Oxygen therapy for children. (World Health Organization, 2016).
3. Bancalari, E. & Claure, N. Oxygenation Targets and Outcomes in Premature Infants. JAMA 309, 2161 (2013).
4. Cummings, J. J., Polin, R. A. & Committee on Fetus and Newborn. Oxygen Targeting in Extremely Low Birth Weight Infants. Pediatrics 138, e20161576 (2016).
5. Manja, V., Lakshminrusimha, S. & Cook, D. J. Oxygen Saturation Target Range for Extremely Preterm Infants: A Systematic Review and Meta-analysis. JAMA Pediatrics 169, 332 (2015).
6. Polin, R. A. & Bateman, D. Oxygen-Saturation Targets in Preterm Infants. New England Journal of Medicine 368, 2141–2142 (2013).
7. Walsh, M. Oxygen Delivery Through Nasal Cannulae to Preterm Infants: Can Practice Be Improved? Pediatrics 116, 857–861 (2005).
8. Locke, R. G., Wolfson, M. R., Shaffer, T. H., Rubenstein, S. D. & Greenspan, J. S. Inadvertent administration of positive end-distending pressure during nasal cannula flow. Pediatrics 91, 135–138 (1993).
9. Sreenan, C., Lemke, R. P., Hudson-Mason, A. & Osiovich, H. High-Flow Nasal Cannulae in the Management of Apnea of Prematurity: A Comparison With Conventional Nasal Continuous Positive Airway Pressure. Pediatrics 107, 1081–1083 (2001).
10. Curless MS, Ruparelia CS, Thompson E, and Trexler PA, eds. 2018. Infection Prevention and Control: Reference Manual for Health Care Facilities with Limited Resources. Jhpiego: Baltimore, MD.
11. World Health Organization. Technical specifications for oxygen concentrators. (World Health Organization, 2016).