E 5 Oxygen Splitter

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

Flow splitters are used when oxygen from one source needs to be delivered to more than one hypoxic patient at low flows.

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

Assessment

Hypoxia contributes to both morbidity and mortality. Flow splitters are accessory devices that divide oxygen from one source to give to several patients at independent, adjustable flow rates.

Flow splitters (2.1) may be used with an oxygen concentrator, oxygen cylinder or walled oxygen to provide standard flow supplemental oxygen to patients. Flow splitters may also be combined with CPAP if the flowmeter allows the required flow rate.

A flow splitter has internal tubing with individual flow regulators that split incoming oxygen flow coming from an oxygen source (i.e., oxygen concentrator or cylinder). (2.2) Oxygen flow splitters generally provide precise low flow rates, from 0.1 up to a maximum of 2 L/min from each port. The oxygen concentration delivered through an oxygen flow splitter remains unchanged from that of the source.

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


? ALERT 2.1: SpO2 & Safe Oxygen Delivery
When making this recommendation the following resources were considered:
  1. According to the Textbook of Neonatal Resuscitation (NRP), 7th Ed., “After birth, the oxygen saturation gradually increases above 90%. However, even healthy term newborns may take 10 minutes or longer to reach this saturation” (p.77).1
  2. Target peripheral oxygen concentrations (SpO2) for newborns vary depending on age and clinical condition. However, most authorities agree that saturations between 90-95% minimises the complications associated with both low and high oxygen levels including death, neurodevelopmental impairment and Retinopathy of Prematurity.3-6

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. Ensure oxygen flow splitter is secured in a location where it cannot be easily dislodged and where staff can easily adjust the flowmeter regulators on the splitter. (3.1) Make sure flow regulators are open.

  2. Connect oxygen splitter tubing from oxygen outlet source to oxygen splitter inlet port. (3.2)
  3. Assess level of oxygen needed from oxygen source. The source of oxygen (e.g., the concentrator) must be adjusted to provide a flow of at least 1L/min oxygen more than the total requirement from all the ports that are in use. (3.3)
    For example: If 2 ports are in use (one port is set at 1L/min, one port is set at 0.5 L/min) and three ports are shut, the total supply of oxygen required from the concentrator is
    2.5 L/min (i.e., 0 + 0.5 + 0 + 1 + 0 (+1 extra L) = 2.5 L/min)
  4. Turn on oxygen at source. The flowmeter beads on the oxygen splitter should pop up.
  5. Adjust each of the port flow meter regulators individually to the required flow rate (3.4), observing the L/min at eyelevel. (3.5) The other outlet ports should not change as each port is individually adjusted. If being used with an oxygen concentrator, some variation may occur cyclically.
  6. Check that the ports have been numbered and number oxygen tubing to prevent infants receiving an incorrect flow. When changing flows for one patient, ensure that any other patients also on the flow splitter are receiving the correct amounts of oxygen.

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 flow splitter should be cleaned according to ward guidelines for disinfecting surfaces, or by wiping down with soapy water followed by 70% alcohol. Flow splitter oxygen ports should be cleaned using forceps wrapped in gauze and soaked in 70% alcohol.
  3. Clean any used equipment that has been in contact with patient or staff.

DISINFECTION AFTER USE

  1. Turn off the oxygen source. Disconnect oxygen tubing from source and flow splitter. If reusing tubing, immediately remove and begin hospital protocol for disinfection as outlined in Oxygen Therapy: Infection Prevention.
  2. Clean the flow splitter housing and regulators using 70% alcohol after every use.

Complications

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

DEVICE COMPLICATIONS

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

Flow splitters should be mounted and secured in a location where nursing staff can regulate and view flows easily, e.g., mounted on a wall with easy and reachable access. The splitter should be able to be adjusted at eye level. If possible, the surface on which the splitter is mounted should have a raised edge to prevent falls. Tubing can be fixed to the wall to distribute oxygen to several cots without the tubing being trailed across the floor. It is a good idea to number the ports and the tubing to prevent infants receiving an incorrect flow.

USER PREVENTIVE MAINTENANCE

The oxygen flow splitter should be connected to an oxygen source and used for at least 15 minutes once a week. Each flowmeter dial should be turned on and allowed to flow at its max flow for this period of time.

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.

1 No flow is emitted from all ports of the flow splitter
  • Check that the oxygen source is on and that oxygen is flowing from the outlet port of the source.(7.1)
  • Check that the oxygen splitter tube is securely connected to the oxygen source and to the flow splitter and that there are no leakages.
  • Check for kinks or blockages in the tubing. If the flowmeter bead pops up but there is no flow at the prongs; then the prong tubing is either blocked or has a leak.
  • If oxygen still does not flow, contact your maintenance department.

2 No flow is emitted from one port of the flow splitter, but the other ports are functional
  • Check the outlet port of the flow splitter for visible blockages like dirt or bother debris. If debris are visible, use a test tube brush or thin rod covered with gauze to remove. Disinfect with 70% alcohol after debris have been removed.
  • If oxygen still does not flow, contact your maintenance department. Meanwhile, label the non-functioning port and continue to use the others until a replacement is found.

3 Oxygen is flowing from the flow splitter port, but not from the oxygen tubing or prongs
  • Visually check the tubing for kinks, blockages or bends.(7.2) If you see any of these obstructions, replace the tubing or prongs.

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).