Note: This guideline is currently under review.

Aim

Introduction

Definition of terms

Infection Control

Normal values and SpO ₂ targets

Indications for oxygen delivery

Nurse initiated oxygen

Patient assessment and documentation

Weaning oxygen

Selecting the delivery method

Low flow delivery method

High flow delivery method

Humidification

Delivery Mode

High Flow

Considerations

Links

Appendix A - Paediatric sizing guides for nasal prongs

Evidence Table

 Aim

The aim of this guideline is to describe the indications and procedure for the use of oxygen therapy, and its modes of delivery.

Introduction

The goal of oxygen delivery is to maintain targeted SpO^₂ levels in children through the provision of supplemental oxygen in a safe and effective way which is tolerated by infants and children to:

• Relieve hypoxaemia and maintain adequate oxygenation of tissues and vital organs, as assessed by SpO₂ /SaO₂ monitoring and clinical signs.
  
• Give oxygen therapy in a way which prevents excessive CO₂ accumulation - i.e. selection of the appropriate flow rate and delivery device. 
  
• Reduce the work of breathing.
  
• Ensure adequate clearance of secretions and limit the adverse events of hypothermia and insensible water loss by use of optimal humidification (dependent on mode of oxygen delivery).
  
• Maintain efficient and economical use of oxygen.
  

Definition of terms

• FiO₂: Fraction of inspired oxygen (%).
• PaCO₂: The partial pressure of CO₂ in arterial blood. It is used to assess the adequacy of ventilation.
  
• PaO₂: The partial pressure of oxygen in arterial blood. It is used to assess the adequacy of oxygenation.
  
• SaO₂: Arterial oxygen saturation measured from blood specimen.
• SpO₂: Arterial oxygen saturation measured via pulse oximetry.
• Heat Moisture Exchange (HME) product: are devices that retain heat and moisture minimizing moisture loss to the patient airway.
• High flow: High flow systems are specific devices that deliver the patient's entire ventilatory demand, meeting, or exceeding the patients Peak Inspiratory Flow Rate (PIFR), thereby providing an accurate FiO2. Where the total flow delivered to the patient meets or exceeds their Peak Inspiratory Flow Rate the FiO2 delivered to the patient will be accurate.  
• Humidification is the addition of heat and moisture to a gas. The amount of water vapour that a gas can carry increases with temperature.
• Hypercapnea: Increased amounts of carbon dioxide in the blood.
• Hypoxaemia: Low arterial oxygen tension (in the blood.)
• Hypoxia: Low oxygen level at the tissues.
• Low flow: Low flow systems are specific devices that do not provide the patient's entire ventilatory requirements, room air is entrained with the oxygen, diluting the FiO₂.
• Minute ventilation: The total amount of gas moving into and out of the lungs per minute. The minute ventilation (volume) is calculated by multiplying the tidal volume by the respiration rate, measured in litres per minute.
• Peak Inspiratory Flow Rate (PIFR): The fastest flow rate of air during inspiration, measured in litres per second.
• Tidal Volume: The amount of gas that moves in, and out, of the lungs with each breath, measured in millilitres (6-10 ml/kg).
• Ventilation - Perfusion (VQ) mismatch: An imbalance between alveolar ventilation and pulmonary capillary blood flow. 

Infection Control 

Should an aerosol generating procedure be undertaken on a patient under droplet precautions then increase to airborne precautions by donning N95/P2 mask for at least the duration of the procedure.

Normal Values and SpO₂ Targets

• Partial pressure of arterial oxygen (PaO₂)
  • 80 -100 mmHg - children/adults
  • 50 - 80 mmHg - neonates
• Partial pressure of arterial CO₂ (PaCO₂)
  • 35 - 45 mmHg children/adults
• pH = 7.35 -7.45
• Generally SpO₂ targets are:
  • 94% - 98% (PaO₂ between 80 and 100 mmHg) in patients without cyanotic congenital heart disease or chronic lung disease 
  • > 70% (PaO₂ 37 mmHg) in patients who have had cardiac surgery of their congenital cyanotic heart disease 
  • > 60% (PaO₂ 32mmHg) in unrepaired congenital cyanotic heart disease
  •  91 - 95% for premature and term neonates ( Click here for Oxygen saturation SpO2 level targeting in neonates)
  • ≥ 90% for infants with bronchiolitis (link to Bronchiolitis CPG) 
    

NB: The above values are generalized to the paediatric population, for age/patient specific ranges please consult the covering medical team. 

The above values are expected target ranges. Any deviation should be documented on the observation chart as MET modifications. 

Indications for oxygen delivery

Where considering the application of oxygen therapy it is essential to perform a thorough clinical assessment of the child.  

• Transient, self-correcting desaturations that have no other physiological correlates (eg. Tachycardia, cyanosis) may not routinely require oxygen therapy in most cases.
• The threshold for oxygen therapy can vary with the child’s general state and point in the illness.
• There is no physiological basis for the application of low flow oxygen therapy to a child with normal SpO₂ and increased work of breathing.
  
• The treatment of documented hypoxia/hypoxaemia as determined by SpO₂ or inadequate blood oxygen tensions (PaO₂).
• Achieving targeted percentage of oxygen saturation (as per normal values unless a different target range is specified on the observation chart.)
• The treatment of an acute or emergency situation where hypoxaemia or hypoxia is suspected, and if the child is in respiratory distress manifested by:
  • dyspnoea, tachypnoea, bradypnoea, apnoea
  • pallor, cyanosis
  • lethargy or restlessness
  • use of accessory muscles: nasal flaring, intercostal or sternal recession, tracheal tug

If you require further information please click here for the Assessment of Severe Respiratory Conditions guideline.

• Short term therapy e.g. post anaesthetic or surgical procedure
• Palliative care - for comfort

Any patient who develops or has an increase in their oxygen requirement should be medically reviewed within 30 minutes.

Nurse initiated oxygen

 OXYGEN THERAPY – STANDING MEDICAL ORDERS FOR NURSES

• Both hypoxaemia and hyperoxaemia are harmful. 
  
• Oxygen treatment should be commenced or increased to avoid hypoxaemia and should be reduced or ceased to avoid hyperoxaemia 
  
• For children receiving oxygen therapy SpO₂ targets will vary according to the age of the child, clinical condition and trajectory of illness. 
  

Oxygen treatment is usually not necessary unless the SpO₂ is less than 92%.
That is, do not give oxygen if the SpO₂ is ≥ 92%. 

Oxygen therapy (concentration and flow) may be varied in most circumstances without specific medical orders, but medical orders override these standing orders.

• Nurses can initiate oxygen if patients breach expected normal parameters of oxygen saturation 
  
• A medical review is required within 30 minutes 

THE FOLLOWING MAY BE UNDERTAKEN BY NURSES WITHOUT MEDICAL ORDERS:

1. Commencement or Increase of Oxygen Therapy:

Oxygen therapy should be commenced if: 

• SpO₂ is less than 92% (PaO₂ less than 80mmHg in patients without cyanotic heart disease
  
• SpO₂ is less than 70% (PaO₂ less than 37mmHg) in patients with cyanotic heart disease who have had cardiac surgery
  
• SpO₂ is less than 60% (PaO₂ less than 32mmHg) in patients with cyanotic heart disease who are waiting for cardiac surgery
  
• <91% in premature and newborn neonates 
• Persistently < 90% for infants with bronchiolitis

2. Reduction or Cessation of oxygen therapy. Oxygen therapy should be reduced or ceased if:   

• SpO₂ is ≥ 92% 
• SpO₂ is ≥ 90% for infants with bronchiolitis 
• The child with cyanotic heart disease reaches their baseline Sp0₂

This direction applies to patients treated with: 

• Face masks and nasal prongs
  
• High flow nasal prong therapy (HFNP) 
  
• Mechanical ventilation (do not alter other ventilator settings) 
  
• Mask-BiPaP or CPAP (do not alter pressure or volume settings without a medical order)
  

Patient assessment and documentation

• Assess the airway and optimise airway position (e.g head tilt, chin lift) as necessary 
  
• Clinical assessment and documentation including but not limited to: cardiovascular, respiratory and neurological systems should be done at the commencement of each shift and with any change in patient condition. 
  
• Check and document oxygen equipment set up at the commencement of each shift and with any change in patient condition. 
  
• Hourly checks should be made for the following: 
  
  • oxygen flow rate 
    
  • patency of tubing 
    
  • humidifier settings (if being used) 
    
• Hourly checks should be made and recorded on the patient observation chart for the following (unless otherwise directed by the treating medical team): 
  
  • heart rate 
    
  • respiratory rate 
    
  • respiratory distress  (descriptive assessment - i.e. use of accessory muscles/nasal flaring -  see Respiratory Distress on EMR) 
    
  • oxygen saturation
    
    • continuous pulse oximetry is recommended for the patients who are severely unwell, and who are likely to have rapid and clinically significant drop in oxygen saturations when the oxygen therapy is disconnected.
      
    • continuous pulse oximetry may not be necessary in the stable patient receiving oxygen therapy. 
      
• Ensure the individual MET criteria are observed regardless of oxygen requirements 
  
  

See below nursing guidelines for additional guidance in assessment and monitoring:

• Observation and Monitoring Nursing Clinical Guideline re: pulse oximetry monitoring 
• Nursing Assessment Nursing Clinical Guideline 

Weaning Oxygen

Unless clinically contraindicated, an attempt to wean oxygen therapy should be attempted at least once per shift.

The child should appear clinically well.  
All vital signs should be with normal limits (ViCTOR white zone or modified zone)
Respiratory Distress (work of breathing) should be mild, or there should be no work of breathing.
Feeding adequate amounts orally.
Level of consciousness (LOC) = alert, colour = pink, behaviour = normal

1. Cease oxygen therapy entirely and maintain line of sight  for approximately 5 minutes 
   
2. If SpO₂ falls below 92%, or specific target as per relevant clinical guideline, or as ordered by  medical staff, recommence oxygen therapy at the lowest flow rate necessary to maintain target SpO₂
   

Clinical observations:
Continuous pulse oximetry for 30 minutes post cessation of oxygen therapy
If oxygen wean successful perform vital sign observation, intermittent SpO₂ monitoring 30 minutes later, then hourly for 2 hours.

• Heart rate
  
• Respiratory rate
  
• WOB remains stable
  
• SpO₂ ≥92% (NB. There are different target SpO₂ range in preterm and term neonates and infants with bronchiolitis)
  • For more information see:
    • Oxygen Saturation SPO₂level target in neonates nursing guideline
    • Bronchiolitis clinical practice guideline
• LOC = alert, note lethargy or irritability

Where oxygen weaning is successful, continuous pulse oximetry monitoring may be discontinued.

Selecting the delivery method

A range of flow meters are available at RCH, 0-1 LPM, 0-2.5 LPM, 0-15 LPM. 
Also 0-50 LPM PICU only. Check on the individual flow meter for where to read the ball (i.e. centre or top of ball), or dial (Perflow brand of flow meters) when setting the flow rate. 

Note: Some flow meters may deliver greater than the maximum flow indicated on the flow meter if the ball is set above the highest amount. Use caution when adjusting the flow meter. 
 
Oxygen delivery method selected depends on: 

• age of the patient 
  
• oxygen requirements/therapeutic goals 
  
• patient tolerance to selected interface 
  
• humidification needs 

Note: Oxygen therapy should not be delayed in the treatment of life threatening hypoxia. 

Low flow delivery method

Low-flow systems include: 

• Simple face mask  
• Non re-breather face mask (mask with oxygen reservoir bag and one-way valves which aims to prevent/reduce room air entrainment) 
  
• Nasal prongs (low flow) 
  
• Tracheostomy mask  
  
• Tracheostomy HME connector 
  
• Isolette - neonates (usually for use in the Neonatal Intensive Care Unit only) 
  

Note: In most low flow systems the flow is usually titrated (on the oxygen flow meter) and recorded in litres per minute (LPM).  Where the Airvo2 is used as an oxygen delivery device the flow from this device is independent to the flow of oxygen.

High flow delivery method 

High flow systems include: 

• Ventilators 
  
• CPAP/BiPaP drivers 
  
• Face mask or tracheostomy mask used in conjunction with an Airvo2 Humidifier 
  
• High Flow Nasal Prong therapy  (HFNP)
  • NB: There is separate CPG for HFNP use in the NICU (see NICU department HFNP guideline)
    

Humidification

Oxygen therapy can be delivered using a low flow or high flow system. All high flow systems require humidification. The type of humidification device selected will depend on the oxygen delivery system in use, and the patient's requirements. The humidifier should always be placed at a level below the patient's head. 

Rationale: 

• Cold, dry air increases heat and fluid loss 
  
• Medical gases, including air and oxygen, have a drying effect on mucous membranes  resulting in airway damage. 
  
• Secretions can become thick & difficult to clear or cause airway obstruction 
  
• In some conditions e.g. asthma, the hyperventilation of dry gases can compound bronchoconstriction. 

Indications: 

• Patients with thick copious secretions 
  
• Non-invasive and invasive ventilation 
  
• Nasal prong flow rates of greater than 2 LPM (under 2 years of age) or 4 LPM (over 2 years of age)
  
• Nasal prong flow rates of greater than 1 LPM in neonates 
  
• Facial mask flow rates of greater than 5 LPM 
  
• Patients with tracheostomy 

RCH predominantly uses the Fisher & Paykel MR850 Humidifier & AIRVO 2 Humidifier. Please consult user manuals for any other models in use. 

Fisher & Paykel MR 850 Humidifier

Follow instructions in the MR850 User Manual in conjunction with this Guideline
Has two modes:

1. Invasive Mode - delivers saturated gas as close to body temperature (37 degrees, 44mg/L) as possible.
   -  Suitable for patients with bypassed airways:
       -  Invasive Ventilation
       -  Tracheostomy attachment or mask
       -  Nasal Prongs
       -  CPAP in NICU (see NICU CPAP nursing clinical guideline) 
   
2. Non-Invasive Mode – delivers gas at a comfortable level of humidity (31-36 degrees, >10mg/L).
   -  Suitable for patients receiving:
       -  Face mask therapy:
       -  Non-invasive ventilation (CPAP/BIPAP)
       -  Nebuliser mask (with RT308 circuit)

AIRVO 2 Humidifier

Follow instructions in the AIRVO 2 User Manual in conjunction with this Guideline. 
Has two modes: 

1. Junior Mode – requires Junior Tube and Chamber Kit
   -  Suitable for patients using Optiflow Junior Infant and Paediatric Nasal Prongs
   -  Minimum flow rate 2 LPM 
2. Standard Mode – requires standard Tube and Chamber Kit
   -  Suitable for patients using: 
       -  Optiflow adult nasal prongs 
       -  Nebuliser mask (via Mask Interface Adaptor) 
       -  Tracheostomy mask (via Mask Interface Adaptor) 
       -  Tracheostomy direct connection
   -  Mimimum flow rate 10 LPM

Link to : Optiflow Nasal Prong Flow Rate Guide 

The AIRVO 2 Humidifier requires cleaning and disinfection between patients. When commencing therapy on a new patient, ensure the disinfection cycle was performed. On device start up, a green traffic light confirms the AIRVO 2 is safe for use on a new patient. An orange traffic light confirms the AIRVO 2 has not been cleaned and disinfected since last use, and is not safe for use on a new patient.
Follow the instructions in the disinfection kit manual: 

Delivery Mode

Click to view the delivery mode quick reference table

Nasal Prong Oxygen Therapy

Nasal prongs without humidification

This system is simple and convenient to use. It allows the oxygen therapy to continue during feeding/eating and the re-breathing of CO₂ isn't a potential complication. 
Simple nasal prongs are available in different sizes.  To ensure the patient is able to entrain room air around the nasal prongs and a complete seal is not created the prong size should be approximately half the diameter of the nares.

Select the appropriate size nasal prong for the patient's age and size. 

For nasal prong oxygen without humidification a maximum flow of:

• 2 LPM in infants/children under 2 years of age
  
• 4 LPM for children over 2 years of age.
  
• 1 LPM for neonates

With the above flow rates humidification is not usually required. However, if humidification is clinically indicated - set up as per the recommended guidelines for the specific equipment used. As with the other delivery systems the inspired FiO2 depends on the flow rate of oxygen and varies according to the patient's minute ventilation. 

Care and considerations of child with simple nasal prongs: 

• Position the nasal prongs along the patient’s cheek and secure the nasal prongs on the patient’s face with adhesive tape.
  
• Position the tubing over the ears and secure behind the patient’s head. Ensure straps and tubing are away from the patient's neck to prevent risk of airway obstruction.
  
• Check nasal prong and tubing for patency, kinks or twists at any point in the tubing and clear or change prongs if necessary. 
  
• Check nares for patency - clear with suction as required. 
  
• Change the adhesive tape weekly or more frequently as required 
  

Nasal prongs with humidification system

If the required flow rate exceeds those as recommended above this may result in nasal discomfort and irritation of the mucous membranes. Therefore, humidification of nasal prong oxygen therapy is recommended.

Humidification can be provided using either the MR850 Humidifier or the AIRVO 2 Humidifier. Follow the manufacturer’s Instructions for use for each device and setup.

For nasal prong oxygen with humidification a maximum flow of:

• 4 LPM in infants/children under 2 years of age
• 6 LPM for children over 2 years of age
• 10 LPM for adolescents ≥ 30kg

 Optiflow Nasal Prongs Humidification using MR850 Humidifier

Optiflow nasal prongs are compatible for use in humidified low or high flow oxygen delivery. 

Note: MR850 Humidifier should be placed in Invasive Mode for Nasal Prongs Therapy.

See guide below for recommended patient sizing and flow rates. 

Fisher and Paykel Optiflow nasal cannula junior range 
Four sizes of prongs: 

1. Premature 
   
2. Neonate 
   
3. Infant 
   
4. Paediatric
   

See Appendix A for further information regarding appropriate junior range sizing: Fisher and Paykel Optiflow junior range sizing guide

Fisher and Paykel Optiflow nasal cannula standard range

Three sizes of prongs

1. Small
2. Medium
3. Large

Paediatric Patients

( RT330 circuit - click here for instructions for use)

High flow  

• Flow of 2 L/kg/min up to 12kg, plus 0.5 L/kg/min for each kg above 12kg (to a maximum of 50 LPM) 
  
• FiO₂ 21-50% (blender must be used) 
  
• FiO₂ above 50% requires PICU review (except if patient is in NICU) 
  

The main safety feature of the RT330 Oxygen Therapy System is the pressure relief valve. The pressure relief valve has been set to a limit of < 40 cm H₂0. This valve has been designed to minimize the risk of excessive pressure being delivered to the infant in the event that the nasal prongs seal around the infant's nares while the mouth is closed. 

The image below is of the RT330 circuit. 

Below is an image of the RT330 pressure relief valve.

Older children and adolescent patients

( RT203 Circuit and O2 stem - click here for instructions for use)

• 3 sizes of prongs:
  • Small
  • Medium
  • Large
• Low flow, a maximum of:
  • 6 LPM for children over 2 years of age
  • FiO₂ 21-100% (direct from O₂ wall source or via a blender)
• High flow
  • Flow of 2L/kg/min up to 12kg, plus 0.5L/kg/min for each kg above 12kg (to a maximum of 50LPM)
  • FiO₂ above 50% requires PICU review

Optiflow Nasal Prongs Humidification using AIRVO 2 Humidifier

The AIRVO 2 Humidifier has two modes: 

1. Junior Mode
   
2. Standard Mode

Junior Mode

Low Flow - Suitable for patients using the Optiflow Junior Nasal Prongs 

Two sizes of Optiflow Junior nasal prongs suitable for use with AIRVO 2 Humidifier:

1. Optiflow Junior Infant 
   
2. Optiflow Junior Paediatric 

FiO₂ 21-95% - Note, the oxygen flow rate from the wall or portable sources should not exceed the flow rate of the Airvo2

High Flow Nasal Prong Therapy (HFNP)

See the HFNP nursing clinical guideline for more information. 
 
Below is an image of the Fisher and Paykel Optiflow nasal cannula junior range for AIRVO 2

Standard Mode

Three sizes of Optiflow nasal prongs suitable for use with AIRVO 2 Humidifer (click here for: Fisher and Paykel Optiflow (adult) nasal cannula standard range guide)

• Small
• Medium
• Large
  

High Flow 

• Flow of 2L/kg/min up to 12kg, plus 0.5L/kg/min for each kg above 12kg (to a maximum of 50 LPM)
• FiO₂ 21-50%
• Any patient who does not exhibit signs of clinical stabilization, as described below, within 2 hours of commencement of HFNP therapy should be reviewed by PICU outreach service
• Any patient who does not exhibit signs of clinical stabilization with 4 hours of commencement of HFNP should be considered for transfer to the PICU.
  
   

Optiflow Nasal Prong junior and standard humidification and flow rate guide for Airvo.

 Face Mask

Click to view the delivery mode quick reference table

Simple Face Mask

The FiO₂ inspired will vary depending on the patient's inspiratory flow, mask fit/size and patient's respiratory rate. At RCH both simple face masks (in various sizes) and tracheostomy masks are available.
 
The minimum flow rate through any face mask or tracheostomy mask is 4 LPM as this prevents the possibility of CO₂ accumulation and CO₂ re-breathing. Select a mask which best fits from the child's bridge of nose to the cleft of jaw, and adjust the nose clip and head strap to secure in place. 
Oxygen (via intact upper airway) via a simple face mask at flow rates of 4LPM does not routinely require humidification. However, as compressed gas is drying and may damage the tracheal mucosa humidification might be indicated/appropriate for patients with increased/thickened secretions, secretion retention, or for generalized discomfort and compliance. Additionally in some conditions (eg. Asthma), the inhalation of dry gases can compound bronchoconstriction. 

Nebuliser mask / Tracheostomy mask / Tracheostomy direct connection

A nebuliser mask, tracheostomy mask with a mask interface adaptor (Fisher&Paykel RT013), or Tracheostomy Direct Connection (Fisher&Paykel OPT870) are intended for use with the AIRVO 2 Humidifier. The AIRVO 2 Humidifier flow rate should be set to meet or exceed the patient’s entire ventilatory demand, to ensure the desired FiO₂ is actually inspired by the patient. This system is useful in accurately delivering concentrations of oxygen (21 – 95%). Patients who require an FiO₂ greater than 50% require PICU medical review. 

Non-rebreathing face mask

A non-rebreathing face mask has an oxygen reservoir bag and one-way valve system which prevents exhaled gases mixing with fresh gas flow. The non-rebreathing mask system may also have a valve on the side ports of the mask which prevents entrainment of room air into the mask. These masks are not commonly used but a non-rebreathing mask can provide higher concentration of FiO₂ (> 60%) than is able to be provided with a standard face mask (which is approximately 40% - 50%) 

Considerations when using a non-rebreathing face mask 

• To ensure the highest concentration of oxygen is delivered to the patient the reservoir bag needs to be inflated prior to placing on the patients face.
  
• Ensure the flow rate from the wall to the mask is adequate to maintain a fully inflated reservoir bag during the whole respiratory cycle (i.e. inspiration and expiration).
  
• Non-rebreathing face mask are not designed to allow added humidification. 
  
• Not routinely used outside of ED and PICU and should only be used in consultation with the medical team. 
  

Tracheostomy

Tracheostomy HME - Heat Moisture Exchange (HME) with oxygen attachment 
In spontaneously breathing tracheostomy patients who require oxygen flow rates of less than 4 LPM there are two options available:

1. OXY-VENT™ with Tubing: The adaptor sits over the TRACH-VENT™ and the tubing attaches to the oxygen source (flow meter). 
   
2. TRACH-VENT+™: Alternatively a Hudson RCI HME - TRACH-VENT+™ has an integrated oxygen side port which connects directly to oxygen tubing which is attached to the oxygen source (flow meter). 

Note: HME are used without a heated humidifier circuit. 

Considerations: 

• The Hudson Trach-Vent™ HME has a dead space of 10mL and is recommended for use in patients who have tidal volumes of 50mL and above.
  
• Trach-Vent's are changed daily or as required if contaminated or blocked by secretions. 

NOTE:

While a specific FiO₂ is delivered to the patient the FiO₂ that is actually inspired by the patient (ie what the patient actually receives) varies depending on: 

• flow rate delivered to the patient 
  
• mask size and fit 
  
• the patient's respiratory rate 
  
  

Incubator

At the RCH, oxygen therapy via an isolette is usually only for use in the Butterfly neonatal intensive care unit. (See Isolette use in paediatric wards, RCH internal link only.)

Considerations

• Supplemental oxygen relieves hypoxaemia but does not improve ventilation or treat the underlying cause of the hypoxaemia. Monitoring of SpO₂ indicates oxygenation not ventilation. Therefore, beware the use of high FiO₂ in the presence of reduced minute ventilation.
  
• Many children in the recovery phase of acute respiratory illnesses are characterised by ventilation/perfusion mismatch (e.g. asthma, bronchiolitis, and pneumonia) and can be managed with SpO₂ in the low 90's as long as they are clinically improving, feeding well and don't have obvious respiratory distress.
  
• Normal SpO₂ values may be found despite rising blood carbon dioxide levels (hypercapnea). High oxygen concentrations have the potential to mask signs and symptoms of hypercapnea. 
  
• Oxygen therapy should be closely monitored & assessed at regular intervals
  Therapeutic procedures & handling may increase the child's oxygen consumption & lead to worsening hypoxaemia 
  
• Children with cyanotic congenital heart disease normally have SpO₂ between 60%- 90% in room air. Increasing SpO₂ > 90% with supplemental oxygen is not recommended due to risk of over circulation to the pulmonary system while adversely decreasing systemic circulation. However, in emergency situations with increasing cyanosis supplemental oxygen should be administered to maintain their normal level of SpO₂ 
• Should an aerosol generating procedure be undertaken on a patient under droplet precautions then increase to airborne precautions by donning N95/P2 mask for at least the duration of the procedure.
  

Potential complications of oxygen use

• CO₂ Narcosis - This occurs in patients who have chronic respiratory obstruction or respiratory insufficiency which results in hypercapnea (i.e. raised PaCO₂). In these patients the respiratory centre relies on hypoxaemia to maintain adequate ventilation. If these patients are given oxygen this can reduce their respiratory drive, causing respiratory depression and a further rise in PaCO₂.
  
• Monitoring of SpO₂ or SaO₂ informs of oxygenation only. Therefore, beware of the use of high FiO₂ in the presence of reduced minute ventilation. 
  
• Pulmonary Atelectasis
  
• Pulmonary oxygen toxicity - High concentrations of oxygen (>60%) may damage the alveolar membrane when inhaled for more than 48 hours resulting in pathological lung changes.
  
• Retinopathy of Prematurity (ROP) - An alteration of the normal retinal vascular development, mainly affecting premature neonates ( <32 weeks gestation or 1250g birthweight), which can lead to visual impairment and blindness.
  
• Substernal pain-due: characterised by difficulty in breathing and pain within the chest, occurring when breathing elevated pressures of oxygen for extended periods. 
  

Oxygen safety

• Oxygen is not a flammable gas but it does support combustion (rapid burning). Due to this the following rules should be followed: 
• Do not smoke in the vicinity of oxygen equipment. 
  
• Do not use aerosol sprays in the same room as the oxygen equipment. 
  
• Turn off oxygen immediately when not in use. Oxygen is heavier than air and will pool in fabric making the material more flammable. Therefore, never leave the nasal prongs or mask under or on bed coverings or cushions whilst the oxygen is being supplied. 
  
• Oxygen cylinders should be secured safely to avoid injury. 
  
• Do not store oxygen cylinders in hot places. 
  
• Keep the oxygen equipment out of reach of children. 
  
• Do not use any petroleum products or petroleum byproducts e.g. petroleum jelly/Vaseline whilst using oxygen. 
  

Links

Product manuals and information 

• Oxygen Saturation Sp02 Level Targeting - Premature neonates
• AIRVO 2 Humidifier user manual
• AIRVO2 Disinfection kit manual
• RT203 Instructions for use
• Optiflow RT330 Instructions for use
• Optiflow Adult Nasal Cannula instructions for use
• Optiflow Junior Nasal Cannula instructions for use
• User manual for MR850
  
• F&P Optiflow Junior Nasal Cannula Fitting Guide
• F&P Optiflow Junior Consult Instructions For Use

RCH Guidelines

• High Flow Nasal Prong Therapy nursing clinical guideline
• PICU High Flow Nasal Prong HFNP oxygen guideline
• NICU Departmental HFNP guideline
• Isolette (RCH internal link)
  
• RCH CPG Assessment of Severity of Respiratory Issues
  
• Clinical Guidelines (Nursing): Nursing Assessment
 

Appendix A - Pediatric sizing guides for nasal prongs

Fisher and Paykel Optiflow junior range sizing guide

Evidence Table

The evidence table for this guideline can be viewed here. 

Please remember to read the disclaimer.

The review of this nursing guideline was coordinated by John Kemp, Nurse Educator, Sugar Glider, and approved by the Nursing Clinical Effectiveness Committee. Dec 2020.