Introduction

The administration of oxygen is the most important

therapeutic manoeuvre in the management of
hypoxaemia and tissue hypoxia.
1
Hypoxaemia is
defined when level of O
2
in the arterial blood is
reduced whereas hypoxia denotes the condition when
reduced amount of O
2
is delivered to tissue.
2
When
oxygen saturation <92% at sea level and <88% at
higher altitude hypoxaemia results.
1,2,3
Factors
affecting oxygen delivery include adequate
ventilation, pulmonary gas exchange, adequate
cardiac output, haemoglobin level and its
saturation.
2
In most of the developing countries
where facilities of blood gas analysis and
measurement of transcutaneous Sao
2
by pulse
oximetry are limited, most physicians rely on clinical
signs to identify hypoxemia.
3
WHO recommended
few clinical signs to predict hypoxemia include fast
breathing (70 or more), grunting, cyanosis, head
nodding, severe lower chest indrawing.
1,3,4
The objective of this review is to discuss about the
different oxygen delivery methods, their benefits &
hazards with monitoring of the patient for desirable
O
2

saturation target.
Oxygen delivery system:
To ensure proper O
2
therapy prescription should
cover the flow rate, delivery system, duration and
monitoring of the patient. Different types of oxygen
delivery systems are used for neonatal and paediatric
patients, including low-flow, reservoir, high-flow and
enclosure systems.
5,6,7
The selection of oxygen
delivery device depends upon the degree of
hypoxemia because O
2
concentration varies
according to the method used. Low flow O
2
delivery
system like nasal cannula /prongs, nasopharyngeal
catheter, simple mask are commonly used in
Paediatric practice. WHO also recommends low flow
method because in this system 30-40% concentration
Oxygen therapy in children
S Khanum
1
, MA Haqq
2
, MR Amin
3
1. Associate Professor, Paediatric Pulmonology, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka
2. Junior Consultant, Paediatrics, Upazilla health complex Nawabganj, Dhaka
3. Professor, Paediatric Pulmonology, Bangladesh Institute of Child Health & Dhaka Shishu Hospital, Dhaka
Correspondence to: Dr. Selina Khanum, Associate Professor, Paediatric Pulmonology, BSMMU, Shahbag, Dhaka
of O
2
can be delivered safely to the hypoxic
children.
7,8,9
In reservoir system partial rebreathing
and non-rebreathing masks are used when higher
concentration of O
2
(FiO
2
>0.60) are warranted.
(eg.during transport). High flow oxygen delivery
devices are used in Paediatric critical care unit when
high fixed concentration of O
2
is required.
2,7,8,9
Low-flow systems:
i) Nasal cannula / prongs is inserted into the
patients anterior nares. Oxygen flows into the
patients nasopharynx, which acts as an anatomic
reservoir. The fractional concentration of
inspired O
2
(FiO
2
) varies with the patients
inspiratory flow.
7
Benefit of this device is here
the child can move, sit up, and eat but there are
some limitations also. Cannula/ prongs are very
difficult to keep in position particularly in small
infants. Maximum flow should be limited to 2L/
min and there is chance of unpredictable
concentration of O
2
with excessive mucus
drainage.
7,10,11
ii) Nasopharyngeal cannula/catheter soft tube
with several distal holes or infant feeding tube
with the tip removed are used and passed through
one nostril to the nasopharynx to a depth equal
to the distance from the side of the nose to the
front of the ear. Usually flow should not exceed
3 L/min. Excessive flow may cause gastric
distention, drying and crusting of nasal mucosa.
The catheter can be blocked by mucus so it
should be cleared frequently. Low concentration
of O
2
is delivered if it is placed in the nose rather
than pharynx.
12,13
Reservoir system:
i) Simple oxygen mask are plastic reservoir
designed to fit over the patients nose and mouth.
Reservoir effect is produced by the volume of
DS (Child) H J 2010; 26 (1) : 46-48
REVIEW ARTICLE
the mask. The FiO
2
varies with the patients
respiratory pattern, inspiratory flow, mask fit.
FiO
2
up to 60% can be achieved with flows 5 to 8
L/min.
2,7
ii) Partial-rebreathing masks are similar to
simple oxygen masks but contain a reservoir at
the base of the mask. The oxygen concentration
of the exhaled gases combined with the supply
of fresh O
2
permits the use of flows lower than
other devices and potentially conserves O
2
use.
Fractional inspired oxygen concentration (FiO
2
)
up to 40 to 70% can be attained with O
2
flows of
6 to 10 L/min.
2,7
iii) Non-rebreahing masks are similar to partial
rebreathing masks where exhaled gas does not
mixed with fresh oxygen. The one-way valve over
the reservoir bag prevents entry of expired gas
and the one-way valve over one of the side ports
limits entrainment of room air. This design
provides higher FiO
2
than simple and partial-
rebreathing masks. In this system minimum flow
should be 10 L/min for providing 60% to 80%
FiO
2
. There are some limitations with masks.
It interfere with feeding, appropriate size may
not be available and chance of rebreathing of
Co
2
may occur when total O
2
flow is
inadequate.
7,14,15
High-flow systems:
i) An air-entrainment mask contains a jet orifice
and air entrainment port which is designed to
fit over the patients nose and mouth. The mask
contain venture valves which use the principle
of jet mixing (Bernoulli effect). Oxygen under
pressure is forced through a small jet orifice
entering the mask.

When oxygen passes through
a narrow orifice it produces a high velocity stream
that draws a constant proportion of room air
through the base of the valve. Total flow provided
by the mask is determined by the cross-sectional
area of the entrainment ports, the diameter of
the jet orifice and oxygen flow to the jet. This
system deliver about 40 L/min of gas through
the mask and here breathing pattern will not
affect FiO
2
. The disadvantage is that high flows
are noisy and create quite breeze that is cooling.
14
ii) Air-entrainment nebulizers are gas-powered
large volume nebulizers that contain an
adjustable air-entrainment port which
determines specific O
2
concentrations. Aerosol
mask, face tent can be used for delivering high
flow humidified oxygen.

This system also produce
high noise.
14,15
Enclosure system:
i) Oxygen hoods are transparent and designed
to surround the head of the neonate or small
infant. A continuous flow of humidified O
2
is to
be supplied in the hood. Transparent enclosures
in larger sizes (so-called tent houses or huts) are
available for older children. The actual
concentration of inspired O
2
is lower than
expected because childs mouth & nose are
nearer to the opening of the box. Flow >7 L/min
is required to wash out Co
2
.
2,7,15
ii) Closed incubators can be used in enclosure
system that provide a warm environment.
Supplemental oxygen can de added for increasing
O
2
saturation. However due to high risk of
infection incubator is not further considered as
O
2
delivery device.
7,15
Monitoring of oxygen therapy:
Oxygen treatment can be monitored by blood gas
analysis or non invasively by pulse oximetry.
Oximetry should be performed within 30 minutes of
starting therapy and further check should be
performed after 2 hours. For severely ill patients
continuous oximetry is indicated. Assessment
depends on clinical signs indicating hypoxemia on
frequent interval where pulse oximetry & blood gas
analysis are not available. When the child is
improving, oxygen could be withdrawn for a few
minutes and the child should be observed for about 10
minutes. Oxygen therapy is no longer needed, if child
is comfortable without oxygen. Maintenance of Sao
2
>92% permits weaning from oxygen support.
15,16,17
Hazards of oxygen therapy:
Oxygen therapy can result in both respiratory and
non respiratory toxicity and depends on important
factors include patient susceptibility, FiO
2
and
duration of therapy. Prolonged high concentrations
of oxygen cause pulmonary atelectasis in areas of low
V/Q ratio.

When the more insoluble nitrogen is
replaced by O
2
in these areas, alveolar volume
decreases because of greater uptake of O
2
causing
alveolar collapse (absorption atelectasis). High
concentration of O
2
generating toxic metabolites
causing injury of the alveolar capillary membrane that
DS (Child) H J 2010; 26 (1)
47
is pathologically and clinically indistinguishable from
ARDS. Pulmonary O
2
toxicity in newborn infants is
manifested as bronchopulmonary dysplasia. Oxygen
therapy in neonates with immature retina can lead
to disorganized vascular proliferation and fibrosis,
retinal detachment and eventual blindness. Neonates
of less than 36 weeks gestational age are at greatest
risk. Finally oxygen has a fire hazard.
1,7,17,18
Conclusion
Choice of appropriate O
2
delivery system and proper
monitoring have to be considered for desirable O
2
saturation to minimize wastage of O
2
and its side
effects.
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