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ClinicalGuidelines(Nursing):Oxygendelivery

Oxygendelivery
Introduction
Definitionofterms
Normalvalues
Indicationsforoxygendelivery
Nurseinitiatedoxygen
Patientassessmentanddocumentation
Selectingthedeliverymethod
Lowflowdeliverymethod
Highflowdeliverymethod
Airentrainmentdevices
Humidification
Fisher&PaykelMR850Humidifier
AIRVO2Humidifier
Deliverymode
Quickreferencetableformodeofdelivery
NasalProngs
Nasalprongswithouthumidification
Nasalprongswithhumidification(seeappendixAforsizingguide)
OptiflowNasalprongshumidificationusingMR850Humidifier
OptiflowNasalprongshumidificationusingAIRVO2humidifier
Facemask
Simplefacemask
Nebulisermask
Nonrebreathingfacemask
Tracheostomy
Isolette
Considerations
Potentialcomplicationsofoxygenuse
OxygenSafety
Linkstorelatedguidelines
AppendixAPaediatricsizingguidesfornasalprongs
EvidenceTable(comingsoon)
References

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Introduction
ThegoalofoxygendeliveryistomaintaintargetedSpO2levelsinchildrenthroughtheprovisionofsupplemental
oxygeninasafeandeffectivewaywhichistoleratedbyinfantsandchildrento:
Relievehypoxaemiaandmaintainadequateoxygenationoftissuesandvitalorgans,asassessedbySpO2
/SaO2monitoringandclinicalsigns.
GiveoxygentherapyinawaywhichpreventsexcessiveCO2accumulationi.e.selectionoftheappropriate
flowrateanddeliverydevice.
Reducetheworkofbreathing.
Maintainefficientandeconomicaluseofoxygen.
Ensureadequateclearanceofsecretionsandlimittheadverseeventsofhypothermiaandinsensiblewaterloss
byuseofoptimalhumidification(dependantonmodeofoxygendelivery.)

Definitionofterms
FiO2:Fractionofinspiredoxygen(%).
PaCO2:ThepartialpressureofCO2intheblood.Itisusedtoassesstheadequacyofventilation.
PaO2:Thepartialpressureofoxygenintheblood.Itisusedtoassesstheadequacyofoxygenation.
SaO2:Arterialoxygensaturationmeasuredfrombloodspecimen.
SpO2:Arterialoxygensaturationmeasuredviapulseoximetry.
Airentrainmentdevice(venturiprinciple):Allowsairtobeincorporatedintotheoxygen/humidification
circuit,resultinginanaccuratepercentageofoxygenbeingdeliveredtothepatient.Thisresultsinanincreased
flowvolumetothepatient,upto45LPM.Wherethetotalflowdeliveredtothepatientmeetsorexceedstheir
PeakInspiratoryFlowRatetheFiO2deliveredtothepatientwillbeaccurate.
HeatMoistureExchange(HME)product:aredevicesthatretainheatandmoistureminimizingmoistureloss
tothepatientairway.
Highflow:Highflowsystemsarespecificdevicesthatdeliverthepatient'sentireventilatorydemand(minute
volume.)Highflowinapprovedareasonly.ConsultyourNUMifunsure.
Humidificationistheadditionofheatandmoisturetoagas.Theamountofwatervaporthatagascancarry
increaseswithtemperature.
Hypercapnea:Increasedamountsofcarbondioxideintheblood.
Hypoxaemia:Lowarterialoxygentension(intheblood.)
Hypoxia:Lowoxygenlevelatthetissues.
Lowflow:Lowflowsystemsarespecificdevicesthatdonotprovidethepatient'sentireventilatory
requirements.
Minuteventilation:Thetotalamountofgasmovingintoandoutofthelungsperminute.Theminuteventilation
(volume)iscalculatedbymultiplyingthetidalvolumebytherespirationrate,measuredinlitresperminute.
PeakInspiratoryFlowRate(PIFR):Thefastestflowrateofairduringinspiration,measuredinlitresper
second.
TidalVolume:Theamountofgasthatmovesin,andout,ofthelungswitheachbreath,measuredinmillilitres
(610ml/kg).
VentilationPerfusion(VQ)mismatch:Animbalancebetweenalveolarventilationandpulmonarycapillary
bloodflow.

NormalValues
Partialpressureofarterialoxygen(PaO2)
80100mmHgchildren/adults

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5080mmHgneonates
PartialpressureofarterialCO2(PaCO2)
3545mmHgchildren/adults
pH=7.357.45
SpO2
>95%forinfants,childrenandadults
>91%forneonates(ClickhereforPrematureNeonatesSpO2guideline)
>60%Cyanoticheartdisease
NB:Theabovevaluesaregenearlisedtothepaediatricpopulation,foragespecificrangespleaseconsultCLARA
and/orthemedicalteam.
Theabovevaluesareexpectedtargetranges.AnydeviationshouldbedocumentedontheobservationchartasMET
modifications.

Indicationsforoxygendelivery
Thetreatmentofdocumentedhypoxia/hypoxaemiaasdeterminedbySpO2orinadequatebloodoxygen
tensions(PaO2).
Achievingtargetedpercentageofoxygensaturation(aspernormalvaluesunlessadifferenttargetrangeis
specifiedontheobservationchart.)
Thetreatmentofanacuteoremergencysituationwherehypoxaemiaorhypoxiaissuspected,andifthechildis
inrespiratorydistressmanifestedby:
dyspnoea,tachypnoea,bradypnoea,apnoea
pallor,cyanosis
lethargyorrestlessness
useofaccessorymuscles:nasalflaring,intercostalorsternalrecession,trachealtug
IfyourequirefurtherinformationpleaseclickherefortheAssessmentofSevereRespiratoryConditionsguideline.
Shorttermtherapye.g.postanaestheticorsurgicalprocedure
Palliativecareforcomfort
Oxygenisadrugandrequiresamedicalorder.Eachepisodeofoxygendeliveryshouldbeorderedonthe
medicationcharteitherasaoneofforderorongoingtreatment.

Nurseinitiatedoxygen
Nursescaninitiateoxygenifpatientsbreachexpectednormalparametersofoxygensaturation
Amedicalreviewisrequiredwithin30minutes
Atthetimeofthemedicalreviewaprescriptionforoxygenshouldbewritten

Patientassessmentanddocumentation
Clinicalassessmentanddocumentationincludingbutnotlimitedto:cardiovascular,respiratoryandneurological
systemsshouldbedoneatthecommencementofeachshiftandwithanychangeinpatientcondition.
Checkanddocumentoxygenequipmentsetupatthecommencementofeachshiftandwithanychangein
patientcondition.
Hourlychecksshouldbemadeforthefollowing:
oxygenflowrate

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patencyoftubing
humidifiersettings(ifbeingused)
Hourlychecksshouldbemadeandrecordedonthepatientobservationchartforthefollowing(unlessotherwise
directedbythetreatingmedicalteam):
heartrate
respiratoryrate
workofbreathing(descriptiveassessmenti.e.useofaccessorymuscles/nasalflaring)
oxygensaturation
EnsuretheindividualMETcriteriaareobservedregardlessofoxygenrequirements
ClinicalGuidelines(Nursing):NursingAssessment

Selectingthedeliverymethod
ArangeofflowmetersareavailableatRCH(01LPM,02.5LPM,015LPM,050LPM(PICUonly).Checkonthe
individualflowmeterforwheretoreadtheball(i.e.centreortopofball),ordial(Perflowbrandofflowmeters)when
settingtheflowrate.
Note:Someflowmetersmaydelivergreaterthanthemaximumflowindicatedontheflowmeteriftheballissetabove
thehighestamount.Usecautionwhenadjustingtheflowmeter.

Oxygendeliverymethodselecteddependson:
ageofthepatient
oxygenrequirements/therapeuticgoals
patienttolerancetoselectedinterface
humidificationneeds
Note:Oxygentherapyshouldnotbedelayedinthetreatmentoflifethreateninghypoxia.

Lowflowdeliverymethod
Lowflowsystemsinclude:
Simplefacemask(withoutairentrainmentdevice)
Nonrebreatherfacemask(maskwithoxygenreservoirbagandonewayvalveswhichaimstoprevent/reduce
roomairentrainment)
Nasalprongs(lowflow)
Tracheostomymask(withoutairentrainmentdevice)
TracheostomyHMEconnector
Isoletteneonates(usuallyforuseintheNeonatalUnitonly)
Note:Inlowflowsystemstheflowisusuallytitrated(ontheflowmeter)andrecordedinlitresperminute(LPM).

Highflowdeliverymethod
Highflowsystemsinclude:

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Ventilators
CPAP/BiPaPdrivers
FacemaskortracheostomymaskusedinconjunctionwithanentrainmentdeviceorAIRVO2Humidifier
Highflownasalprongs(HFNP)

Airentrainmentdevices
Whenusinganairentrainmentdeviceitisimportantthat:
Oxygenmustbehumidifiedandwarmed(MR850HumidifiersetonNonInvasiveMode)ascompressedgasis
dryingandmaydamagethetrachealmucosa.
ToachievethedesiredFiO2usethediagrambelow.Thistableadvisestheappropriateairentrainmentposition
fordesiredFiO2theoxygenflowrateandtotalflowthatwillbedeliveredtopatientwhenthesesettingsare
utilized.ToensurethepatientisbreathingtheFiO2thatthedeviceisdeliveringthetotalflowshouldequalor
exceedthepatientsPeakInspiratoryFlowRate.Thisisnotreallymeasureablebutisatleast3to4timesthe
patientsminuteventilation.
Note:AirentrainmentdevicesarenoteffectivefordeliveringFiO2greaterthan50%
Documentation:
DocumenttheFiO2asindicatedonairentrainmentdevice&totalflowasperAirEntrainerchartbelowandwall
O2flowmeterflow.

AirEntrainer:%O2torecommendedoxygenflowguide

Humidification

Oxygentherapycanbedeliveredusingalowfloworhighflowsystem.Allhighflowsystemsrequirehumidification.
Thetypeofhumidificationdeviceselectedwilldependontheoxygendeliverysysteminuse,andthepatient's
requirements.Thehumidifiershouldalwaysbeplacedatalevelbelowthepatient'shead.
Rationale:

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Cold,dryairincreasesheatandfluidloss
Medicalgasesincludingairandoxygenhaveadryingeffectandmucousmembranesbecomedryresultingin
airwaydamage.
Secretionscanbecomethick&difficulttoclearorcauseairwayobstruction
Insomeconditionse.g.asthma,thehyperventilationofdrygasescancompoundbronchoconstriction.
Indications:
Patientswiththickcopioussecretions
Noninvasiveandinvasiveventilation
Nasalprongflowratesofgreaterthan2LPM(under2yearsofage)or4LPM(over2yearsofage)
Facialmaskflowratesofgreaterthan5LPM
Patientswithtracheostomy
RCHpredominantlyusestheFisher&PaykelMR850Humidifier&AIRVO2Humidifier.Pleaseconsultusermanuals
foranyothermodelsinuse.

Fisher&PaykelMR850Humidifier
FollowinstructionsintheMR850UserManualinconjunctionwiththisGuideline
Hastwomodes:
InvasiveModedeliverssaturatedgasasclosetobodytemperature(37degrees,44mg/L)aspossible.
Suitableforpatientswithbypassedairways:
InvasiveVentilation
Tracheostomyattachmentormask
NasalProngs
NonInvasiveModedeliversgasatacomfortablelevelofhumidity(3136degrees,>10mg/L).
Suitableforpatientsreceiving:
Facemasktherapy:
Noninvasiveventilation(CPAP/BIPAP)
Nebulisermask(withRT308circuit)

AIRVO2Humidifier
FollowinstructionsintheAIRVO2UserManualinconjunctionwiththisGuideline.
Hastwomodes:
JuniorMode
SuitableforpatientsusingOptiflowJuniorInfantandPaediatricNasalProngs
StandardMode
Suitableforpatientsusing:
Optiflowadultnasalprongs
Nebulisermask(viaMaskInterfaceAdaptor)
Tracheostomymask(viaMaskInterfaceAdaptor)
Tracheostomydirectconnection
Linkto:OptiflowNasalProngFlowRateGuide
WARNING:DonotcoverAirvobreathingcircuitwithlinen,oruseonapatientinanisoletteoroverheadheatercot
(seeUserManual)
TheAIRVO2Humidifierrequirescleaninganddisinfectionbetweenpatients.
Followtheinstructionsinthedisinfectionkitmanual:

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Forroutinecleaninginstructionspleaserefertothefollowinglink:RCHEquipmentCleaningTablePreparedby
InfectionPreventionandControlTeam
Whencommencingtherapyonanewpatient,ensurethedisinfectioncyclewasperformed.Ondevicestartup,a
greentrafficlightconfirmstheAIRVO2issafeforuseonanewpatient.AnorangetrafficlightconfirmstheAIRVO2
hasnotbeencleanedanddisinfectedsincelastuse,andisnotsafeforuseonanewpatient.

DeliveryMode
Clicktoviewthedeliverymodequickreferencetable

SimpleNasalProngs
Nasalprongswithouthumidification
Thissystemissimpleandconvenienttouse.Itallowstheoxygentherapytocontinueduringfeeding/eatingandthe
rebreathingofCO2isn'tapotentialcomplication.
SimplenasalprongsareavailableindifferentsizesToensurethepatientisabletoentrainroomairaroundthenasal
prongsandacompletesealisnotcreatedtheprongsizeshouldbeapproximatelyhalfthediameterofthenares.
Selecttheappropriatesizenasalprongforthepatient'sageandsize.
Note:Donotuseairentrainmentdevicewithsimplenasalprongs.
Amaximumflowof:
2LPMininfants/childrenunder2yearsofage
4LPMforchildrenover2yearsofage.

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Withtheaboveflowrateshumidificationisnotusuallyrequired.However,ifhumidificationisclinicallyindicatedset
upaspertherecommendedguidelinesforthespecificequipmentused.Aswiththeotherdeliverysystemsthe
inspiredFiO2dependsontheflowrateofoxygenandvariesaccordingtothepatient'sminuteventilation.
Careandconsiderationsofchildwithsimplenasalprongs:
Positionthenasalprongsalongthepatient'scheekandsecurethenasalprongsonthepatient'sfacewith
adhesivetape.
Positionthetubingovertheearsandsecurebehindthepatient'shead.Ensurestrapsandtubingareawayfrom
thepatient'snecktopreventriskofairwayobstruction.
Checknasalprongandtubingforpatency,kinksortwistsatanypointinthetubingandclearorchangeprongs
ifnecessary.
Checknaresforpatencyclearwithsuctionasrequired.
Changetheadhesivetapeweeklyormorefrequentlyasrequired

Nasalprongswithhumidificationsystem
Iftheflowrateexceedsthoseasrecommendedabovethismayresultinnasaldiscomfortandirritationofthemucous
membranes.Therefore,humidificationofnasalprongoxygentherapyisrecommended.
Note:Donotuseairentrainmentdevicewithsimplenasalprongs
HumidificationcanbeprovidedusingeithertheMR850HumidifierortheAIRVO2Humidifier.Followthe
manufacturer'sInstructionsforUseforeachdeviceandsetup.

OptiflowNasalProngsHumidificationusingMR850Humidifier
Optiflownasalprongsarecompatibleforuseinhumidifiedloworhighflowoxygendelivery.
Note:MR850HumidifiershouldbeplacedinInvasiveModeforNasalProngsTherapy.
Seeguidesbelowforrecommendedpatientsizingandflowrates.
FisherandPaykelOptiflownasalcannulajuniorrange
Foursizesofprongs:
Premature
Neonate
Infant
Paediatric

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SeeAppendixAforfurtherinformationregardingappropriatejuniorrangesizing:FisherandPaykelOptiflowjunior
rangesizingguide
FisherandPaykelOptiflownasalcannulastandardrange
Threesizesofprongs
Small
Medium
Large

PaediatricPatients
(RT330circuitclickhereforinstructionsforuse)
Highflow(inapprovedareasonly,seerelevantguidelines)
Flowof2L/kg/minupto10kg,plus0.5L/kg/minforeachkgabove10kg(toamaximumof50LPM)
FiO22150%(blendermustbeused)
FiO2above50%requiresPICUreview
ThemainsafetyfeatureoftheRT330OxygenTherapySystemisthepressurereliefvalve.Thepressurereliefvalve
hasbeensettoalimitof<40cmH20.Thisvalvehasbeendesignedtominimizetheriskofexcessivepressurebeing
deliveredtotheinfantintheeventthatthenasalprongssealaroundtheinfant'snareswhilethemouthisclosed.
TheimagebelowisoftheRT330circuit.

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BelowisanimageoftheRT330pressurereliefvalve.

Olderchildrenandadolescentpatients
(RT203CircuitandO2stemclickhereforinstructionsforuse)
3sizesofprongs:
Small
Medium
Large
Lowflow,amaximumof:
4LPMforchildrenover2yearsofage
FiO221100%(directfromO2wallsourceorviaablender)
Highflow(inapprovedareasonly,seerelevantrecommendationsabove)
Flowof2L/kg/minupto10kg,plus0.5L/kg/minforeachkgabove10kg(toamaximumof50LPM)
FiO2above50%requiresPICUreview

OptiflowNasalProngsHumidificationusingAIRVO2Humidifier
TheAIRVO2Humidifierhastwomodes:
JuniorMode
StandardMode

JuniorMode
SuitableforpatientsusingtheOptiflowJuniorNasalProngs
TwosizesofOptiflowJuniornasalprongssuitableforusewithAIRVO2Humidifier

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OptiflowJuniorInfant
OptiflowJuniorPaediatric
FiO22195%
HighFlow(inapprovedareasonly,seerelevantguideline)
Flowof2L/kg/minupto10kg,plus0.5L/kg/minforeachkgabove10kg(toamaximumof50LPM)
FiO22150%
PatientsrequiringFiO2>50%requireamedicalreviewandclosemonitoring.ConsiderPICUtransferif
afteronehournoclinicalimprovementhasoccurred
FisherandPaykelOptiflownasalcannulajuniorrangeforAIRVO2

BelowisanimageoftheFisherandPaykelOptiflownasalcannulajuniorrangeforAIRVO2

StandardMode
ThreesizesofOptiflownasalprongssuitableforusewithAIRVO2Humidifer(clickherefor:FisherandPaykel
Optiflow(adult)nasalcannulastandardrangeguide)
Small
Medium
Large
HighFlow(inapprovedareasonly)
Flowof2L/kg/minupto10kg,plus0.5L/kg/minforeachkgabove10kg(toamaximumof50LPM)
FiO22150%
PatientsrequiringFiO2>50%requireamedicalreviewandclosemonitoring.ConsiderPICUtransferif
afteronehournoclinicalimprovementhasoccurred

OptiflowNasalProngjuniorandstandardhumidificationandflowrateguideforAirvo.

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FaceMask
Clicktoviewthedeliverymodequickreferencetable

SimpleFaceMask
TheFiO2inspiredwillvarydependingonthepatient'sinspiratoryflow,maskfit/sizeandpatient'srespiratoryrate.At
RCHbothsimplefacemasks(invarioussizes)andtracheostomymasksareavailable.

Theminimumflowratethroughanyfacemaskortracheostomymaskis4LPMasthispreventsthepossibility
ofCO2accumulation,CO2rebreathinganddrowsiness.Selectamaskwhichbestfitsfromthechild'sbridgeof
nosetothecleftofjaw,andadjustthenoseclipandheadstraptosecureinplace.
Oxygen(viaintactupperairway)viaasimplefacemaskatflowratesof4LPMdoesnotrequireroutinehumidification.
However,ascompressedgasisdryingandmaydamagethetrachealmucosahumidificationmightbe
indicated/appropriateforpatientswithsecretionsretention,ordiscomfort.Additionallyinsomeconditions(eg.
Asthma),theinhalationofdrygasescancompoundbronchoconstriction.

Nebulisermask
Nebulisermaskortracheostomymaskinconjunctionwithahumidificationsystem
AnebulisermaskortracheostomymaskwithanairentrainmentdeviceisintendedforusewithaMR850Humidifier).
Byentrainingroomairintothedeliverysystem,thetotalgasflowtothepatientcanbeincreaseduptoapproximately
45LPM.Whentheinstructionsontheairentrainmentdevicearefollowed,itispossibletodeliveraspecificFiO2.This
systemisusefulinaccuratelydeliveringlowconcentrationsofoxygen(2850%).
AnebulisermaskortracheostomymaskwithamaskinterfaceadaptorisintendedforusewithanAIRVO2Humidifier.
AtracheostomydirectconnectionmaybeusedwithanAIRVO2Humidifier.TheAIRVO2Humidifierflowrateshould
besettomeetorexceedthepatient'sentireventilatorydemand,toensurethedesiredFiO2isactuallyinspiredbythe
patient.Thissystemisusefulinaccuratelydeliveringconcentrationsofoxygen(2195%).Patientswhorequirean
FiO2greaterthan50%requiremedicalreview.
Withbothsystems,asthegasflowis>4LPMrebreathingofexpiredgasisnotapotentialproblem.Thereforethis
systemreducestheriskofcarbondioxideretention.
NOTE:WhileaspecificFiO2isdeliveredtothepatienttheFiO2thatisactuallyinspiredbythepatient(iewhatthe
patientactuallyreceives)variesdependingon:
flowratedeliveredtothepatient(seeairentrainmentdevicebelow)
masksizeandfit
thepatient'srespiratoryrate

Nonrebreathingfacemask

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Anonrebreathingfacemaskisamaskwithanoxygenreservoirbagthathasaonewayvalvesystemwhichprevents
exhaledgasesmixingwithfreshgasflow.Thenonrebreathingmasksystemmayalsohaveavalveonthesideports
ofthemaskwhichpreventsentrainmentofroomairintothemask.Thesemasksarenotcommonlyusedbutanon
rebreathingmaskcanprovidehigherconcentrationofFiO2(>60%)thanisabletobeprovidedwithastandardface
mask(whichisapproximately40%50%)
Considerationswhenusinganonrebreathingfacemask
Toensurethehighestconcentrationofoxygenisdeliveredtothepatientthereservoirbagneedstobeinflated
priortoplacingonthepatientsface.
Ensuretheflowratefromthewalltothemaskisadequatetomaintainafullyinflatedreservoirbagduringthe
wholerespiratorycycle(i.e.inspirationandexpiration).
Donotusewithhumidificationsystemasthiscancauseexcessive'rainout'inthereservoirbag.
NotroutinelyusedoutsideofEDandPICUandshouldonlybeusedinconsultationwiththemedical
team.

Tracheostomy
Clicktoviewthedeliverymodequickreferencetable
TracheostomyHMEHeatMoistureExchanger(Swedishnosefilter)withoxygenattachment
Inspontaneouslybreathingtracheostomypatientswhorequireoxygenflowratesoflessthan4LPMtherearetwo
optionsavailable:
OXYVENTwithTubing:TheadaptorsitsovertheTRACHVENTandthetubingattachestotheoxygen
source(flowmeter).
TRACHVENT+:AlternativelyaHudsonRCIHMETRACHVENT+(Swedishnosefilter)hasanintegrated
oxygensideportwhichconnectsdirectlytooxygentubingwhichisattachedtotheoxygensource(flowmeter).
Note:HMEareusedwithoutaheatedhumidifiercircuit.
Considerations:
TheHudsonTrachVentHMEhasadeadspaceof10mLandisrecommendedforuseinpatientswhohave
tidalvolumesof50mLandabove.
TrachVent'sarechangeddailyorasrequiredifcontaminatedorblockedbysecretions.

Isolette
AttheRCH,oxygentherapyviaanisoletteisusuallyonlyforuseintheButterflyneonatalintensivecareunit.(See
Isoletteuseinpaediatricwards,RCHinternallinkonly.)

Considerations
Oxygenisadruganduseoutsideofanemergencysituationshouldbeprescribedbyamedicalpractitioner
Supplementaloxygenrelieveshypoxaemiabutdoesnotimproveventilationortreattheunderlyingcauseofthe
hypoxaemia.MonitoringofSpO2indicatesoxygenationnotventilation.Therefore,bewaretheuseofhighFiO2
inthepresenceofreducedminuteventilation.
Manychildrenintherecoveryphaseofacuterespiratoryillnessesarecharacterisedbyventilation/perfusion
mismatch(e.g.asthma,bronchiolitis,andpneumonia)andcanbemanagedwithSpO2inthelow90'saslongas
theyareclinicallyimproving,feedingwellanddon'thaveobviousrespiratorydistress.
NormalSpO2valuesmaybefounddespiterisingbloodcarbondioxidelevels(hypercapnea).Highoxygen
concentrationshavethepotentialtomasksignsandsymptomsofhypercapnea.
Oxygentherapyshouldbecloselymonitored&assessedatregularintervals
Therapeuticprocedures&handlingmayincreasethechild'soxygenconsumption&leadtoworsening
hypoxaemia

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ChildrenwithcyanoticcongenitalheartdiseasenormallyhaveSpO2between60%90%inroomair.Increasing
SpO2>90%withsupplementaloxygenisnotrecommendedduetoriskofovercirculationtothepulmonary
systemwhileadverselydecreasingsystemiccirculation.However,inemergencysituationswithincreasing
cyanosissupplementaloxygenshouldbeadministeredtomaintaintheirnormallevelofSpO2

Potentialcomplicationsofoxygenuse
CO2NarcosisThisoccursinpatientswhohavechronicrespiratoryobstructionorrespiratoryinsufficiency
whichresultsinthemdevelopinghypercapnea(i.e.raisedPaCO2).Inthesepatientstherespiratorycentrerelies
onhypoxaemiatomaintainadequateventilation.Ifthesepatientsaregivenoxygenthiscanreducetheir
respiratorydrive,causingrespiratorydepressionandafurtherriseinPaCO2resultinginincreasedCO2levelsin
thebloodandCO2narcosis.
MonitoringofSpO2orSaO2informsofoxygenationonly.Therefore,bewareoftheuseofhighFiO2inthe
presenceofreducedminuteventilation.
PulmonaryAtelectasis
PulmonaryoxygentoxicityHighconcentrationsofoxygen(>60%)maydamagethealveolarmembrane
wheninhaledformorethan48hoursresultinginpathologicallungchanges.
Retrolentalfibroplasia(alsoknownasretinopathyofprematurity)Analterationofthenormalretinalvascular
development,mainlyaffectingprematureneonates(<32weeksgestationor1250gbirthweight),whichcanlead
tovisualimpairmentandblindness.
Substernalpaindue:characterisedbydifficultyinbreathingandpainwithinthechest,occurringwhen
breathingelevatedpressuresofoxygenforextendedperiods.

Oxygensafety
Oxygenisnotaflammablegasbutitdoessupportcombustion(rapidburning).Duetothisthefollowingrulesshould
befollowed:
Donotsmokeinthevicinityofoxygenequipment.
Donotuseaerosolspraysinthesameroomastheoxygenequipment.
Turnoffoxygenimmediatelywhennotinuse.Oxygenisheavierthanairandwillpoolinfabricmakingthe
materialmoreflammable.Therefore,neverleavethenasalprongsormaskunderoronbedcoveringsor
cushionswhilsttheoxygenisbeingsupplied.
Oxygencylindersshouldbesecuredsafelytoavoidinjury.
Donotstoreoxygencylindersinhotplaces.
Keeptheoxygenequipmentoutofreachofchildren.
Donotuseanypetroleumproductsorpetroleumbyproductse.g.petroleumjelly/Vaselinewhilstusing
oxygen.

Linktorelatedguidelines
PICUHighFlowNasalProngHFNPoxygenguideline
Isolette(RCHinternallink)
OxygenSaturationSp02LevelTargetingPrematureneonates
AIRVO2Humidifierusermanual
AIRVO2Disinfectionkitmanual
RT203Instructionsforuse
OptiflowRT330Instructionsforuse
OptiflowAdultNasalCannulainstructionsforuse
OptiflowJuniorNasalCannulainstructionsforuse
RCHCPGAssessmentofSeverityofRespiratoryIssues
UsermanualforMR850
F&POptiflowJuniorNasalCannulaFittingGuide
F&POptiflowJuniorConsultInstructionsForUse
ClinicalGuidelines(Nursing):NursingAssessment

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AppendixAPediatricsizingguidesfornasalprongs
FisherandPaykelOptiflowjuniorrangesizingguide

EvidenceTable
...comingsoon

References
Bateman,N.T.&Leach,R.M.(1998).ABCofOxygenAcuteoxygentherapy.BMJ,September19317(7161):798
801.
Dunn,L.,&Chisholm,H.(1998).OxygenTherapy.NursingStandard,13(7),5760.
Fell,H.,&Boehm,M.(1998).Easingthediscomfitofoxygentherapy.NursingTimes,94(38),5658.
Frey,B.,&Shann,F.(2003).Oxygenadministrationininfants.ArchivesofDiseaseinChildhoodFetalandNeonatal
Edition,88,F84F88.
Oh,T.E.(1990).IntensiveCareManual3rdEdition.Sydney:Butterworths.
Shann,F.,Gatachalian,S.,&Hutchinson,R.(1988).Nasopharyngealoxygeninchildren.TheLancet.12381240.
St.Clair,N.,Touch,S.M.,&Greenspan,S.(2001)SupplementalOxygenDeliverytotheNonventilatedNeonate.
NeonatalNetwork.20(6),3945.
Bersten,A.&Soni,N.(Eds).(2009).Oh'sIntensiveCareManual6thEdition.China:ButterworthHeinemannElsevier
Schibler,A.,Pham,T.,Dunster,K.,Foster,K.,Barlow,A.,Gibbons,K.,andHough,J.(2011)Reducedintubationrates
forinfantsafterintroductionofhighflownasalprongoxygendelivery.IntensiveCareMedicine.May37(5):84752

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McKieman,C.,Chua,L.C.,Visintainer,P.andAllen,P.(2010)HighFlowNasalCannulaeTherapyinInfantswith
Bronchiolitis.JournalofPediatrics156:63438
Spentzas,T.,Minarik,M.,Patters,AB.,Vinson,B.andStidham,G.(2009)Childrenwithrespiratorydistresstreated
withhighflownasalcannula.JournalofIntensiveCareMedicine.24(5):3238
Miyamoto,K.&Nishimura,M."NasalDrynessDiscomfitinIndividualsReceivingDryOxygenviaNasalcannula"
RespiratoryCareApril(2008)Vol35No.4503504
Ricard,J.&Boyer,A."Humidificationduringoxygentherapyandnoninvasiveventilation:doweneedsomeandhow
much"?IntensiveCareMed(2009)35:963965
Campbell,E.Baker,D.&CritesSilver,P."SubjectiveEffectsofHumidificationofoxygenfordeliverybynasal
cannula"Chest(1988)Vol93:2289293
Pleaseremembertoreadthedisclaimer.

RevisionoftheOxygendeliveryguideline,origionallypublishedOct2012,wascoordinatedbySueellanJones,RespiratoryNurseConsultant,
DepartmentofRespiratoryMedicine,andBrendaSavill,NurseEducator,NursingEducation.ApprovedbytheClinicalEffectivenessCommittee.
AuthorisedbyBernadetteTwomey,ExecutiveDirectorNursingServices.RevisedguidelinespublishedNovember2013.

Contentauthorisedby:Webmaster.Enquiries:Webmaster.

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