Oxygen Therapy in Neonates

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Oxygen Therapy inNeonates


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Contents

Introduction

Goals of Oxygen Therapy

Clinical signs and symptoms

Oxygen Delivery system: Low-flow systems, Reservoir system,

Enclosures

Monitoring on Oxygen Therapy

Oxygen Therapy during resuscitation

Adding humidification to oxygen therapy

Advanced oxygen therapy

Complications of Oxygen Therapy


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Introduction

Neonates presenting with respiratory distress is compromised

with inadequacy and variability of gas exchange.

Hypoxemia in neonates can result from:

Reduced alveolar oxygen content

Decrease ventilation-perfusion ratio

Reduced diffusion capacity

Extra-pulmonary rightleft shunts

Chr istine A. Gleason et al. Avery's Diseases of the Newborn, 9th Editi on


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Oxygen is an odorless, tasteless, colorless, and transparent gas.

It is slightly heavier than air.

Oxygen supports combustion, there is always danger of fire,

when oxygen is being used, oxygen can be dispensed from a

cylinder, piped in system, liquid oxygen reservoir or oxygen

concentrated.

Whatis Oxygen ???


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Maintain adequate tissue oxygenation while minimizing

cardiopulmonary work

Specific clinical objectives are:

Better O2perfusion to the tissues of vital organs

Improves hemodynamics adaptation to extrauterine life

evident by persistently elevated PVR and patency ductus

arteriosus

Goals of Oxygen Therapy

Chr istine A. Gleason et al. Avery's Diseases of the Newborn, 9th Editi on


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Clinical signs and symptoms

Early clinical manifestation of hypoxia are

tachycardia, tachypnea, cyanosis, retraction,

grunting.

Worsening of hypoxia leads to decrease ventilation,

apnea and bradycardia.

Arterial blood gas showing PaO2


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Flowmeters and Blenders

Two method to provide oxygen:

Flowmeters with Blender system

Flowmeters with 100% oxygen source


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Categorized by designs:

Low flow system

Reservoir systems

Enclosures

All the designs share functional characteristics,

capabilities and limitations

Design and delivery performance

Robert L Wilkins et al. Egans Fundamental of Respiratory Care: Oxygen Therapy. 9thedition; 868-890


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Flow of 8L/min or less

Oxygen provided with low-flow device is always

diluted with air ; hence low and variable FiO2

The devices are :

Nasal cannula

Nasal catheter

nasopharyngeal catheter

Low-flow systems

Robert L Wilkins et al. Egans Fundamental of Respiratory Care: Oxygen Therapy. 9thedition; 868-890


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Nasal cannula

Consists of flexible bore tubing ending in two soft prongs about

1cm in length.

Oxygen concentration of 24% to 45% (varies with patients

inspiratory flow*).

Allows greater mobility, which may increase interactions with

patientscaregiver and environment. **

*Ooi R et al: An evaluation of Oxygen delivery using nasal prongs, Anesthesia; 1992;47:591

** Walsh M et al: Oxygen Therapy through nasal cannulae to preterm infants: Pediatrics 2005;116:857


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Cannula are contraindicated in nasal obstruction:- facial

trauma and choanal atresia


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Nasal Catheter

A nasal catheter is a thin, flexible tube which is passed through

nose and ends with its tip in the nasal cavity.

Distance is from side of nostril to the posterior part of nasal

cavity.

Distance is about 2.5 cm. Nasal catheters are well tolerated, and

are unlikely to be dislodged.

World Health Organisation. Oxygen therapy for acute respiratory infections in young children in developingcountries. Geneva: World Health Organisation, 1993:WHO/ARI 93.28.


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Nasopharyngeal catheter

Nasopharyngeal catheters are inserted into the nose to

pharynx below the soft palate. *

Nasopharyngeal catheters can also become blocked with

mucus, and accumulation of mucus can cause upper airway

obstruction**

.

*World Health Organisation. Oxygen therapy for acute respiratory infections in young children indeveloping countries. Geneva: World Health Organisation, 1993:WHO/ARI 93.28.

** Weber MW, Palmer A, Oparaugo A, et al. Comparison of nasal prongs and nasopharyngeal catheter forthe delivery of oxygen in children with hypoxemia because of a lower respiratory tract infection. J Pediatr

1995;127:37883


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Nasal cannula, nasal catheters, and nasopharyngeal catheters are

more invasive methods of giving oxygen

Questions arise about airway obstruction, gastric distension, theneed for humidification, and changes in lung function.*

* B Frey, F Shann. Oxygen administration in infants. Arch Dis Child Fetal Neonatal Ed 2003;88:F84F88


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Most commonly used is Simple face mask

Body of mask itself gathers and stores oxygen between

patient breath.

Exhalation passes through open holes.

If oxygen flow ceases, patient can draw air through

these holes and around edges of the mask.

Reservoir system


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Simple face mask

It is a light weight , single use plastic reservoir.

FiO2 35% to 50%varies withpatients inspiratory flow and oxygen

flow into the mask.*

Room air is entrained through the mask if the patientsinspiratory

flow rate exceeds the oxygen flow rate of 6 to 10L/min.**

.

*Cairo JM, Pilbeam SP: Administering medical gases: regulators, flowmeters and controlling devices. In

Mosbys respiratory care equipment, edition 7, St. Louis: Mosby

** Redding JS et al: Oxygen concentration received from commonly used delivery systems, South Med J

1978;71-72


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Simple face mask

If less than 5 L/min, the mask volume acts as a dead space and

causes carbon-dioxide rebreathing.


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Simple face mask contd

Indications: used for infants and children.

Used during medical transport, emergency stabilization, post

anesthesia recovery and during medical procedures.

Application: designed to fit over a patients nose and mouth

and is secured by an elastic straps around the neck.

Complications: uncomfortable straps, skin irritation, interferes

with breast feeding, eating and speech

Brian K Walsh et al. Perinatal and Paediatric Respiratory Care. Oxygen Therapy; 3rdedition:147-164


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Enclosures: Oxygen tents

Primary method of oxygen administration.

Provides cool and oxygen-enriched environment with high

humidity.

High output aerosol generators or large volume nebulizers

powered by oxygen to produce dense mist.

Variable oxygen concentration >50% with flow of >10L/min.



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Oxygen tents

Indications: Infants and children with laryngo

tracheobronchitis

Hazards: Electrical shock or sparks

Complications: Excessive mist may not be

able to observe child in the tent. May cause

claustrophobia

Close monitoring is required



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Enclosures: Oxygen Hood

It is a transparent enclosure constructed of clear plastic

material in a box like design

Oxygen is administered through a large bore via a corrugated

tubing attached to the back of the hood

It surrounds only the head of the baby

Variation in the hood designs allow access to thebabyshead

by removing the top lid



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Oxygen Hood

Hoods are used to provide controlled over FiO2and increased

heated humidity.

Oxygen Hood is also used to perform hyperoxia test inspontaneously breathing neonates


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Larger head box and higher lid position, results in lower oxygen

concentration, at a given oxygen flow rate.

Oxygen concentration achieved in babies is lesser than the

concentration achieved in a dummy.

Flow rates of less than 4L/min in small and 3L/min in medium

and large sized head boxes are associated with CO2retention.


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Enclosures: Incubators

Environmental delivery systems because they provide large

volumes of oxygen enriched gas to the atmosphere

immediately surrounding the patient.

Designed an enclosed incubator to provide a warm

environment for premature infants.

Current incubators allow variable control of the environment

temperature, humidity and FiO2



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Temperature and humidity of the gas in the

incubator are regulated by a servo controlled

mechanism connected to a fan that

circulates environmental gas over heating

coils and a blow-by humidifier.

Supplemental oxygen can be provided with

a heated humidifier directly to the incubator.

Incubators



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Monitoring on oxygen therapy

Pulse-oximetry

Transcutaneous monitoring

Arterial


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Pulse oximetry

Target Saturation:

For a Preterm baby: 88%-95%

For a Term baby: >95%

Targeted pre-ductal

SPO2 after birth

1 min- 60-65%2 min- 65-70%

3 min- 70-75%

4 min- 75-80%

5 min- 80-85%

10 min- 85-95%

Pre-ductal saturation Post-ductal saturation

Hay WW et al. Reliability of conventional and new pulse oximetry in neonatal patients. J Perinatol. 2002;22:360 366.

ODonnell CP et al.Feasibility of and delay in obtaining pulse oximetry during neonatal resuscitation. J Pediatr. 2005;147:698 699.Dawson JA et al. Oxygen saturation and heart rate during delivery room resuscitation of infants 30 weeks gestation with air or 100%oxygen. Arch Dis Child Fetal Neonatal Ed. 2009;94:F87F91


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The pulse oximeter measures the pulsatile waveform,

plethysmogram (PPG), and oxygen saturation using integrated

Masimo SETtechnology.

Newer pulse oximeters, which employ probes designed

specifically for neonates, have been shown to provide reliable

readings within 1 to 2 minutes following birth.

Hay WW et al. Reliability of conventional and new pulse oximetry in neonatal patients. J Perinatol. 2002;22:360 366.ODonnell CP et al.Feasibility of and delay in obtaining pulse oximetry during neonatal resuscitation. J Pediatr. 2005;147:698

699.Dawson JA et al. Oxygen saturation and heart rate during delivery room resuscitation of infants 30 weeks gestation with air or

100% ox en. Arch Dis Child Fetal Neonatal Ed. 2009 94:F87F91


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Transcutaneous Monitoring

Provides continuous, non-invasive

estimates of arterial PO2and PCO2through

a surface skin sensor

The device arterializes the underlying

blood by heating the skin, this increases the

skin permeability of O2and CO2,

Then measured as transcutaneous (tc)

partial pressure PtcO2and Ptc CO2


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Arterial Blood Gas

Target blood gas

7.25

>7.25

7.50-7.60 7.35-7.45

Deorari . Blood gas analysis. AIIMS 2008


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Oxygen Therapy during Resuscitation

Can be delivered through these devices:

Self Inflating Bag

Flow Inflating Bag

T-Piece resuscitator


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Insufficient evidence to recommend a policy of using room air

over 100% oxygen, for newborn resuscitation.

A reduction in mortality has been seen in infants resuscitated

with room air, and no evidence of harm has been demonstrated.

Further randomised controlled trials assessing mortality and

long term neurodevelopmental outcome is essential.


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Unrestricted, unmonitored oxygen therapy has potential harms,

without clear benefits.

However, the question of what is the optimal target range for

maintaining blood oxygen levels in preterm/LBW infants was not

answered

The BOOST trial (BOOST (Australia)) is assessing the effect of

higher oxygen levels


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Adding Humidification to Oxygen

Therapy

Neonatal resuscitation guidelines recommend techniques to

minimize heat loss in the delivery room and during oxygen

therapy.

Use of humidified and heated oxygen therapy for neonates who

need respiratory support in the NICU is a standard care .

PEDIATRICS Volume 125, Number 6, June 2010


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Used of heated and humidified gas during respiratory support in very

preterm infants at birth have a positive effect on temperature.

A larger study, preferably randomized and blinded, is needed to

investigate short-term and long-term effects.

More research is needed on the physiologic consequences of gas

conditions on the preterm lung when it is given in a short period.


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Advance Oxygen Therapy

Non-invasive Ventilation: CPAP and NIPV

Invasive Ventilation


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Complication of Oxygen Therapy

Retinopathy of Prematurity

Depression of ventilation

Absorption atelectasis

Neurological impairment

Chronic lung disease/ Broncho pulmonary Dysplasia

Fire Hazard


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References

Christine A. Gleason et al. Avery's Diseases of the Newborn, 9th Edition

Robert L Wilkins et al. Egans Fundamental of Respiratory Care: OxygenTherapy. 9thedition; 868-890

Ooi R et al: An evaluation of Oxygen delivery using nasal prongs, Anesthesia;1992;47:591

Walsh M et al: Oxygen Therapy through nasal cannulae to preterm infants:Pediatrics 2005;116:857

World Health Organisation. Oxygen therapy for acute respiratory infections inyoung children in developing countries. Geneva: World Health Organisation,1993: WHO/ARI 93.28.

Weber MW, Palmer A, Oparaugo A, et al. Comparison of nasal prongs andnasopharyngeal catheter for the delivery of oxygen in children with hypoxemiabecause of a lower respiratory tract infection. J Pediatr 1995;127:37883

B Frey, F Shann. Oxygen administration in infants. Arch Dis Child FetalNeonatal Ed 2003;88:F84F88


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References

Cairo JM, Pilbeam SP: Administering medical gases: regulators, flowmeters

and controlling devices. In Mosbys respiratory care equipment, edition 7, St.

Louis: Mosby

Redding JS et al: Oxygen concentration received from commonly used

delivery systems, South Med J 1978;71-72 Brian K Walsh et al. Perinatal and Paediatric Respiratory Care. Oxygen

Therapy; 3rdedition:147-164

Hay WW et al. Reliability of conventional and new pulse oximetry in

neonatal patients. J Perinatol. 2002;22:360366.

ODonnell CP et al. Feasibility of and delay in obtaining pulse oximetryduring neonatal resuscitation. J Pediatr. 2005;147:698699.

Dawson JA et al. Oxygen saturation and heart rate during delivery room

resuscitation of infants 30 weeks gestation with air or 100% oxygen. Arch

Dis Child Fetal Neonatal Ed. 2009;94:F87F91

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Oxygen Therapy in Neonates