In this section
Note: This guideline is currently under review.
Definition of terms
Indications for oxygen delivery
Nurse initiated oxygen
Patient assessment and documentation
Selecting the delivery method
Low flow delivery method
High flow delivery method
Air entrainment devices
Links to related guidelines
Appendix A - Paediatric sizing guides for nasal prongs
Evidence Table (coming soon)
The goal of oxygen delivery is to maintain targeted SpO2 levels in children through the provision of supplemental oxygen in a safe and effective way which is tolerated by infants and children to:
NB: The above values are genearlised to the paediatric population, for age specific ranges please consult CLARA and/or the medical team.
The above values are expected target ranges. Any deviation should be documented on the observation chart as MET modifications.
If you require further information please click here for the Assessment of Severe Respiratory Conditions guideline.
Oxygen is a drug and requires a medical order. Each episode of oxygen delivery should be ordered on the medication chart either as a one-off order or on-going treatment.
A range of flow meters are available at RCH (0-1 LPM, 0-2.5 LPM, 0-15 LPM, 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:
Note: Oxygen therapy should not be delayed in the treatment of life threatening hypoxia.
Low-flow systems include:
Note: In low flow systems the flow is usually titrated (on the flow meter) and recorded in litres per minute (LPM).
High flow systems include:
When using an air entrainment device it is important that:
Air Entrainer: %O2 to recommended oxygen flow guide
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.
RCH predominantly uses the Fisher & Paykel MR850 Humidifier & AIRVO 2 Humidifier. Please consult user manuals for any other models in use.
Follow instructions in the MR850 User Manual in conjunction with this Guideline Has two modes:
Follow instructions in the AIRVO 2 User Manual in conjunction with this Guideline. Has two modes:
Link to: Optiflow Nasal Prong Flow Rate Guide
WARNING: Do not cover Airvo breathing circuit with linen, or use on a patient in an isolette or overhead heater cot (see User Manual)
The AIRVO 2 Humidifier requires cleaning and disinfection between patients.
Follow the instructions in the disinfection kit manual:
For routine cleaning instructions please refer to the following link: RCH Equipment Cleaning Table Prepared by Infection Prevention and Control Team
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.
Click to view the delivery mode quick reference table
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.
Note: Do not use air entrainment device with simple nasal prongs.
A maximum flow of:
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:
If the 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. Note: Do not use air entrainment device with simple nasal prongs 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.
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 guides below for recommended patient sizing and flow rates.
Fisher and Paykel Optiflow nasal cannula junior range Four sizes of prongs:
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
(RT330 circuit - click here for instructions for use)
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.
(RT203 Circuit and O2 stem - click here for instructions for use)
The AIRVO 2 Humidifier has two modes:
Below is an image of the Fisher and Paykel Optiflow nasal cannula junior range for AIRVO 2
Optiflow Nasal Prong junior and standard humidification and flow rate guide for Airvo.
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, CO2 re-breathing and drowsiness. 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 require routine humidification. However, as compressed gas is drying and may damage the tracheal mucosa humidification might be indicated/appropriate for patients with secretions retention, or discomfort. Additionally in some conditions (eg. Asthma), the inhalation of dry gases can compound bronchoconstriction.
Nebuliser mask or tracheostomy mask in conjunction with a humidification system A nebuliser mask or tracheostomy mask with an air entrainment device is intended for use with a MR850 Humidifier). By entraining room air into the delivery system, the total gas flow to the patient can be increased up to approximately 45 LPM. When the instructions on the air entrainment device are followed, it is possible to deliver a specific FiO2. This system is useful in accurately delivering low concentrations of oxygen (28-50%).
A nebuliser mask or tracheostomy mask with a mask interface adaptor is intended for use with an AIRVO 2 Humidifier. A tracheostomy direct connection may be used with an 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 medical review. With both systems, as the gas flow is > 4LPM re-breathing of expired gas is not a potential problem. Therefore this system reduces the risk of carbon dioxide retention. 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:
A non-rebreathing face mask is a mask with an oxygen reservoir bag that has a 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
Click to view the delivery mode quick reference table
Tracheostomy HME - Heat Moisture Exchanger (Swedish nose filter) with oxygen attachment
In spontaneously breathing tracheostomy patients who require oxygen flow rates of less than 4 LPM there are two options available:
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.)
Oxygen is not a flammable gas but it does support combustion (rapid burning). Due to this the following rules should be followed:
Appendix A - Pediatric sizing guides for nasal prongs
Fisher and Paykel Optiflow junior range sizing guide
... coming soon
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Spentzas, T., Minarik, M., Patters, AB., Vinson, B. and Stidham, G. (2009) Children with respiratory distress treated with high-flow nasal cannula. Journal of Intensive Care Medicine. 24(5): 323-8
Miyamoto, K. & Nishimura, M. "Nasal Dryness Discomfit in Individuals Receiving Dry Oxygen via Nasal cannula" Respiratory Care April (2008) Vol 35 No. 4 503 – 504
Ricard, J. & Boyer, A. "Humidification during oxygen therapy and non-invasive ventilation: do we need some and how much"? Intensive Care Med (2009) 35: 963-965
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Please remember to read the disclaimer.
Revision of the Oxygen delivery guideline, origionally published Oct 2012, was coordinated by Sueellan Jones, Respiratory Nurse Consultant, Department of Respiratory Medicine, and Brenda Savill, Nurse Educator, Nursing Education. Approved by the Clinical Effectiveness Committee. Authorised by Bernadette Twomey, Executive Director Nursing Services. Revised guidelines published November 2013.