In this section
Definition of terms
Normal values and SpO2 targets
Indications for oxygen delivery
Nurse initiated oxygen
Patient assessment and documentation
Selecting the delivery method
Low flow delivery method
High flow delivery method
Appendix A - Paediatric sizing guides for nasal prongs
The aim of this guideline is to describe the indications and procedure for the use of oxygen therapy, and its modes of delivery.
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 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.
Where considering the application of oxygen therapy it is essential to perform a thorough clinical assessment of the child.
If you require further information please click here for the Assessment of Severe Respiratory Conditions guideline.
Any patient who develops or has an increase in their oxygen requirement should be medically reviewed within 30 minutes.
OXYGEN THERAPY – STANDING MEDICAL ORDERS FOR NURSES
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.
THE FOLLOWING MAY BE UNDERTAKEN BY NURSES WITHOUT MEDICAL ORDERS:
Commencement or Increase of Oxygen Therapy:
This direction applies to patients treated with:
See below nursing guidelines for additional guidance in assessment and monitoring:
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
Clinical observations:Continuous pulse oximetry for 30 minutes post cessation of oxygen therapyIf oxygen wean successful perform vital sign observation, intermittent SpO2 monitoring 30 minutes later, then hourly for 2 hours.
Where oxygen weaning is successful, continuous pulse oximetry monitoring may be discontinued.
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:
Note: Oxygen therapy should not be delayed in the treatment of life threatening hypoxia.
Low-flow systems include:
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.
See also below guidelines for additional information:
High flow systems include:
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
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:
For routine cleaning instructions please refer to the following link: RCH Equipment Cleaning Table
Prepared by Infection Prevention and Control Team
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. For nasal prong oxygen without humidification 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 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
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
nasal prong oxygen with
humidification a maximum flow of:
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:
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:
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:
FiO2 21-95% - Note, the oxygen flow rate from the wall or portable sources should not exceed the flow rate of the Airvo2High Flow Nasal Prong Therapy (HFNP) in approved areas only, 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
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)
High Flow (in approved areas only)
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 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.
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.
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
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:
Note: HME are used without a heated humidifier circuit.
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:
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.)
Appendix A - Pediatric sizing guides for nasal prongs
Fisher and Paykel Optiflow junior range sizing guide
The evidence table for this guideline can be viewed here.
Please remember to read the disclaimer.
development of this nursing guideline was coordinated by John Kemp, Nurse Educator, Sugar Glider,
and approved by the Nursing Clinical Effectiveness Committee. Updated July 2017.