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Oct.28.2020

Oxygen Therapy and Oxygen Delivery: Pediatric (Home Health Care) - CE

ALERT

Fire is a significant hazard where oxygen is used. Do not permit flames, sparks, or smoking.

OVERVIEW

Oxygen delivery systems are categorized as low-flow (variable performance) systems or high-flow (fixed performance) systems. With low-flow systems, 100% oxygen mixes with room air during inspiration, and room air is entrained, making the percentage of delivered oxygen variable. High-flow devices provide such a high flow of premixed gas that the patient is not required to inhale room air.

Many patients in home care with ongoing oxygen needs have a plan in place for increasing oxygen requirements in times of illness and stress. The nurse should be aware of this plan and how to administer oxygen when there are signs of the need for increased oxygen consumption.

A variety of oxygen delivery devices are used in home care. A patients may have more than one device depending on his or her need and condition. A nasal cannula, oxygen mask (e.g., simple face mask, partial rebreather mask with reservoir, a nonrebreather mask with reservoir, Venturi mask), face tent, and oxygen hood deliver supplemental oxygen to children to treat hypoxia, respiratory distress, and respiratory failure (Table 1)Table 1 (Table 2)Table 2 (Table 3)Table 3.undefined#ref1">1 Because oxygen can dry the respiratory system for flow rates over 1 L/min humidification should be provided.3

  • A nasal cannula is a low-flow oxygen delivery device (Table 1)Table 1. For infants and toddlers who may poorly tolerate a mask, nasal prongs may be a good alternative. The nasal cannula allows breathing through the mouth or nose. The patient inspires room air in addition to the supplemental oxygen, and a variable concentration of oxygen is delivered.2 A nasal cannula can deliver 22% to 60% oxygen with appropriate oxygen flow rates of 0.5 to 2 L/minute.2
  • A simple face mask is a low-flow oxygen delivery device (Table 2)Table 2. A simple face mask can deliver 35% to 60% oxygen with an appropriate flow rate of 6 to 10 L/min. A minimum of 6 L/min of oxygen flow is needed to prevent rebreathing of exhaled carbon dioxide.2
  • A partial rebreather mask with a reservoir bag is a face mask that delivers moderate to high concentrations of oxygen. Frequent inspection of the reservoir bag is required to ensure that it remains inflated. If it is deflated, exhaled air collects in it, which results in the patient rebreathing exhaled carbon dioxide. Side port openings on the mask vent exhaled air on expiration and allow room air to enter on inspiration. The delivered oxygen percentage varies, depending on the rate and depth of the patient's breathing.
  • A nonrebreather mask with reservoir is a high-flow oxygen delivery device used for patients requiring a higher concentration of oxygen (Table 2)Table 2. A nonrebreather mask can deliver a concentration of up to 95% oxygen with an oxygen flow rate of 10 to 15 L/min.2
  • A Venturi mask is a cone-shaped device with entrainment ports of various sizes at its base. The entrainment ports adjust to deliver various oxygen concentrations. The mask is useful because it delivers a more precise concentration of oxygen to the patient.
  • A face tent is a shieldlike device that fits under the patient’s chin and encircles his or her face. It is used primarily for humidification and for oxygen only when the patient cannot or will not tolerate a tight-fitting mask. Because the tent is so close to the patient's face, the concentration of oxygen delivered to the patient cannot be estimated.
  • Oxygen tents and hoods can provide high concentrations of humidified oxygen, which is useful in a patient with airway inflammation, epiglottitis, croup, or other respiratory tract infections.

Home oxygen equipment is designated as durable medical equipment in the home health setting. Home oxygen therapy must be prescribed. Pulse oximetry measurement should be available in the home as it is the most common method of monitoring pediatric patients on home oxygen therapy.3

EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Explain the oxygen delivery device, including the rationale for its use and the risks.
  • Explain the expected duration and outcome of supplemental oxygen delivery.
  • Explain hypoxemia and the signs and symptoms of respiratory distress.
  • Explain the necessary assessments during supplemental oxygen delivery.
  • Discuss safety precautions for oxygen use.
  • Encourage questions and answer them as they arise.

PROCEDURE

  1. Perform hand hygiene.
  2. Introduce yourself to the patient, family, and caregivers.
  3. Verify the correct patient using two identifiers.
  4. Explain the procedure to the patient, family, and caregivers and ensure that the patient and family agrees to oxygen therapy and oxygen delivery.
  5. Verify the practitioner’s order and assess the patient for pain.
  6. Assess the patient’s developmental level and ability to interact.
  7. Assess the patient for signs and symptoms of inadequate oxygenation and ventilation.
    1. Increased work of breathing (e.g., tachypnea, nasal flaring, grunting, intercostal retractions, subcostal retractions)
    2. Decreased oxygen saturation levels
    3. Cyanosis
    4. Anxiety
    5. Altered level of consciousness
  8. Review the patient’s health history for increased oxygen requirements or a baseline of lower-than-normal oxygen saturation levels (e.g., cyanotic heart disease).
  9. Verify the practitioner’s order for oxygen delivery and concentration, including the plan for increased oxygen requirements.
  10. Prepare an area in a clean, convenient location and assemble the necessary supplies.
  11. Place the selected oxygen delivery device on the patient.
  12. Adjust the flowmeter to deliver the desired liter flow of oxygen. Ensure that the liter flow is appropriate for the device.
  13. Apply and secure the noninvasive oxygen delivery device, ensuring that it is the correct size.
    1. If using a mask, ensure that it covers the patient’s mouth and nose but not the eyes.
    2. Use adhesives to secure a nasal cannula or an elastic strap for a face mask.
  14. Evaluate the patient’s oxygen delivery device for proper fit.
    1. Ensure that nasal cannula prongs remain in the nares.
    2. Ensure that the infant’s head remains in the oxygen hood.
  15. Monitor cardiopulmonary status, including vital signs, oxygen saturation, and indicators of oxygenation and ventilation.
    Report increased work of breathing, agitation, anxiety, altered mental status, changes in oxygen saturation, and changes in peripheral perfusion.
  16. Assess the skin frequently for breakdown.
    Rationale: The bridge of the nose and the cheeks are prone to skin breakdown.
  17. Monitor the patient for signs of dry mucous membranes.
    Rationale: Dry and sore mucous membranes can develop with the delivery of oxygen.
  18. Provide humidification when the supplemental oxygen delivery is greater than 1 L/min.3 If humidified oxygen is used, check the linens frequently and change them as needed.
    Rationale: Oxygen can dry the respiratory system, resulting in thick secretions that are more difficult to mobilize. Dry air can lead to breakdown of the nasal mucosa, resulting in nosebleeds.
  19. Discard or store supplies and perform hand hygiene.
  20. Document the procedure in the patient’s record.

EXPECTED OUTCOMES

  • Signs of improved oxygenation and ventilation
  • Decrease in hypoxemia-related adverse effects, including anxiety
  • Respiratory, cardiovascular, and neurologic stability
  • No skin breakdown
  • Adequate pain control during the procedure
  • Safe oxygen delivery

UNEXPECTED OUTCOMES

  • Signs of inadequate oxygenation and ventilation
  • Increased work of breathing
  • Complications with supplemental oxygen
  • Increasing cardiovascular, respiratory, or neurologic compromise
  • Skin breakdown
  • Inadequately managed pain and anxiety
  • Unsafe oxygen delivery

DOCUMENTATION

  • Delivery device and liter flow or concentration of oxygen delivered
  • Respiratory status, including work of breathing and breath sounds
  • Vital signs and pulse oximeter reading as indicated
  • Patient’s response to supplemental oxygen
  • Unexpected outcomes and related interventions
  • Education
  • Patient’s and family’s progress toward goals

REFERENCES

  1. American Heart Association (AHA). (2017). Part 3: Systematic approach to the seriously ill or injured child. Pediatric advanced life support provider manual (pp. 29-67). Dallas: AHA. (Level VII)
  2. American Heart Association (AHA). (2017). Resources for management of respiratory emergencies. Pediatric advanced life support provider manual (pp. 147-170). Dallas: AHA. (Level VII)
  3. Hayes, D. and others; American Thoracic Society Assembly on Pediatrics. (2019). Home oxygen therapy for children: An official American Thoracic Society Clinical Practice Guideline. American Journal of Respiratory and Critical Care Medicine, 199(3), e5-e23. doi:10.1164/rccm.201812-2276ST (Level VII)

ADDITIONAL READINGS

Wang, K.K-W. and others. (2016). Primary caregivers of in-home oxygen-dependent children: Predictors of stress based on characteristics, needs and social support. Journal of Advanced Nursing, 72(7), 1592-1601. doi:10.1111/jan.12934

Elsevier Skills Levels of Evidence

  • Level I - Systematic review of all relevant randomized controlled trials
  • Level II - At least one well-designed randomized controlled trial
  • Level III - Well-designed controlled trials without randomization
  • Level IV - Well-designed case-controlled or cohort studies
  • Level V - Descriptive or qualitative studies
  • Level VI - Single descriptive or qualitative study
  • Level VII - Authority opinion or expert committee reports

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