Oxygen Therapy and Oxygen Delivery (Pediatric) - CE/NCPD

ALERT

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

OVERVIEW

The administration of oxygen to pediatric patients requires the selection of an oxygen delivery system that suits the patient’s age, size, needs, clinical condition, and therapeutic goals. 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. Supplemental oxygen therapy is often recommended for pediatric patients when peripheral oxygen saturation is consistently below 94%.^{undefined#ref1">1}

A nasal cannula, oxygen mask (e.g., simple face mask, partial rebreathing mask with reservoir, a nonrebreathing mask with reservoir, Venturi mask), face tent, and oxygen hood deliver supplemental oxygen to pediatric patients to treat hypoxia, respiratory distress, and respiratory failure (Table 1) (Table 2) (Table 3). Because oxygen can dry the respiratory system, many oxygen delivery systems allow for humidification.

• A nasal cannula is a low-flow oxygen device (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 24% to 45% oxygen with appropriate oxygen flow rates of 0.5 to 2 L/minute.²
• A simple face mask is a low-flow oxygen device (Table 2). A simple face mask can deliver 35% to 50% oxygen with an appropriate flow rate of 6 to 10 L/minute. A minimum of 6 L/minute of oxygen flow is needed to prevent rebreathing of exhaled carbon dioxide.²
• A partial rebreathing 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 can be as high as 60%, but percentage varies, depending on the rate and depth of the patient's breathing.
• A nonrebreathing mask with reservoir is a high-flow oxygen delivery device used for pediatric patients requiring a higher concentration of oxygen (Table 2). A nonrebreathing mask can deliver a concentration of up to 90% oxygen with an oxygen flow rate of 10 to 15 L/minute.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.
• A face tent is a shieldlike device that fits under the patient’s chin and encircles the 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.

SUPPLIES

See Supplies tab at the top of the page.

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.

ASSESSMENT AND PREPARATION

Assessment

1. Perform hand hygiene before patient contact.
2. Introduce yourself to the patient and family.
3. Verify the correct patient using two identifiers.
4. Assess the patient's developmental level and ability to interact.
5. 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
6. Determine if a condition in the medical history predisposes the patient to baseline lower-than-normal oxygen saturation levels (e.g., cyanotic heart disease).
7. Assess the patient's and family's understanding of the reasons for and the risks and benefits of the procedure.

Preparation

1. Select the appropriate oxygen delivery device per the practitioner's order (Table 1) (Table 2) (Table 3).

PROCEDURE

1. Perform hand hygiene and don gloves and, if the patient's health status requires, a gown, mask, and eye protection or face shield.
2. Verify the correct patient using two identifiers.
3. Explain the procedure to the patient and family and ensure that they agree to treatment.
4. Place the selected oxygen device on the patient. If one method of oxygen delivery upsets the patient, consider changing to another method.
5. Adjust the flowmeter to deliver the desired concentration of oxygen. Ensure that the liter flow is appropriate for the device.
6. Apply and secure the noninvasive oxygen delivery device, ensuring that it is the correct size.

   Rationale: The correct size device ensures optimal delivery of the prescribed concentration of oxygen and reduces the risk of skin breakdown.

   1. If using a mask, ensure that it covers the mouth and nose but not the eyes.
   2. Use adhesives to secure a nasal cannula or an elastic strap for a face mask.
7. 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.
8. Discard supplies, remove personal protective equipment (PPE), and perform hand hygiene.
9. Document the procedure in the patient's record.

MONITORING AND CARE

1. Monitor cardiopulmonary status, including vital signs, oxygen saturation, and indicators of oxygenation and ventilation.

   Reportable conditions: Tachypnea, bradypnea, apnea, increased work of breathing, nasal flaring, retractions, diminished or abnormal breath sounds, agitation, anxiety, altered mental status, changes in oxygen saturation, changes in blood gas values, arrhythmias (including tachycardia and bradycardia), hypertension, hypotension, changes in skin color such as pallor or cyanosis, changes in peripheral perfusion

2. Monitor the patient's respiratory status and need for increased or decreased oxygen therapy.

   Rationale: Changes in oxygen delivery to avoid oxygen-related complications are based on the patient's condition.

3. Monitor the patient for signs of hypercarbia.

   Rationale: If gas flow is too low, hypercarbia may develop.

   Reportable conditions: Increasing agitation, rapid and deep respiration, dyspnea, progressive lethargy

4. Monitor a patient in an oxygen hood carefully.

   Rationale: Suffocation may occur if the patient puts the mouth or nose against the plastic walls.

5. Assess the skin frequently for breakdown.

   Rationale: The bridge of the nose and the cheeks are prone to skin breakdown.

   Reportable condition: Skin breakdown associated with the device

6. Monitor the patient for signs of dry mucous membranes.

   Rationale: Dry and sore mucous membranes can develop with the delivery of oxygen.

   Reportable conditions: Dry or cracked mucous membranes

7. Provide humidification when the supplemental oxygen delivery device permits. 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.

8. Assess, treat, and reassess pain.

   Rationale: Pain in pediatric patients can decrease the ability to breathe deeply, thereby affecting gas exchange.

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

UNEXPECTED OUTCOMES

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

DOCUMENTATION

• Delivery device and concentration of oxygen delivered
• Respiratory status, including work of breathing and breath sounds
• Vital signs
• Pulse oximeter reading as indicated
• Patient's response to supplemental oxygen
• Pain assessment and related interventions
• Unexpected outcomes and related interventions
• Education

REFERENCES

1. Topjian, A.A. and others. (2020). Part 4: Pediatric basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 142(16 Suppl. 2), S469-S523. doi:10.1161/CIR.0000000000000901 Retrieved November 15, 2023, from https://www.ahajournals.org/doi/10.1161/CIR.0000000000000901 (Level I)
2. Walsh, B.K. (2023). Chapter 33: Oxygen administration. In B. Walsh, and others (Eds.), Neonatal and pediatric respiratory care (6th ed., pp. 535-547). St. Louis: Elsevier.

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

Clinical Review: Suzanne M. Casey, MSN-Ed, RN

Published: January 2024