Oxygen Therapy in

Neonates
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






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

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.

What is Oxygen ???
Maintain adequate tissue oxygenation while minimizing
cardiopulmonary work
Specific clinical objectives are:
Better O
2
perfusion 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
Christine A. Gleason et al. Avery's Diseases of the Newborn, 9th Edition

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 PaO
2
<50mmHg and
SaO
2
<85%.

Flowmeters and Blenders
Two method to provide oxygen:
Flowmeters with Blender system
Flowmeters with 100% oxygen source

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. 9
th
edition; 868-890
Flow of 8L/min or less
Oxygen provided with low-flow device is always
diluted with air ; hence low and variable FiO
2
The devices are :
Nasal cannula
Nasal catheter
nasopharyngeal catheter
Low-flow systems
Robert L Wilkins et al. Egans Fundamental of Respiratory Care: Oxygen Therapy. 9
th
edition; 868-890
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
patients caregiver 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
Cannula are contraindicated in nasal obstruction:- facial
trauma and choanal atresia


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 developing
countries. Geneva: World Health Organisation, 1993:WHO/ARI 93.28.
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 in
developing 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 for
the delivery of oxygen in children with hypoxemia because of a lower respiratory tract infection. J Pediatr
1995;127:37883
Nasal cannula, nasal catheters, and nasopharyngeal catheters are
more invasive methods of giving oxygen
Questions arise about airway obstruction, gastric distension, the
need for humidification, and changes in lung function.*






* B Frey, F Shann. Oxygen administration in infants. Arch Dis Child Fetal Neonatal Ed 2003;88:F84F88
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
Simple face mask
It is a light weight , single use plastic reservoir.
FiO
2
35% to 50%varies with patients inspiratory flow and oxygen
flow into the mask.*
Room air is entrained through the mask if the patients inspiratory
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
Simple face mask
If less than 5 L/min, the mask volume acts as a dead space and
causes carbon-dioxide rebreathing.

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; 3
rd
edition:147-164
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.

Brian K Walsh et al. Perinatal and Paediatric Respiratory Care. Oxygen Therapy; 3
rd
edition:147-164
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
Brian K Walsh et al. Perinatal and Paediatric Respiratory Care. Oxygen Therapy; 3
rd
edition:147-164
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 the babys head
by removing the top lid

Brian K Walsh et al. Perinatal and Paediatric Respiratory Care. Oxygen Therapy; 3
rd
edition:147-164
Oxygen Hood
Hoods are used to provide controlled over FiO
2
and increased
heated humidity.
Oxygen Hood is also used to perform hyperoxia test in
spontaneously breathing neonates
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 CO
2
retention.
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 FiO
2

Brian K Walsh et al. Perinatal and Paediatric Respiratory Care. Oxygen Therapy; 3
rd
edition:147-164
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
Brian K Walsh et al. Perinatal and Paediatric Respiratory Care. Oxygen Therapy; 3
rd
edition:147-164
Monitoring on oxygen therapy
Pulse-oximetry
Transcutaneous monitoring
Arterial
Pulse oximetry
Target Saturation:
For a Preterm baby: 88%-95%
For a Term baby: >95%





Targeted pre-ductal
SPO
2
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
The pulse oximeter measures the pulsatile waveform,
plethysmogram (PPG), and oxygen saturation using integrated
Masimo SET

technology.
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% oxygen. Arch Dis Child Fetal Neonatal Ed. 2009;94:F87F91
Transcutaneous Monitoring
Provides continuous, non-invasive
estimates of arterial PO
2
and PCO
2
through
a surface skin sensor
The device arterializes the underlying
blood by heating the skin, this increases the
skin permeability of O
2
and CO
2
,
Then measured as transcutaneous (tc)
partial pressure PtcO
2
and Ptc CO
2


Arterial Blood Gas
Target blood gas

<28 wks

28-40
wks
Term
infant

Infants
with
BPD
PaO
2
45-65 50-70 80-100 80-100
PaCO
2
40-50 40-60 35-45 45-70
PH >7.25 >7.25 7.50-7.60 7.35-7.45
Deorari . Blood gas analysis. AIIMS 2008
Oxygen Therapy during Resuscitation
Can be delivered through these devices:
Self Inflating Bag
Flow Inflating Bag
T-Piece resuscitator

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.

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
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
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.
Advance Oxygen Therapy
Non-invasive Ventilation: CPAP and NIPV
Invasive Ventilation
Complication of Oxygen Therapy
Retinopathy of Prematurity
Depression of ventilation
Absorption atelectasis
Neurological impairment
Chronic lung disease/ Broncho pulmonary Dysplasia
Fire Hazard






References
Christine A. Gleason et al. Avery's Diseases of the Newborn, 9th Edition
Robert L Wilkins et al. Egans Fundamental of Respiratory Care: Oxygen
Therapy. 9
th
edition; 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 in
young 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 and
nasopharyngeal catheter for the delivery of oxygen in children with hypoxemia
because of a lower respiratory tract infection. J Pediatr 1995;127:37883
B Frey, F Shann. Oxygen administration in infants. Arch Dis Child Fetal
Neonatal Ed 2003;88:F84F88

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; 3
rd
edition:147-164
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