OXYGEN Therapy How much oxygen and type of administration is needed when you treat a newborn, neonate or infant?

Is therapy helping the child or damaging? When to start and when to stop? Or when to increase and when to wean off from oxygen?

Note: The following oxygen therapy / oxygenation is strictly based on continuous monitoring of the child through clinical symptoms, arterial blood gases and pulse-oximeter reading. Oxygen can be given in high or low concentration in all the conditions associated with hypoxemia. The following specific indices are used while prescribing long term oxygen therapy : 1) At rest in non-recumbent position, if PaO2 55 mmHg. 2) Patient with PaO2 more than 55 mmHg if: a) While on optimal medical treatment, shows features of hypoxic organ dysfunction like secondary pulmonary hypertension, corpulmonale, polycythemia, or CNS dysfunction. b) Patient shows fall in PaO2 below 55mmHg during sleep with disturbed sleep pattern, cardiac arrhythmia, or pulmonary hypertension. These patients are benefited by nocturnal oxygen therapy. c) There is fall in PaO2 during exercise and oxygen therapy improves exercise tolerance. In acute lung conditions like pulmonary embolism, pneumonia, tension pneumothorax, acute severe asthma, pulmonary oedema, or myocardial infarction, a higher concentration of oxygen can be given. Similarly in fibrosing alveolitis, there is no retention of CO2, so high concentration can be given as in these conditions there is no danger of induction of hypoventilation. Maintaining PaO2 above 60 mmHg gives O2 saturation of 90%. therefore following type of administration is used.

Biochemical characteristics for pulmonary insufficiency: Level of Insufficiency Normal I II III PaO2 8-10kPa / 6080mmHg (below 70) (below 50) PaCO2 4 5.6kPa / 3042mmHg Normal pH 7.35 7.45 Normal Normal

Types of oxygen delivery/administration: Nasal cannulae Medium concentration mask Fixed concentration mask Non-rebreather bag Humidified circuits High flow systems

Type adminis. Mask

Fi02 0.4 0.6

Quantity O2/min 5 10 L

Advantages Easily applied

Disadvantages Uncomfortable for infants and unsecured oxygenation Pharynx irritated Sweating, face unaccesible Risk of pneumothorax, infections, stricture

Nasal Cannulae Fixed concentrated mask Mechanic ventilation

0.3 0.4 0.5 1.0 Pressure limited/volume limited

1.5 4 L 5 10 L

Easily applied Stable, secured oxygenation Control hypercapnea

Oxygen given via nasal cannula or face mask or catheter at a flow rate of 4-6 L/min is to achieve FiO2 of 35-40%. Flow rate may be adjusted to maintain PaO2 of about 80 mmHg or more. By using oxygen at flow rate of 1,2,3 L/min, we can achieve roughly 24%, 28%, and 35% with mask, catheter, or cannulae. FiO2 can be calculated by the formula 20+4xO2 flow (L/min). Assisted Ventilation is by two types, either Pressure limited or Volume limited. Ventilator controlled administration of oxygen is often with PEEP(positive end expiratory pressure), & desirable PaO2 of about 60 mmHg with lowest possible FiO2 is achieved with PEEP of about 10-15 cmH2O. After the initial 24 hours, FiO2 should not exceed 60% (to reduce the risk of O2 toxicity). Oxygen therapy should be given continuously and should not be stopped abruptly until the patient has recovered, since sudden discontinuation can wash-out small body stores of oxygen resulting in fall of alveolar oxygen tension. The dose of oxygen should be calculated carefully. Partial pressure of oxygen can be measured in the arterial blood. Complete saturation of haemoglobin in arterial blood should not be attempted. Arterial PO2 of 60 mmHg can provide 90% saturation of arterial blood, but if acidosis is present, PaO2 more than 80 mmHg is required. Finally, conclusion about how much it is necessary - it is upon the individual need or condition of the child and his laboratory parameters. It is not possible to answer all the questions but hope the above mentioned values will give you brief idea on how to approach a child. Thank You. Vaseem Zamair, MD Consultant Pediatrician & Neonatologist.