PURPOSE Standards and guidelines for care and management of patients requiring oxygen therapy. STANDARDS Ongoing management of oxygen therapy requires a prescriber s order. The order must specify oxygen flowrate and/or minimum oxygen saturation levels to maintain. Initiation of oxygen to treat an episode of hypoxemia does not require a physician's order. Refer to Treatment of Hypoxemia Nurse Initiated Activity. SITE APPLICABILITY Applicable in all clinical areas across BCCH and SHHC. PRACTICE LEVEL/COMPETENCIES Oxygen therapy using low flow oxygen delivery devices is a foundational competency for nurses. Oxygen therapy using high flow oxygen delivery devices is considered an advanced nursing competency and is practiced after the nurse has the required education and has had his/her learning validated at the bedside with the appropriate clinical support person. Use of high flow and low flow delivery devices are foundational competencies for respiratory therapists. DEFINITIONS Hypoxemia: Deficiency of oxygen in the blood. Note: "suspected hypoxemia" is the presence of signs and symptoms, reduced pulse oximetry value, without actual blood oxygen levels available. Hypoxia: Deficiency of oxygen in tissue. A condition in which there is insufficient oxygen in the arterial blood to meet the metabolic demands of the tissues and cells. EQUIPMENT flow meter (for flows above 3 LPM, use 0-15 LPM flow meter; for flows less than 3 LPM, use 0-3 LPM flow meter) oximeter with cable and probe appropriate sized nasal prongs or mask see chart below for guidance; : Nasal Prongs Mask Size Age Size Age Infant or intermediate infant 0-2 yrs Pediatric <8 years Pediatric 2-12 yrs Adult >8 years Adult >12 yrs OXYGEN DELIVERY SYSTEMS Low Flow Oxygen Delivery Systems for patients requiring less than 40% inspired oxygen Flow rates: 1/8 Litres per Minute (LPM) to 4 LPM With flows less than 3 LPM use a 0-3 LPM flowmeter. 1. Nasal Cannula/Prongs: Oxygen concentration is dependent on the child s tidal volume, inspiratory flow rate, and degree of mouth breathing. Consider using duoderm under the tube to protect skin and tegaderm or tender grips over the tube to secure it in place. Contraindicated in patients with nasal obstruction. CC.09.10 BC Children s Hospital Child & Youth Health Policy and Procedure Manual Page 1 of 5
NEVER trim nasal prongs. Guidelines for Maximum flowrates by nasal cannula/prongs: less than 15 up to 2 LPM kg 15-30 kg up to 3 LPM above 30 kg up to 4 LPM 2. Simple Oxygen Mask: Flow rates: 6-10 LPM,.. Flow rates must always exceed 6 LPM to avoid rebreathing of carbon dioxide. Use of a simple mask is for emergency management and is not recommended for on-going management If higher flowrates are required to meet prescribed O2 saturations - consult the RT. Can be placed over nasal cannula for sudden respiratory distress. Note: the more distressed the patient is, the greater their inspiratory flow resulting in increased room air entrainment which decreases the amount of oxygen delivered to the patient. 3. Blow-by Oxygen Oxygen delivery via blow-by device should only be used if patient is not able to tolerate nasal prongs or mask. Blow by should never be the first delivery choice for oxygen because it is not very accurate or consistent. A simple mask may be used and propped close to child s face directing oxygen towards mouth and nose. Adjust flow as needed to maintain oxygen saturation as prescribed/required. Note: If the child is active and unable to keep their head still this form of oxygen delivery is ineffective as it will be extremely difficult to keep the delivery devise close to the mouth and/or nose. CC.09.10 BC Children s Hospital Child & Youth Health Policy and Procedure Manual Page 2 of 5
High Flow Oxygen Delivery Systems for patients requiring 40% oxygen or above: A Respiratory Therapist (RT) will provide and set-up these systems. An RT will assess a patient receiving high flow oxygen in the non-critical care areas every shift or more often at the request of the RN. 1. Hi-Ox 80 Oxygen Mask: Enables the delivery of high concentrations of oxygen. Delivers above 80% oxygen at 8 LPM(LPM (ensure flowrate exceeds patient s minute ventilation). No port holes in the mask (ensure flowrate is set to keep the bag 1/3 inflated during inhalation). Limits room air dilution of inspired oxygen. Low resistance one-way valves. Reduces aerosalization of microorganisms reducing the risk of infection among health care workers. 2. Non-Rebreathing Oxygen Mask: Enables the delivery of high concentrations of oxygen Recommended for use in critically ill patients Flowrate of 8 LPM is recommended so the oxygen reservoir bag does not collapse during inspiration (ensure flowrate exceeds patient s minute ventilation) NASAL HIGH FLOW CANNULA: Refer to Policy c.c.09.13 Nasal High Flow Oxygen (jr. optiflow) Initiation, escalation, weaning and discontinuation of high flow will be carried out by the Respiratory Therapist in consultation with the Respirologist in the Emergency Department and with the Intensivist in PICU. PROCEDURE Rationale 1. IDENTIFY patient and EXPLAIN procedure. Failure to correctly identify patients prior to procedures may result in errors. Reduces child and family s anxiety. Evaluates and reinforces understanding of previously taught information and confirms consent for treatment. 2. ATTACH oximeter probe to patient and commence Monitors effectiveness of oxygen therapy on an Oximetry (SpO 2 ) Monitoring. ongoing basis. 3. SET-UP oxygen delivery system: Steps for proper set-up of equipment. a. ATTACH appropriate flow meter to oxygen outlet b. ATTACH oxygen tubing of nasal prongs/ mask to nipple of flowmeter TURN oxygen on to ensure patency and apply nasal cannula/mask to patient c. ADJUST oxygen flow to obtain oxygen CC.09.10 BC Children s Hospital Child & Youth Health Policy and Procedure Manual Page 3 of 5
saturations within acceptable range. 4. MONITOR oxygen saturation continuously via pulse oximeter and document oxygen saturation and oxygen supply levels at least every 4 hours or as ordered or more frequently if patient condition warrants. Change probe site every 4 hours. 5. CHECK the oxygen delivery system from site to source every hour. 6. 7. NOTIFY respiratory therapy and the physician, if the patient: a. requires increasing oxygen flow/concentration to maintain oxygen saturation as ordered b. is in increasing respiratory distress c. has nasal prongs at maximum flow for age d.. DOCUMENTATION Evaluates effectiveness of interventions. To ensure proper functioning of equipment and to evaluate tubing entanglement risk in at-risk patients. Allows early identification and prompt intervention for patient deterioration. DOCUMENT on appropriate record(s): method of oxygen delivery rate and concentration of oxygen vital signs and SpO 2 readings (at least every 4 hours and more often if clinically indicated or ordered) patient s response to treatment patient/family education any other pertinent actions or observations REFERENCES AARC Clinical Practice Guideline. (2002). Oxygen Therapy for Adults in the Acute Care Facility- 2002 Revision and Update. American Association for Respiratory Care. AARC Clinical Practice Guideline. (2002). Selection of an Oxygen Delivery Device for Neonatal and Pediatric Patients - 2002 Revision and Update. American Association for Respiratory Care. AARC Clinical Practice Guideline. (2007). Clinical Practice Guideline: Oxygen Therapy in the Home or Alternate Site Health Care Facility-2007 Revision and Update. Aylott, M. (2006). Observing the sick child: part 2a respiratory assessment. Paediatric Nursing. 18(9): 38-44. Bailey, P. (2008). Oxygen Delivery Systems for Infants and Children. UptoDate, version 17.3. Retrieved from www.uptodate.com. Baren, J.M. and Rothrock, S.G. Pediatric Emergency Medicine. Saunders Elsevier, Philadelphia, PA: 2008. Beattie, S. (2006). Back to basics with O 2 therapy. RN. 69(9): 37-40. Boyle, L. and Nelson, E. (2008). Noninvasive Oxygen Delivery Devices. In Trivets Verger, J. and Lebet, R.M. (Ed), AACN Procedure Manual for Pediatric Acute and Critical Care (pp.46-52). St. Louis, Missouri:Saunders Elsevier. Brown, M. and Swanson, C. (1993). Understanding Children with Chronic Lung Disease. Part II: Respiratory Supports and Treatments. Infants and Young Children. 5(3):57-63. Calianno, C., Clifford, D.W. and Titano, K. (1995). Oxygen Therapy. Nursing, 35(12):33-38. Fuchs, S. Initial assessment and stabilization of children with respiratory or circulatory compromise. Up to Date, Last updated: November 2013. CC.09.10 BC Children s Hospital Child & Youth Health Policy and Procedure Manual Page 4 of 5
Jevon, P. (2007). Respiratory Procedures: Use of a Non-Rebreathing Oxygen Mask. Nursingtimes.net. Pease, P. (2006). Oxygen Administration: is Practice Based on Evidence? Paediatric Nursing, 18(8):14-18. CC.09.10 BC Children s Hospital Child & Youth Health Policy and Procedure Manual Page 5 of 5