B. A clinical emergency exists in which a profound hypoxia is determined to be present.

I. Subject: Oxyhood-Oxygen Therapy for Neonates II. Policy: Oxygen therapy by oxyhood shall be initiated upon a physician's order by nurses and Respiratory Therapy personnel trained in the principles of oxygen administration. Oxygen therapy may be initiated by nursing personnel or Respiratory Therapy personnel pending a specific order by a physician in the following situations: A. Oxygen administration is included in an approved written treatment protocol, or B. A clinical emergency exists in which a profound hypoxia is determined to be present. III. Indications: Hypoxemia- A. Documented hypoxemia- 1) PaO2 less than 60 mmhg and/or SpO2 less than90% or capillary oxygen tension (PaO2) < 40 mmhg B. An acute situation in which hypoxemia is suspected C. Disease states in which hypoxemia may accompany include: 1) Transient tachypnea of newborn 2) Meconium aspiration 3) Persistent fetal circulation or persistent pulmonary hypertension 4) Respiratory distress syndrome of the newborn (hyaline membrane disease) 5) Pneumonia 6) Bronchopulmonary dysplasia (BPD) 7) Congenital heart defects 8) Lung hypoplasia 1

IV. Contraindications: There are no specific contraindications for oxygen administration when indications are judged to be present. V. Rationale: Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air with the intent of treating or preventing the symptoms and manifestations of hypoxia. The direct effect of breathing increased oxygen concentration is to increase alveolar oxygen tensions, thus increasing the pressure gradient for oxygen diffusion into the blood system. These increased alveolar oxygen concentrations may result in less pulmonary work needed to maintain a given alveolar oxygen tension and/or less myocardial work. Oxygen can be administered by oxyhood in concentrations up to 100%. The specific concentration prescribed depends on the patient's condition and the therapeutic goal. Administration of oxygen by oxyhood is a high flow system which provides the entire gas flow inspired by the patient. The flow rate must be great enough to exceed the patient's minute ventilation requirements and clear the neonate's expired gas from the enclosure. Oxygen therapy by oxyhood utilizes an oxygen blender for precise control of FIO2. The system also provides heated humidification by use of a large volume nebulizer. Care must be taken to prevent over-cooling of the neonate and over-hydration. VI. Materials: Oxygen blender with flowmeter Large volume nebulizer prefilled with sterile water Aerosol tubing Drain bag Heater Thermometer Oxyhood Adaptor for bleed in of additional oxygen and oxygen supply tubing (optional) Oxygen analyzer 2

VII. Procedure: A. Check order- Verify the physician's order as follows: 1) Compare the requisition with the physician's order to ensure that no discrepancies exist. 2) Review the order to ensure that the oxygen concentration is prescribed. 3) If any part of the order is unfamiliar, question its accuracy. B. Confirm patient- Check armband for correct name and birthdate. C. Review chart- Based on the patient data, identify the following: 1) Conditions that indicate the need for oxygen therapy 2) Potential hazards of oxygen for the patient D. Maintain cleanliness- While performing the remainder of this procedure, it is expected that clean conditions will be maintained. E. Obtain equipment- Collect the equipment and supplies listed in Section VI. Select the appropriate size oxyhood. F. Assemble equipment- Prepare equipment for use as follows: 1) Place the heater collar on the large volume, prefilled nebulizer and attach the nebulizer to the blender flowmeter. 2) Set the oxygen percentage on the nebulizer to 21% or that prescribed by physician order. 3) Connect adequate lengths of large bore aerosol tubing to the nebulizer, place the drain bag in line at the lowest point, and connect the distal end to the oxyhood. 4) Connect the blender gas supply hoses to the oxygen and air source gases. G. Test Equipment- 1) Turn on the oxygen blender flowmeter to a flowrate of 6-10 L/min and verify the presence of aerosol into the oxyhood. 3

H. Implement procedure- 1) Set the prescribed oxygen concentration on the oxygen blender. 2) Turn on the flowmeter to the range of 6-10 L/min. Adjust heater to 5-6 on the temperature control dial. 3) Carefully place the hood over the infant's head. 4) Place a previously calibrated oxygen analyzer probe inside the oxyhood and continuously monitor the FIO2. Make any adjustments to the blender settings as needed to achieve desired outcome. 5) Place temperature probe on oxyhood and maintain environment at 37 degrees C. Adjust heated control dial on the nebulizer heater as necessary. 6) Assess patient for appropriate clinical signs which indicate adequate oxygenation. I. Record results- Document each shift the therapy as follows: 1) Record the following data on the patient's chart: a. Date/Time b. Oxyhood device in use. Indicate the gas flow rate and FIO2. c. Oxyhood environment temperature d. Any complications, abnormal patient conditions, and observations of patient's condition. VIII. Special Considerations: A. Administration of additional oxygen flow may be necessary to achieve very high (greater than90%) oxygen concentrations. This may be accomplished by adding an adaptor connected at the inlet part of the oxyhood and connecting this to a flowmeter by oxygen supply tubing. The flowmeter is turned on and flowrate adjusted until the desired FIO2 is achieved. Precautions must be taken to avoid cooling of neonate, or inadequate humidification. B. Retinopathy of prematurity may occur with exposure of premature infants with immature retinal vasculature to PaO2 levels greater than 80 mmhg and durations as short as six (6) hours. 4

C. In all cases, the minimum FIO2 should be employed to assure adequate oxygenation. IX. Hazards/Complications: A. Oxygen toxicity- 1) In general, the lowest FIO2 should be used that achieves an acceptable PaO2, and the oxygenation status of the infant monitored closely. B. Absorption atelectasis C. Retinopathy of prematurity 1) In premature infants PaO2 >80 mmhg should be avoided D. Increased PaO2 can contribute to closure or constriction of the ductus arteriosus which is a possible concern in infants with ductus dependent heart lesions. E. Excessive cooling of infant F. Over-Hydration G. BPD H. Fire Hazard 5