Oxygen Therapy Administration In Non Emergency Situations In Acute Paediatrics for Children & Young People

Oxygen Therapy Administration In Non Emergency Situations In Acute Paediatrics for Children & Young People Author: Eirlys Thomas / Janice Price Specialty: Paediatric Services Approved Body: W&CH Quality & Safety Group Approval Date: January 2013 Date for Review: December 2016

Contents Rationale page 3 Oxygen.page 4 Summary of Facts..page 5 Target Oxygen Saturations..page 5 Methods of Administration..page 6, 7 Oxygen Delivery..page 9 Procedure for Administering Oxygen.page 10 Safety page 11 Appendix MHRA Top Tips on Cylinders page 12 References/Reading.page 14 2

Rationale The aim of these guidelines is to present clear instructions in administering oxygen safely within the acute environment of Child Health, in non emergency situations as per NPSA Alert (2009). The target audience is the clinicians who prescribe and administer oxygen safely to children in non emergency situations in the hospital environment. Oxygen Therapy in Non Emergency Care Oxygen is one of the most commonly used medicines, used in a range of health care settings (NPSA 2009). Oxygen therapy can be defined as the administration of oxygen at concentrations greater than ambient air (National Guideline Clearing House 2006). The main principle in the use of oxygen therapy is to decrease the work of breathing by increasing alveolar oxygen tension and is administered in pulmonary and non pulmonary conditions (Coyne et. al. 2010) Excessive use of oxygen has been demonstrated showing insufficient attention to responding to physiological and pharmaceutical principles (Jeffrey et al 1989, Albin et al 1992, Small et al 1992, Kor and Lim 2000, NPSA 2009) Concentrations required are dependent upon the child condition. Inappropriate concentrations can have potentially serious effects for example : pulmonary damage, retinal damage particularly in neonates Mask Respiratory Depression Carbon dioxide retention Post operative patients receiving opiates Some Indications for use of Oxygen Therapy Hypoxia Signs and symptoms of shock Chronic respiratory disease Respiratory failure Dyspnoea Post Operatively Pneumothorax Suspected carbon monoxide poisoning This is not an exhaustive list 3

Oxygen Up to 60% concentration reduces the risk of hyperventilation but high concentration oxygen can have detrimental effects on the respiratory system. This can occur following prolonged use of oxygen therapy and can lead to respiratory distress due to atelectasis. In the premature infant high concentration oxygen can cause retrolental fibroplasia, a side effect due to vasoconstriction and can lead to permanent blindness. To ensure that high concentration oxygen is safely administered in the right concentration: There is an ABM Patient Group Directive for the emergency administration of oxygen where there is hypoxia in a seriously ill child Oxygen therapy will be adjusted (through medical instructions) according to the child/young person s respiratory effort and oxygen saturations. Low concentration of oxygen is used to correct hypoxia by using an accurate amount of oxygen without depleting maintenance of carbondioxide and respiratory acidosis Arterial blood gases can be undertaken to measure precise concentration of oxygen required for children in emergency situations. It is expected that medical staff will prescribe oxygen for children who are acutely and chronically unwell in non emergency situations (BTS 2009, NPSA 2009). If there is an oxygen prescription, a target oxygen saturation range should be indicated on the chart and medical notes (NPSA 2009) Safety rounds should be undertaken by the allocated/named Registrant, when undertaking vital signs of the patient to check the correct delivery of oxygen and the appropriate oxygen saturation range is obtained Document amount of oxygen given in the nursing records, include as a part of the plan of care and evaluate outcome. Oxygen equipment is checked daily and at the start of every shift, check lists completed at every shift by the nurse. 4

Place an appropriate sized saturation probe around/on the child s finger, ear lobe or toe. The site chosen should be warm and well perfused with good capillary refill. Summary of Facts Regarding Oxygen Therapy (taken from BTS Guidelines for Home Oxygen in Children). Oximeters from different manufacturers may give different oxygen saturations The median baseline saturation in healthy term infants during the first year of life is 97-98% In only 5% of healthy infants is the arterial oxygen saturation measured by pulse oximetry less than 90% for more than 4% of the time. The median baseline SPO2 in healthy children aged 1 year or more is 98% with a 5 th centile 0f 96%-97% A healthy child aged 5-11 years spend no more than 5% of the time below a SpO2 of 94% while asleep BTS August 2009 Target Oxygen Saturations for Children/young people Oxygen saturations greater than 92% for infants/ children and young people unless otherwise indicated by the paediatrician For children suffering from heart conditions target oxygen saturations will be determine individually by the condition and will be documented by the paediatrician on the prescription chart and the notes Oxygen saturation monitoring depends on right placement and application of the probe. The Provision of Long Term Oxygen Therapy for Patients with Chronic Hypoxaemia. (LTOT) Guidance for LTOT according to BTS Guidance (2009) Long term oxygen therapy is defined as the provision of oxygen for continuous use at home for patients with chronic hypoxaemia in order to maintain target oxygen saturations. 5

Requirements vary between 24-hour dependency and dependency during periods of sleep. Principally aims to improve symptoms and prevent harm from chronic hypoxaemia. Indications for long term oxygen therapy: chronic lung disease neonatal lung conditions congenital heart disease with pulmonary hypertension pulmonary hypertension secondary to respiratory disease intra pulmonary shunting interstitial lung disease Obliterative bronchiolitis cystic fibrosis and other causes of severe bronchiectasis Chronic hypoventilation Sickle cell disease obstructive sleep apnoea and other sleep related disorders palliative care for symptom relief Child /Young Person and Families Age appropriate verbal information must be given to the child/young person. Family members must be adequately informed of the following information: need for oxygen therapy rationale and explanation for method of delivery positive/expected benefits of treatment possible side effects of treatment minimum duration of treatment Baseline Assessment A full set of baseline observations should always be obtained and be documented appropriately on relevant documents. Method of Administration The oxygen requirement and potential for tolerability of the child, delivery methods must be decided and potential methods of delivery. The selection of an appropriate oxygen delivery system must take into account clinical condition, the patient's size, needs and therapeutic goals high concentration oxygen is usually delivered via incubator or humidified head box nasal cannula face masks re-breathe mask humidified oxygen wafting 6

nebulisation tracheostomy ventilation circuit Face mask Supplied in child sizes, but has been found that children do not always tolerate masks. Ensure the mask covers both nose and mouth, tighten elastic to ensure a good fit. Types of face masks dependant on the condition of the child. Simple oxygen mask (variable flow masks) Vents in the mask allow for the dilution of oxygen. This is the most commonly used mask. High Concentration oxygen masks Used for emergency situations with reservoir that allows oxygen only to be breathed in by the child. This prevents the inhalation of mixed gases. The approximate oxygen received is 99 per cent Humidified This can be delivered via a face mask or head box, dependent upon child age/co-operation. Humidified oxygen should be utilised when oxygen therapy is required for prolonged periods, and in those with chronic respiratory illness, to prevent drying of the mucosa and secretions Humidified oxygen should be only administered when the flow of oxygen exceeds 4 litres per minute and via a face mask (as per NPSA 2009 Guidance and consultation with medical staff) Wafting When conventional delivery methods are not tolerated, wafting of oxygen via a face mask has been shown to deliver concentrations of 30-40 per cent with 10 litres oxygen per minute, to an area of 35x32cm from top of the mask. Wafting is only appropriate for short term use only, ie whilst feeding. A standard paediatric oxygen mask placed on the chest can give significant oxygen therapy with minimal distress to the patient Via nebulisation If the child is oxygen dependant the nebuliser is delivered via oxygen Tracheostomy Oxygen can be delivered via a tracheostomy mask, Swedish nose or headbox. Consider child s individual needs. 7

Nasal cannula Can be used for long-term oxygen use, whilst allowing the child to vocalise and eat. The concentration is often not controlled, resulting in a low inspiratory oxygen concentration. The cannula must always be used as described on the packaging. The use of nasal cannulae can, in the sensitive child, produce dermatitis and mucosal drying Only low flow rates of up to two litres per minute can be given comfortably due to inadequate humidification. Nasal cannula oxygen does not need to be humidified. Via a ventilation circuit Accurate measurement of inspired oxygen is difficult. The work of breathing/respiratory effort, and pulse oximetry must be observed and documented. Can be delivered at various points throughout the ventilation circuit. Bag valve mask Comes in three sizes: 250mls, 500mls and 1,500mls. The smallest one is ineffective even at birth. Two smallest bags have a pressure limiting valve set at 4.41kPa (45cm H 2 0) to protect the lungs from barotrauma (damage caused to tissues by a change in pressure inside and outside the body). 8

Oxygen Delivery Selection of the most appropriate method of administration Method Concentration Comments Flow below four litres could Simple oxygen mask High concentrations can potentially result in carbon be delivered safely dioxide retention. High concentration oxygen masks 10-15 litres required For use in emergency situations. Nasal cannula oxygen should not be humidified. Humidified 26-65 per cent Fi0 2 Prolonged periods of high percentage oxygen should be humidified 30-40 per cent with 10 Wafting Conventional methods of litres oxygen per minute oxygen delivery recommended if tolerated Assessment to identify deterioration of the child and this would include: Change in colour Level of consciousness Respiratory rate Use of accessory muscles Presence of sounds such as wheeze, stridor, grunting Nasal flaring, tracheal tug, insuction, recession Capillary refill time Agitation/confusion 9

Procedure for Administering Oxygen Ensure adequate and working oxygen supply. If wall valve supply being utilised, then working order must be established first). If portable oxygen cylinders being used, these should enable adequate oxygen provision Litres in cylinders/litres needed per minute = minutes of oxygen available Calculate Oxygen requirements for journey Ie. Flow (1/min) x 60 x journey time in hours x 2 or Minute volume x 60 x journey time in hours x 2 Lightweight CD cylinders = 460L Other cylinders available D cylinders= 340L E cylinders= 680L F cylinders= 1360L All valves on portable oxygen cylinders must be open. Refer to the patient's individual prescription. Give the oxygen via the approved, or tolerated, method for the patient. Tubing from chosen methods of delivery to be attached to oxygen supply device. Administration device set up to enable effective administration as per manufacturer's instructions. Initiate and maintain oxygen flow rate and concentration. Oxygen should be delivered at the lowest concentration possible and for the shortest possible time. Assess whether the delivery system requires humidification. Monitor the child s vital signs, level of consciousness and responsiveness during the administration of oxygen. Monitor the child s colour, respiratory rate and depth and for signs of respiratory distress. Determine the reason for the oxygen requirements. Flow meters Oxygen flow meters to deliver oxygen from the outlet are designed for high flow, (up to 15 litres) low flow (up to 1 litre). Each bed space that is available for occupancy should have an oxygen high flow meter. The flow meter will be changed (to low flow) according to the needs of the infant/child/ young person. 10

Safety Check and clean each oxygen outlet, oxygen cylinder and delivery system daily to ensure good working order. (Those in patient use) Check each oxygen outlet, following the discharge of the patient, clean the oxygen equipment (as per Infection control policy) and replace used oxygen equipment for delivery such as tubing, mask. Document that each oxygen outlet and delivery system is clean and checked Oxygen should not be delivered near a naked flame. Lubricating jells and paraffin should not be used on the lips or face of the patient or on the equipment Check oxygen cylinders prior to use to ensure sufficient oxygen is available for a journey/transfer see table Ensure that the air outlet is clearly labelled. Use top tips in cylinder care (April 2008) see appendix 1 If any aspect of the guidance is not followed, complete a risk assessment and escalate immediately 11

Appendix 1 Top tips on care and handling of Oxygen cylinders and their regulators MHRA Staff should be fully trained in the use of oxygen cylinders, the attachment of regulators if required, and aware of all the related risks such as fire and manual handling. Carry out full checks on oxygen cylinders and their regulators prior to each use and ensure that they contain enough oxygen for the required therapy. In patient transfers ensure there is sufficient oxygen for the whole journey, allowing for changes in oxygen requirements and delays such as faulty lifts or heavy traffic. Check the cylinder labels to make sure the oxygen is within its use-by date and any regulators attached are suitable for the cylinder pressure and have been serviced regularly. Ensure hands are clean before handling oxygen cylinders due to the risk of combustion from oils and grease. In particular, make sure that hands are adequately dried after the use of alcohol gels. Make sure that the oxygen cylinder outlet and oxygen regulator inlet are clean before attaching a regulator. Always open the cylinder slowly and check for leaks. Close cylinder valves when not in use and before returning the cylinder to the supplier. Handle oxygen cylinders with care. If the cylinder is dropped or knocked in use it must be checked before further use; cylinders with integral valves should be returned to the supplier; separate regulators should be sent to the service department for inspection. Have spare cylinders available, ensure they are full and have an opening key if required. Ensure oxygen cylinders are securely attached to beds, trolleys or walls when in use. Modern light-weight oxygen cylinders can be damaged by sharp objects such as securing screws. 12

Store oxygen cylinders in a secure area that is well ventilated, clean and dry. This area must be free from any sources of ignition such as patients/staff smoking or machinery. If using a bull-nose regulator, double-check you are attaching it to an oxygen cylinder as they can be mistakenly fitted onto cylinders of medical air and other gases. Carry out magnetic testing of all oxygen cylinders, and their attachments, before taking them into an MRI environment. Report defective oxygen cylinders to the Defective Medicines Reporting Centre (DMRC) and defective detachable regulators to the Adverse Incident Centre (AIC), both at the MHRA (www.mhra.gov.uk). April 2008 13

References and Reading Ashurst S (1995) Oxygen therapy. Br J Nurs 4 (9): 508-15. Albin RJ, Criner GJ, Thomas S, Abou-Jaoude S (1992) Pattern of non-icu inpatient supplemental oxygen utilization in a university hospital. Chest Balfour-Lynn IM, Primhak RA, Shaw BN (2005) Home oxygen for children: who, how and when?thorax 60 (1): 76-81. Balfour-Lynn IM, Primhak RA, Shaw BNJ (2005) Clinical Component for the Domiciliary Oxygen Service for Children in England and Wales. www.evidence.nhs.u 7: Bell C (1995) Is this what the doctor ordered? Accuracy of oxygen therapy prescribed and delivered in hospital. Prof Nurse 10 (5): 297-300. Chandler T (2001) Oxygen Administration. www.perinatal.nhs.uk. Viewed on: 21/06/2006 102 (6): 1672-5. Duck A (2009) Does oxygen need humidification. www.nursingtimes.net. Davies P, Cheng D, Fox A, Lee L (2002) The efficacy of noncontact oxygen delivery methods. Pediatrics 110 (5): 964-7. Dinesh AB, Mehta DK (Ed.) (1996) British National Formulary. London, British Medical Association Dinwiddie R (1997) Diagnosis and management of Paediatric Respiratory Disease. London, Churchill Livingstone Downs JB (2003) Has oxygen administration delayed appropriate respiratory care? Fallacies regarding oxygen therapy. Respir Care 48 (6): 611-20. Fulmer JD, Snider GL (1984) American College of Chest Physicians/National Heart, Lung, and Blood Institute National Conference on Oxygen Therapy. Heart Lung 13 (5): 550-62. Great Ormond Street hospital for Children NHS Foundation Trust (2012) Oxygen Therapy Administration in an Non Emergency Situation. London. Great Ormond Street. Gravil JH, O'Neill VJ, Stevenson RD (1997) Audit of oxygen therapy. Int J Clin Pract 51 (4): 217-8. Jamieson E, McCall JM, Whyte LA (1999) Clinical Nursing Practices. London, Churchill Livingstone Jefferies A, Turley A (1999) Respiratory System. London, Mosby 14

Jeffrey AA, Ray S, Douglas NJ (1989) Accuracy of inpatient oxygen administration. Thorax 44 (12): 1036-7. Joint Formulary Committee (2006) British National Formulary. London, British Medical Association and Royal Pharmaceutical Society of Great Britain Kbar FA, Campbell IA (2006) Oxygen therapy in hospitalized patients: the impact of local guidelines. J Eval Clin Pract 12 (1): 31-6. Kor AC, Lim TK (2000) Audit of oxygen therapy in acute general medical wards following an educational programme. Ann Acad Med Singapore 29 (2): 177-81. Mallet J, Bailey C (1996) The Royal Marsden NHS Trust Manual of Clinical Nursing Procedures (4th Ed). London, Blackwell Science Moules T, Ramsey J (1998) The Textbook of Children's Nursing. Cheltenham, Stanley Thornes Myers TR, American Association for Respiratory Care (AARC) (2002) AARC Clinical Practice Guideline: selection of an oxygen delivery device for neonatal and pediatric patients--2002 revision & update. Respir Care 47 (6): 707-16. National Patient Safety Agency (2010) Making Oxygen use Safer in Hospital. Nursing Times vol 106. no 19. www.nursingtimes.net National Patient Safety Agency (2009) Oxygen Safety in Hospitals Rapid Response Report NPSA/2009/RRR006. National Guideline Clearinghouse (2006) Complete Summary: Oxygen therapy for adults in an acute care facility: 2002 revision and update. www.guidelines.gov. Viewed on: 15/5/2008 Primhak RA (2003) Discharge and aftercare in chronic lung disease of the newborn. Semin Neonatol 8 (2): 117-26. Royal Pharmaceutical Society of Great Britain (2005) British National Formulary for Children. London, BNJ Publishing House Ltd Simonds AK (2007) Non-invasive Respiratory Support. London, Hodder Arnold Small D, Duha A, Wieskopf B, Dajczman E, Laporta D, Kreisman H, Wolkove N, Frank H (1992) Uses and misuses of oxygen in hospitalized patients. Am J Med 92 (6): 591-5. Tucker SM, Canobbia MM, Paquette EV, Wells MF (1992) Patient Care Standards 15

Directorate of Women & Child Health Checklist for Clinical Guidelines being Submitted for Approval by Quality & Safety Group Title of Guideline: Name(s) of Author: Chair of Group or Committee supporting submission: Oxygen Therapy Administration in Non emergency Situations in Hospital Sharon Littlehales, Rachel Evans Sian Passey/Eirlys Thomas/Rachel Evans Issue / Version No: 1 Next Review / Guideline Expiry: 2014 Details of persons included in consultation process: Lead Nurses, Ward Mangers, CNS, Consultant Paediatricians on both sites Brief outline giving reasons for document being submitted for ratification To have a document with clear guidance for oxygen therapy in non emergency situation as per NPSA guidance. Name of Pharmacist (mandatory if drugs involved): Please list any policies/guidelines this document will supercede: None None Keywords linked to document: Oxygen therapy Date approved by Directorate Quality & Safety Group: File Name: Used to locate where file is stores on hard drive 23 rd January 2013 ABM_W&CH_mgt\Clinical Governance\Policies & Procedures etc - Ratified\Paediatrics * To be completed by Author and submitted with document for ratification to Clinical Governance Facilitator 16