Version 10 From: Feb 2022 – To: Feb 2025 Author(s) Nurse Practice Group Page 1 of 14

SETTING Bristol Royal Hospital for Children

FOR STAFF Registered Nurses/Practitioners and Non-Registered Nurses/Practitioners under direct supervision of a Registered Practitioner

PATIENTS Paediatric inpatients and Emergency Department

_____________________________________________________________________________ Purpose of the Guidance Administering Acute Oxygen Therapy Correct Oxygen Administration Quick Reference Guide for Choosing Correct Oxygen Administration Equipment Used in the Delivery of Oxygen - Nasal Cannula - Simple Face Mask (Variable Flow) - Reservoir Mask (Non-Breathe Mask) - Hudson Humidification System - Bucket Mask - Head box Oxygen - Related Documents

Clinical Guideline

PAEDIATRIC OXYGEN THERAPY

Version 10 From: Feb 2022 – To: Feb 2025 Author(s) Nurse Practice Group Page 2 of 14

PURPOSE OF THE GUIDANCE Following careful assessment, administering supplementary oxygen may be seen as appropriate management. Oxygen therapy should therefore be considered for any child with one or more of the following

• Hypoxia – oxygen saturations ≤92% • Acute and chronic hypoxemia (PaO2 <10 kPa, SaO2 ≤92%) • Signs and symptoms of shock • Low cardiac output and metabolic acidosis (HCO3 <18mmol/l) • Cardiac or respiratory arrest • Chronic type 2 respiratory failure (hypoxia and hypercapnia) • Postoperatively depending upon instruction from the surgical team • Treatment of pneumothorax • Dyspnea (shortness of breath) without hypoxaemia • Children with cyanotic congenital heart disease – advice should be sought from

cardiologists Oxygen is a drug and therefore must be prescribed on the drug administration chart in all but emergency situations:

• In a life threatening situation 100% oxygen may be given; The Advanced Life Support Group (2016) states that in any emergency situation high flow oxygen should be applied to the child via a non rebreathe mask as long as the airway is patent.

• The amount of oxygen prescribed depends on the circumstances or is in response to careful monitoring of blood gas levels/target saturations

There are potential risks related to the administration of oxygen and therefore only the lowest amount of oxygen should be given for the shortest period of time to maintain required oxygen levels. Possible complications of too high a concentration include,

• Permanent lung damage caused by pulmonary oxygen toxicity due to lengthy exposure to high levels of oxygen.

• Potentially in children with chronic lung disease if they are dependent on hypoxic rather than hypercarbic drive. This could lead to respiratory failure.

The method used to deliver oxygen to the child will depend on the age and condition of the child and the FiO2 level required. The initial assessment of the need for oxygen is based on an ABCDE approach.

Version 10 From: Feb 2022 – To: Feb 2025 Author(s) Nurse Practice Group Page 3 of 14

ADMINISTERING ACUTE OXYGEN THERAPY ACTION RATIONALE The type of delivery system used will depend on the needs and comfort of the child.

To provide accurate oxygen delivery.

Ensure oxygen is prescribed. Oxygen should be regarded as a drug and should be prescribed British Thoracic Society National guidelines (2017) and British National Formulary Children (2019). The exception to this action would be during an emergency situation where the resuscitation guideline should be followed.

Ensure that the oxygen concentration is clearly indicated. If nasal cannula or reservoir masks are being used check that the flow rate is clearly indicated on the prescription and observation chart.

In accordance with the administration of medicines policy. Certain groups of children may require different target ranges for their oxygen saturation. For example

- Some children with cardiac conditions - Some chronic respiratory conditions

Inform child/carer of the combustibility of oxygen.

Oxygen supports combustion therefore there is always a danger of fire when oxygen is being used.

Show and explain the oxygen delivery system to the child or parent/carer.

To obtain consent and cooperation.

Assemble the oxygen delivery system carefully.

To ensure oxygen is administered correctly.

Attach oxygen delivery system to oxygen source.

To ensure oxygen supply is ready.

Attach oxygen delivery system to child according to manufacturer’s instructions.

For oxygen to be administered to patient.

Turn on oxygen flow in accordance with prescription and manufacturers instruction.

To administer correct amount of oxygen.

Ensure child has access to either a drink (if appropriate) or mouthwash if nil by mouth.

To prevent drying of the oral mucosa.

Assess and record observations: Heart rate, respirations, oxygen saturations, temperature, capillary refill time at least hourly or as condition dictates. Assess work of breathing. Blood pressure if condition dictates. Identify appropriate physiological parameters with medical team and document on observation chart. Children with a chronic oxygen requirement that is unchanged may have observations recorded less frequently but the rationale must be recorded on the PEWs chart.

To identify if oxygen therapy is maintaining the target saturation or if an increase or decrease in oxygen therapy is required. Calculate Paediatric Early Warning Score (PEWS) and action as per the escalation guidance on the observation chart

The oxygen delivery device and oxygen flow rate should be recorded alongside the oxygen saturation on the observation chart.

To provide an accurate record and allow trends in oxygen therapy and saturation levels to be identified.

Version 10 From: Feb 2022 – To: Feb 2025 Author(s) Nurse Practice Group Page 4 of 14

Saturation higher than target specified or >98% for an extended period of time.

Step down oxygen therapy as per guidance for delivery.

The child will require weaning down from current oxygen delivery system.

Consider discontinuation of oxygen therapy. The child’s clinical condition may have improved negating the need for supplementary oxygen.

Saturation lower than target specified Check all elements of oxygen delivery system for faults or errors.

Equipment faults should be checked for.

Any sudden fall in oxygen saturation should lead to clinical review.

To assess the child’s clinical status.

Saturation within target specified Continue with oxygen therapy, and monitor to ensure oxygen is weaned in a timely manner.

A change in delivery device (without an increase in O2 therapy) does not require review by the medical team.

The change may be made in stable patients due to the child’s preference or comfort.

Ongoing safety checks Each shift the following checks must be performed and documented:

- Set alarm limits on the saturation monitor

If patient is receiving continuous oxygen a secondary source of oxygen must be available for emergency use. This may be via a double oxygen point or a portable oxygen cylinder which must be stored safely by the bedside.

Version 10 From: Feb 2022 – To: Feb 2025 Author(s) Nurse Practice Group Page 5 of 14

QUICK REFERENCE GUIDE FOR CHOOSING CORRECT OXYGEN ADMINSTRATION to be used in conjunction with the Oxygen guideline Method Nasal

cannula Face mask Simple

Non Rebreathe mask Reservoir bag

Head Box Humidified Oxygen Bucket mask

Minimum flow 0.5 Litre 4 Litres 10 Litres 5 Litres Flow 5 Litres Flow

28% Maximum flow 2 Litres 15 Litres 15 Litres 15 Litres

flow 15 Litres flow

Duration As long as required

Up to one hour if needed for longer need to convert to humidified oxygen

Up to one hour if needed for longer need to convert to humidified oxygen

As long as required

As long as required

Sizes available

Two sizes available – Paediatric and Adult

Child and adult Child and adult

Three sizes available – up to 9 months

Child and adult mask plus bucket mask

% Oxygen delivered

25 – 30% 35 – 50% >95% 30 – 60% 30 – 60%

EQUIPMENT USED IN THE DELIVERY OF OXYGEN • Oxygen source (piped or cylinder) • Flow meter • Saturation monitor • Oxygen delivery system

Version 10 From: Feb 2022 – To: Feb 2025 Author(s) Nurse Practice Group Page 6 of 14

NASAL CANNULA

DESCRIPTION Nasal cannulae consist of a pair of tubes about 1 -1.5cm long, each projecting into the nostril and stemming from a tube which passes over the ears and which is thus self-retaining. Flow rate: up to 2 litres/min. PURPOSE To administer oxygen. They have the advantage of not interfering with feeding and are not as inconvenient as masks during coughing and sneezing. ACTION Position the tips of the cannula in the patient’s nose so that the tips do not extend more than 1cm into the nose. Place tubing over the ears and under the chin. Educate patient re: prevention of pressure areas on the back of the ear. RATIONALE To allow optimum comfort for the patient. To prevent pressure sores. Set the flow rate to achieve the desired target oxygen saturation. Increased flows will cause damage to the nasal mucosa.

Version 10 From: Feb 2022 – To: Feb 2025 Author(s) Nurse Practice Group Page 7 of 14

SIMPLE FACE MASK (VARIABLE FLOW)

Variable Percentage (Delivers unpredictable concentrations that vary with flow rate). DESCRIPTION Mask has a soft plastic face piece, vent holes are provided to allow air to escape. Minimum 4 litres/min Maximum 15 litres/min (max 50-60% oxygen on higher flows). PURPOSE The oxygen concentration delivered will be influenced by:

a. the oxygen flow rate (litres per minute used) b. leakage between the mask and face; the patient’s tidal volume and breathing rate.

ACTION If using simple face mask gently place mask over the patient’s face, position the strap behind the head or the loops over the ears then carefully pull both ends through the front of the mask until secure. Check that strap is not across ears and if necessary insert padding between the strap and head. Adjust the oxygen flow rate. RATIONALE Ensure a comfortable fit and delivery of prescribed oxygen is maintained. To prevent irritation.

Version 10 From: Feb 2022 – To: Feb 2025 Author(s) Nurse Practice Group Page 8 of 14

RESERVOIR MASK (NON-BREATHE MASK)

DESCRIPTION The mask has a soft plastic face piece with flap-valve exhalation ports which may be removed for emergency air-intake. There is also a one-way valve between the face mask and reservoir bag. PURPOSE In non re-breathing systems the oxygen may be stored in the reservoir bag during exhalation by means of a one-way valve. With a fitted mask high concentrations of oxygen 80-90% can be achieved at relatively low flow rates. Oxygen flows directly into the mask during inspiration and into the reservoir bag during exhalation. All exhaled air is vented through a port in the mask and a one-way valve between the bag and mask, which prevents re-breathing of CO2.

ACTION Ensure the reservoir bag is inflated before placing mask on patient, this can be maintained by using 10-15 litres of oxygen per min. Adjust the oxygen flow to the prescribed rate. RATIONALE To ensure the optimal flow of oxygen to the patient. Inadequate flow rates may result in administration of inadequate oxygen concentration to the patient. BRHC EMERGENCY DEPARTMENT If the child’s condition improves quickly and prompt weaning of oxygen delivery is possible. i.e. humidified oxygen is not required and reduced oxygen % is possible, it is acceptable to use oxygen flows of between 4 -10 litres/min with a non rebreathe mask instead of changing to a simple face mask for the weaning process.

Version 10 From: Feb 2022 – To: Feb 2025 Author(s) Nurse Practice Group Page 9 of 14

BUCKET MASK

Variable Percentage (Delivers unpredictable concentrations that vary with flow rate). DESCRIPTION A plastic mask that sits loosely over the child’s mouth and nose. Humidified oxygen can be achieved by connecting the mask to the MR810 humidifier. PURPOSE Useful for children over the age of one. Concentrations of 40 – 60% oxygen may be achieved. ACTION Adjust the oxygen flow to the prescribed rate. Use 810Humidifier (see below). Use blue indicators on flow meter up to 50% and red indicator for 60%. RATIONALE To ensure the optimal flow of oxygen to the patient.

Version 10 From: Feb 2022 – To: Feb 2025 Author(s) Nurse Practice Group Page 10 of 14

MR810 HUMIDIFIER High flow oxygen administered for more than 1 hour must be humidified. This helps to prevent drying of the nasal /oral mucosa and secretions.

NOTES If administering oxygen via the MR810 humidifier: • Set the temperature to full (all three bars lit); • Ensure that water bag is not empty and that the water is in the chamber; • Always turn off the heater first before turning off the oxygen supply.

HEADBOX OXYGEN DESCRIPTION Boxes come in three sizes and can be useful in infants up until approximately nine months of age. Humidified oxygen can be delivered up to a maximum of 50 -60 % LIST OF ITEMS NEEDED

Setting Up Head box: 1. Head box 2. Oxygen analyzer 3. Bag of sterile water for ventilation 4. RT408 Breathing Circuit pack 5. MR810 Humidifier mounted on pole 6. Oxygen Connector Tubing with connectors 7. Double oxygen point

*if double point not available, second source of oxygen must be available at bed side, i.e. a portable cylinder, this must be at least two thirds full.

STORAGE Head boxes are stored in the Medical Equipment Library (Penguin Ward), on Caterpillar Ward and in the Emergency Department.

Analysers are stored in the Medical Equipment library and on Caterpillar Ward.

All other supplies are held by the wards. The MR810 Humidifier units tend to be spread around the wards and additional units are kept in equipment library. All wards should have some double oxygen points.

Version 10 From: Feb 2022 – To: Feb 2025 Author(s) Nurse Practice Group Page 11 of 14

SETTING UP 1.

Slide water chamber into MR810 humidifier

2.

Attach bag of sterile water for inhalation via prong and hang from stand.

3.

Place clear oxygen tubing on top of grey flowmeter, and connect to wall oxygen. Adjust flow between 5 and 15 litre 30 – 50% oxygen using the dial

4.

Attach Blue tubing with integral heater wire to the left side of the chamber and pointed to back of dome. Connect grey electric heater wire (as shown).

5.

Connect the tubing from the humidifier to the circular hole in the head box (usually on the back or the side of the head box) and secure with adaptor.

6.

Turn Humidifier on and set temperature to full, (i.e. ensure three lights are lit), if not on full, to increase temperature press temperature button until all three lights lit. • Turn the oxygen on to 5litre = 30% – 10litres= 40% 15litre = 50%. Escalate treatment if child

is needing >50% headbox oxygen. • Turn the flow meter on the chamber to desired % level using the red indicator

Version 10 From: Feb 2022 – To: Feb 2025 Author(s) Nurse Practice Group Page 12 of 14

• Regularly check the water bag is not empty and that the water is running 7.

• An oxygen analser must be used to accurately record the level of oxygen the patient is receiving.

• The oxygen analyser must be calibrated with the sensor in room air before each use and 8 hourly thereafter.

• To calibrate, switch the machine on by the I/O button. If the screen is flashing, the machine is unlocked. If it is not flashing, you will need to press the Lock/Unlock button.

• Press ‘CAL’, the machine will then count from 9 to 1 and should then read approximately 21%. If it does not, repeat calibration.

• If the screen is still flashing, you will need to press the lock/unlock button to lock in the calibration.

• Position oxygen analyser outside the head box with the sensor inside The machine will then give you an the accurate reading of the amount of oxygen present in the head box. This is known as the fraction of inspired oxygen (Fi02) reading, this should be recorded hourly on the observation chart.

• This reading is what you should be guided by as this is the actual level of oxygen your patient is receiving, not necessarily what you have set on the mixer on the humidification unit.

8.

Always ensure the oxygen analyser sensor is close to the patients face to ensure accuracy of your readings in relation to your patient. Setting alarm limits on the oxygen analyser may be useful to ensure your patient is receiving enough oxygen. • To set an upper limit: Unlock the analyser

by pressing the lock/unlock button, and select the HI button. The lower right number will flash, you can then use the arrows to select a limit. Press the

Version 10 From: Feb 2022 – To: Feb 2025 Author(s) Nurse Practice Group Page 13 of 14

lock/unlock button to confirm the alarm limit.

• To set a lower limit: Unlock the analyser by pressing the lock/unlock button, and select the Lo button. The lower left number will flash, you can then use the arrows to select a limit. Press the lock/unlock button to confirm the alarm limit.

If the analyser reads outside of this range set, the machine will alarm.

9.

Tilting the cot may facilitate therapeutic positioning of the patient. Always ensure the head box is secure and not slipping down the cot. A rolled up towel blanket underneath your patients legs/bottom can also prevent them from slipping down the cot.

Version 10 From: Feb 2022 – To: Feb 2025 Author(s) Nurse Practice Group Page 14 of 14

Table A REFERENCES Advanced Paediatric Life Support Group (2016) A Practical Approach to

Emergencies. Sixth edition. Wiley Blackwell. British National Formulary for Children 2019 British Thoracic Society (2017) Guidelines for Oxygen use in Adults in Healthcare and Emergency Settings. Thorax International Journal of Respiratory Medicine; 72: 1 -90 Jatana S, Dhingra S, Nair M, Gupta, G (2007) Controlled FiO² Therapy to Neonates by Oxygenhood in the Absence of Oxygen Analyser. Medical Journal Armed Forces India; 63: 149-153 Kelsey J, McEwing G (2008) Clinical Skills in Clinical Health Practice. Churchill Livingstone Macqueen S, Bruce E, Gibson F, (2012) The Great Ormond Street Hospital Manual of Children’s Practices. Wiley – Blackwell

RELATED DOCUMENTS AND PAGES

High Flow Nasal Cannula Oxygen Therapy (Airvo 2 Optiflow) http://nww.avon.nhs.uk/dms/download.aspx?did=17640 Medicines Code. Chapter M9: Administration of Medicines http://nww.avon.nhs.uk/dms.download.aspx?did=3485 Continuous Positive Airway Pressure CPAP for Infants with Bronchiolitis on the Medical High dependency Unit http://nww.avon.nhs.uk/dms/download.aspx?did=21160 Paediatric Core Care Plan

AUTHORISING BODY

Nurse Practice Group Paediatric Respiratory Governance Group

SAFETY None QUERIES AND CONTACT

Critical Care Outreach Team Bleep 2968 General Paediatric Team