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Oxygen therapy administration in a non-emergency situation

This guideline is to provide guidance on the administration of oxygen therapy in a non-emergency situation at Great Ormond Street Hospital (GOSH).

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" (National Guideline Clearinghouse 2006).

Oxygen therapy is used to decrease work of breathing by increasing alveolar oxygen tension.

Background

An essential part of clinical practice, oxygen therapy is widely utilised in pulmonary and non-pulmonary conditions. However, some have been critical of its wide use (Downs 2003). 

Excessive use of oxygen has been demonstrated in several studies, showing that insufficient attention is shown to pharmacological and physiological principles (Jeffrey et al 1989; Albin et al 1992; Small et al 1992; Gravil et al 1997; Kor and Lim 2000).

Concentrations required are dependant upon condition. Inappropriate concentrations have potentially serious effects, leading to pulmonary epithelial damage (broncho-pulmonary dysplasia), convulsions and retinal damage, particularly in neonates (Jefferies and Turley 1999).

Oxygen must be considered as a medication and the use of oxygen must be documented for each patient (Royal Pharmaceutical Society of Great Britain 2005).

Indications for oxygen therapy

Any individual with one or more of the following:

  • peri and post cardiac or respiratory arrest
  • hypoxia - diminished blood oxygen levels (oxygen saturation levels of <92%)
  • acute and chronic hypoxemia (PaO2 < 65mmHg, SaO2 < 92%)
  • signs and symptoms of shock
  • low cardiac output and metabolic acidosis (HCO3 < 18mmol/l)
  • chronic type two respiratory failure (hypoxia and hypercapnia) (Balfour-Lynn et al 2005a)

Despite a lack of supportive data, oxygen is also administered in the following conditions:

There remains a lack of consensus regarding fundamental issues in paediatric oxygen therapy, but principle differences from adult care must be taken into account in the care of children:

  • assessment process - difficulty to obtain arterial blood samples
  • clinical conditions in infancy are exclusive although overlaps exist in adolescents
  • prognosis in infancy usually positive - children often require oxygen therapy for limited periods
  • many children require long term oxygen therapy overnight only - this differs from the 15 hours forming the adult long term therapy definition
  • low flow equipment is sometimes required
  • supervision from parent/carer essential
  • oxygen provision may be necessary within school (Balfour-Lynn et al 2005b)

Types of oxygen therapy

High concentration oxygen therapy 

Up to 60 per cent oxygen results in the reduced risk of hypoventilation and retention of carbon dioxide (Joint Formulary Committee 2006). High concentration oxygen therapy can have detrimental effects on the respiratory system, particularly after prolonged usage, and can lead to respiratory distress due to absorption atelectasis (collapse of alveolus due to blockage). 

In the premature infant, retrolental fibroplasias can be a side effect due to vasoconstriction and could lead to permanent blindness (Jefferies and Turley 1999).

Low concentration oxygen therapy (controlled oxygen therapy)

Used to correct hypoxaemia by using an accurate amount of oxygen, without depleting existing maintenance of carbon dioxide and respiratory acidosis. Blood gases should be used to measure the precise concentration of oxygen (Joint Formulary Committee 2006).

Long term oxygen therapy (LTOT)

The provision of continuous oxygen therapy for patients with chronic hypoxaemia. Requirements vary between 24-hour dependency and dependency during periods of sleep. Principally aims to improve symptoms and prevent harm from chronic hypoxaemia. Any child likely to require LTOT for longer than three weeks should be considered for domiciliary oxygen. 

Patient groups potentially affected by chronic hypoxaemia include those with:

  • chronic lung disease

  • congenital heart disease with pulmonary hypertension

  • pulmonary hypertension secondary to respiratory disease

  • interstitial lung disease

  • obliterative bronchiolitis

  • cystic fibrosis and other causes of severe bronchiectasis

  • obstructive sleep apnoea and other sleep related disorders

  • palliative care for symptom relief (Balfour-Lynn et al 2005)

Inform child and family

Age appropriate information must be given to the child. Family members must be adequately informed (Rationale 1 and 2).

Include 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

Wherever possible, a set of baseline observations should always be obtained (Rationale 3).

This should be documented appropriately on relevant Trust paperwork.

Method of administration

Considering oxygen requirement and potential for tolerability of the child, delivery methods must be decided (Rationale 4) and potential methods of delivery are listed below.

The selection of an appropriate oxygen delivery system must take into account clinical condition, the patient's size, needs and therapeutic goals (Myers 2002):

  • high concentration oxygen is usually delivered via incubator or humidified head box

  • for concentrations below 50 per cent, oxygen can be delivered via nasal cannula

  • face masks

  • re-breathe mask

  • humidified oxygen

  • wafting

  • via nebulisation

  • tracheostomy

  • nasal cannula

  • via a ventilation circuit

Face mask

Supplied in child sizes, but has been found that children do not always tolerate them (Moules and Ramsey 1998). There are two types of face masks dependant on the condition of the child (Woodhams et al 1996):

Simple oxygen mask (variable flow masks)

Vents in the mask allow for the dilution of oxygen (Chandler 2001). High concentrations of oxygen can be safely administered. If low concentration of oxygen (below four litres) required, then there is a risk of a carbon dioxide build up (Bell 1995).

High concentration oxygen masks

Used for emergency situations (Advanced Life Support Group 1997) due to a large 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 (Bell 1995).

Humidified

This can be delivered via a face mask or head box, dependent upon child age/co-operation. Humidified oxygen should be utilised when high percentages of oxygen are required for  prolonged periods, and in those with chronic respiratory illness, to prevent drying of the mucosa and secretions (Chandler 2001).

Nasal cannula oxygen does not need to be humidified (Rationale 5).

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 via green oxygen tubing has been assessed as 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 (Davies et al 2006).

Via nebulisation

If the child is oxygen dependant, nebulisers should be delivered via oxygen and not air.

Tracheostomy

Oxygen can be delivered via a tracheostomy mask, Swedish nose or headbox. Consider child’s individual needs (Rationale 6).

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 use of nasal cannulae can, in the sensitive child, produce dermatitis and mucosal drying (Joint Formulary Committee 2006). Only low flow rates of up to two litres per minute can be given comfortably (Mallet and Bailey 1996) due to inadequate humidification (Jamieson 1999).

Nasal cannula oxygen does not need to be humidified (Rationale 5).

Via a ventilation circuit

Accurate measurement of inspired oxygen is difficult and pulse oximetry must be maintained. Can be delivered at various points throughout the ventilation circuit (Simonds 2007) but always before the humidification unit as oxygen is a cold gas that needs to be warmed and humidified.

Via an Ayres T piece – open ended bag

Used frequently by anaesthetists and experience gives a reliable impression of the state of the lungs.  This technique allows manual application of PEEP (positive end-expiratory pressure). It is completely reliant on an effective oxygen source (Advanced Life Support Group 2003).

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 H20) to protect the lungs from barotrauma (damage caused to tissues by a change in pressure inside and outside the body).

The reservoir bag enables the delivery of oxygen concentrations up to 98 per cent. Without the reservoir bag it is not possible to supply more than 50 per cent oxygen (Advanced Life Support Group 2003).

Selection of most appropriate method of delivery

Selection of the most appropriate method of administration
Method Concentration Comments

Simple oxygen mask

High concentrations can be delivered safely Flow below four litres could potentially result in carbon dioxide retention (Bell 1995).

High concentration oxygen masks

10-15 litres required For use in emergency situations.

Humidified

26-65 per cent Fi02

Nasal cannula oxygen should not be humidified. 

Prolonged periods of high percentage oxygen should be humidified (Chandler 2001).

Wafting

30-40 per cent with 10   litres oxygen per minute

Green oxygen tubing should be used.

Conventional methods of oxygen delivery recommended if tolerated (Davies et al 2006).

 

Continuous assessment of child

Frequent assessment and observations should be an integral part of care, enabling the detection of changes in the child’s condition (Rationale 7 and 8).

Effort of breathing including:

Carrying out procedure

Ensure adequate and working oxygen supply (Rationale 18).

If wall valve supply being utilised, then working order must be established first (Rationale 18).

If portable oxygen cylinders being used, these should enable adequate oxygen provision

  • Litres in cylinders/litres needed per minute = minutes of oxygen available 

All valves on portable oxygen cylinders must be open (See Appendix 1).

Refer to the patient's individual prescription (Bell 1995)(Rationale 19).

Give the oxygen via the approved, or tolerated, method for the patient (Rationale 20).

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 (Dinesh and Mehta 1996)(Rationale 21).

Oxygen should be delivered at the lowest concentration possible and for the shortest possible time (Tucker et al 1992)(Rationale 22).

Assess whether the delivery system requires humidification (Rationale 23).

Monitor the child’s vital signs, level of consciousness and responsiveness during the administration of oxygen (Rationale 24).

Monitor the child’s colour, respiratory rate and depth and for signs of respiratory distress (Rationale 25).

Determine the reason for the oxygen requirements (Rationale 26 and 27).

Assess the patient's level of anxiety and give appropriate explanations (Rationale 28 and 29).

Follow the prescribed protocol for each individual child regarding acceptable oxygen saturations and prescribed oxygen therapy (Rationale 30, 31 and 32).

All oxygen therapy administered must be documented on appropriate chart.

Effects of depleted oxygen on other organs

Holistic monitoring of the child must be carried out:

Safety considerations

Ensure that adequate education regarding safety of oxygen therapy is established.

Oxygen should not be delivered in the vicinity of any naked flames (Ashurst 1995)(Rationale 40).

Determine the reason for the oxygen requirements (Rationale 41, 42, 43, 44).

If oxygen requirements increase

Continue to monitor child.

Inform nurse in charge and medical team as necessary.

Follow acutely unwell child clinical practice guideline as necessary.

Discharge planning

Discharge planning should begin on admission in line with the British Thoracic Society Guidelines (Balfour-Lynn et al 2005)(Rationale 45).

The child's community team should be contacted as soon as discharge planning commenced.

The child's discharge should be planned in a consistent, systematic and collaborative manner (Rationale 46).

The clinical decision that a child will receive home oxygen is made by the consultant in charge of the child’s care (Rationale 47).

Each child's management plan should include the following:

  • oxygen prescription
  • amount of oxygen required
  • sliding scale of parameters with indications of when to seek advice and from whom
  • mode of delivery
  • delivery system required
  • medical decision required regarding whether the use of a pulse oximeter and/or apnoea alarm is appropriate for the home environment (Primhak 2003; Fulmer and Snider 1984)(Rationale 48, 49, 50, 51).
  • parents/carers should understand the need for home oxygen therapy and are willing and competent to look after the child in the home environment (Rationale 52)
  • family are aware of the risks involved in the child having home oxygen therapy (Rationale 53)
  • parents/carers are able to assess their child’s respiratory pattern, recognise respiratory distress and be able to take relevant and appropriate action (Rationale 54)
  • ensure the child on home oxygen therapy receives all relevant equipment (Rationale 55)
  • parents/carers should have support from the oxygen supplier with regards to equipment (Rationale 56)
  • the child will receive oxygen therapy whilst at school if required (Rationale 57)
  • the child should have open access to their nearest hospital (Balfour-Lynn et al 2005)(Rationale 58).

Appendix

Appendix 1: Portable oxygen cylinder guidelines.

Rationale

Rationale 1: To gain informed consent.
Rationale 2: To provide reassurance and psychological support.
Rationale 3: Any subsequent changes in status will be noticed.
Rationale 4: To ensure maximum benefit is obtained from treatment.
Rationale 5: Environmental and physiological humidification is sufficient.
Rationale 6: All care should be delivered on an individual basis.
Rationale 7: To provide an accurate picture of the child’s condition and to assess the effectiveness of the oxygen therapy.
Rationale 8: Early recognition and management of potential respiratory failure will reduce mortality and potential secondary morbidity.
Rationale 9: To allow detection of increase work of breathing.
Rationale 10: Intercostal, subcostal or sternal recession show increased effort, particularly in children, resulting from their compliant chest walls.
Rationale 11: Head bobbing demonstrates use of the sternomastoid muscle with each breath.
Rationale 12: Indication of broncho-constriction, usually expiratory.
Rationale 13: Sound during respiration when there is a partial obstruction or collapse of the trachea or larynx.
Rationale 14: Sign of severe respiratory distress.
Rationale 15: Indication of reduced blood oxygen levels.
Rationale 16: To establish peripheral perfusion levels.
Rationale 17: As part of AVPU score and general assessment.
Rationale 18: To facilitate effective treatment.
Rationale 19: Oxygen is classed as a drug and the planned delivery of oxygen therapy requires by law to be prescribed by a doctor or a non medical prescriber.
Rationale 20: Each individual patient is unique and the established method for the delivery of oxygen would have been agreed.
Rationale 21: Administration of an inappropriate concentration of oxygen can have serious or even lethal consequences.
Rationale 22: Oxygen toxicity can occur with oxygen concentrations of 50 per cent or higher and administered for 24-48 hours or more.
Rationale 23: This depends on several factors, especially the method of administration, the length of time of administration and the patient's requirements.
Rationale 24: To provide an accurate picture of the child’s condition and to assess the effectiveness of the oxygen therapy.
Rationale 25: To be alert to early signs of a worsening condition and to enable early detection of the child’s respiratory distress.
Rationale 26: A thorough assessment should be made in order to continue with appropriate management.
Rationale 27: To assess if there is adequate chest expansion or if the child needs repositioning.
Rationale 28: Be aware that it may be frightening for the child.
Rationale 29: Provide appropriate and adequate emotional support.
Rationale 30: Each child has their own acceptable parameters.
Rationale 31: To ensure that individual prescriptions are adhered to.
Rationale 32: This allows the variations in acceptable parameters.
Rationale 33: Hypoxia produces tachycardia.
Rationale 34: Bradycardia can be caused by severe or prolonged hypoxia.
Rationale 35: Hypoxia initially causes vaso-constriction and skin pallor.
Rationale 36: Visible cyanosis is a late sign of respiratory distress.
Rationale 37: Cyanosis could result from cyanotic cardiac disease.
Rationale 38: Profound cyanosis may not be visible in the severely anaemic child.
Rationale 39: Hypoxia can cause the child to be drowsy and/or agitated.
Rationale 40: Oxygen is an oxidising agent that strongly supports combustion.
Rationale 41: To consider if alternative strategies would be appropriate.
Rationale 42: To determine if the child requires suction.
Rationale 43: To determine if there is adequate chest expansion or if the child needs to be repositioned.
Rationale 44: A thorough assessment should be made in order to continue with appropriate management.
Rationale 45: To ensure a smooth transition to the home environment.
Rationale 46: Communication of information between professionals and families is vital in order to ensure best follow-up care.
Rationale 47: Each child will have their own management plan, which will include guidelines for use and information relating to clinical signs and symptoms.
Rationale 48: Limited evidence that the use of oxygen saturation monitors improve patient’s care at home. In fact, can result in carers increasing oxygen flow.
Rationale 49: An adequate respiratory assessment should be used and reliance should not be placed on oxygen saturations monitor.
Rationale 50: Alarms are often activated by movement.
Rationale 51: The American Thoracic Society supports the use of oximeters in the home because they feel it reduces the providence of hospital admissions (Fulmer and Snider 1984).
Rationale 53: Oxygen is a potential source of combustion and oxygen increases the rate at which fire spreads.
Rationale 54: Parents/carers are aware of early signs of hypoxia and respiratory distress in order to reduce the risk of further deterioration in the child’s condition.
Rationale 55: To maintain a quality of life and to ensure that equipment is providing desired outcomes.
Rationale 56: Parents/carers should be competent and confident about using equipment and home oxygen therapy in the community.
Rationale 57: To minimise the disruption oxygen therapy can cause to a child’s lifestyle and allow the child to access education.
Rationale 58: In case of emergency admission.

References

Reference 1:
Advanced Life Support Group (2003) Advanced Paediatric Life Support 3rd Ed. London, BMJ Books

Reference 2:
Advanced Life Support Group (1997) Advanced Paediatric Life Support - The Practical Approach. London, BMJ Publishing House

Reference 3:
Albin RJ, Criner GJ, Thomas S, Abou-Jaoude S (1992) Pattern of non-ICU inpatient supplemental oxygen utilization in a university hospital. Chest 102 (6): 1672-5.

Reference 4:
Ashurst S (1995) Oxygen therapy. Br J Nurs 4 (9): 508-15.

Reference 5a:
Balfour-Lynn IM, Primhak RA, Shaw BN (2005) Home oxygen for children: who, how and when?Thorax 60 (1): 76-81.

Reference 6b:
Balfour-Lynn IM, Primhak RA, Shaw BNJ (2005) Clinical Component for the Domiciliary Oxygen Service for Children in England and Wales. www.evidence.nhs.uk. Viewed on: 21/06/2006

Reference 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.

Reference 8:
Chandler T (2001) Oxygen Administration. www.perinatal.nhs.uk. Viewed on: 21/06/2006

Reference 9:
Davies P, Cheng D, Fox A, Lee L (2002) The efficacy of noncontact oxygen delivery methods. Pediatrics 110 (5): 964-7.

Reference 10:
Dinesh AB, Mehta DK (Ed.) (1996) British National Formulary. London, British Medical Association and Royal Pharmaceutical Society

Reference 11:
Dinwiddie R (1997) Diagnosis and management of Paediatric Respiratory Disease. London, Churchill Livingstone

Reference 12:
Downs JB (2003) Has oxygen administration delayed appropriate respiratory care? Fallacies regarding oxygen therapy. Respir Care 48 (6): 611-20.

Reference 13:
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.

Reference 14:
Gravil JH, O'Neill VJ, Stevenson RD (1997) Audit of oxygen therapy. Int J Clin Pract 51 (4): 217-8.

Reference 15:
Jamieson E, McCall JM, Whyte LA (1999) Clinical Nursing Practices. London, Churchill Livingstone

Reference 16:
Jefferies A, Turley A (1999) Respiratory System. London, Mosby

Reference 17:
Jeffrey AA, Ray S, Douglas NJ (1989) Accuracy of inpatient oxygen administration. Thorax 44 (12): 1036-7.

Reference 18:
Joint Formulary Committee (2006) British National Formulary. London, British Medical Association and Royal Pharmaceutical Society of Great Britain

Reference 19:
Kbar FA, Campbell IA (2006) Oxygen therapy in hospitalized patients: the impact of local guidelines. J Eval Clin Pract 12 (1): 31-6.

Reference 20:
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.

Reference 21:
Mallet J, Bailey C (1996) The Royal Marsden NHS Trust Manual of Clinical Nursing Procedures (4th Ed). London, Blackwell Science

Reference 22:
Moules T, Ramsey J (1998) The Textbook of Children's Nursing. Cheltenham, Stanley Thornes

Reference 23:
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.

Reference 24:
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

Reference 25:
Primhak RA (2003) Discharge and aftercare in chronic lung disease of the newborn. Semin Neonatol  8 (2): 117-26.

Reference 26:
Royal Pharmaceutical Society of Great Britain (2005) British National Formulary for Children. London, BNJ Publishing House Ltd

Reference 27:
Simonds AK (2007) Non-invasive Respiratory Support. London, Hodder Arnold

Reference 28:
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.

Reference 29:
Tucker SM, Canobbia MM, Paquette EV, Wells MF (1992) Patient Care Standards (5th Ed). New York, Mosby Year Book

Reference 30:
Woodhams K et al (1996) The Respiratory System McQuaid L, Huband S, Parker E In: Children's Nursing. New York, Churchill Livingstone

Document control information

Lead author(s)

Heather-Elizabeth Hatter, Practice Educator, Respiratory Medicine 

Additional authors
Zoey Gater, Practice Educator (previous)

Document owner
Heather-Elizabeth Hatter, Practice Educator, Respiratory Medicine

Approved by
Guideline Approval Group

First introduced: 4 June 2008
Date approved:
2 June 2014 
Review schedule:
Three years
Next review:
2 June 2017 
Document version:
2.0 
Replaces version:
1.1