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Oxygen Guideline July 2012 of 42

Approved on: July 2012

6.6

GUIDELINE /PROCEDURE

SUBJECT: OXYGEN THERAPY AND DELIVERY DEVICES FORPAEDIATRICS JHCH (Excluding NICU, ED, ICU)

DOCUMENT NUMBER: 6.6

DATE DEVELOPED: June 2006

DATES REVISED: November 2011, August 2012

DATE APPROVED: August 2012

REVIEW DATE: August 2016

DISTRIBUTION:

JHCH – H1, J1, J2A, J2Day Stay, Oncology Day Stay

PERSON RESPONSIBLE FOR MONITORING AND REVIEW:

Paediatric Respiratory CNC

COMMITTEE RESPONSIBLE FOR RATIFICATION AND REVIEW:

Kaleidoscope GNS Quality Committee

Keywords: children, device, oximetry, oxygen, therapy, SaO2

Disclaimer : It should be noted that this document reflects what is currently regarded as a safe and appropriate approachto care. However, as in any clinical situation there may be factors that cannot be covered by a single set ofguidelines, this document should be used as a guide, rather than as a complete authorative statement ofprocedures to be followed in respect of each individual presentation. It does not replace the need for theapplication of clinical judgment to each individual presentation.

SAFE WORK PRACTICE

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SAFE WORK PRACTICE

1. Oxygen is highly combustible; therefore anything that supports or initiates

combustion should be avoided e.g. smoking, candles.

2. All electrical equipment, wall oxygen and cylinder oxygen will be operated within the

guidelines of safe work practices for both patient and staff.

3. All oxygen delivery circuits are single patient use as per infection control guidelines.

TABLE OF CONTENTS:

DEFINITIONS / ABBREVIATIONS ................................................................................... 4

1. OUTCOMES............................................................................................................. 5

2. INDICATIONS .......................................................................................................... 5

3. PRECAUTIONS ....................................................................................................... 5

4. OXYGEN THERAPY PROCEDURE ......................................................................... 6

4.1 OBSERVATIONS ............................................................................................. 6

4.1.1 SIGNS AND SYMPTOMS OF RESPIRATORY DISTRESS ................... 7

4.1.2 OBSERVATION TO ASSESS THE SIGNS AND SYMPTOMS OF

RESPIRATORY DISTRESS .................................................................. 8

4.1.3 NORMAL RANGES IN BLOOD GAS ANALYSIS ................................... 9

5. NURSING CARE FOR ALL CHILDREN ON OXYGEN THERAPY ........................... 10

6. DELIVERY SYSTEMS .............................................................................................. 11

6.1 NASAL CANNULA ............................................................................................ 11

6.1.1 NASAL CANNULA PROCEDURE ......................................................... 12

6.1.2 ADDITIONAL NURSING CARE FOR NASAL CANNULARS ................. 12

6.2 NASAL CANNULA WITH WARMED HUMIDIFIED OXYGEN (WHO) VIA THEFISHER & ® PAYKEL HUMIDIFICATION SYSTEM ................................................ 13

TABLE 1: F & P HUMIDIFIER CURCUITS, CORRESPONDING PRONGS &

USE .................................................................................................. 14

6.2.1 WARMED HUMIDIFICATION ................................................................ 15

6.2.2 WHO EQUIPMENT ................................................................................ 16

TABLE 2: F & P BC RANGE NASAL CANNULA SIZE SELECTION TO USE

WITH CIRCUIT RT329 INFANT RESPIRATORY CARE SYSTEM .... 17

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TABLE 3: F & P OPTIFLOW JUNIOR NASAL CANNULA SIZE SELECTION TO

USE WITH CIRCUIT RT330 OPTIFLOW TUBING KIT ..................... 17

6.2.3 ASSEMBLE WHO EQUIPMENT ............................................................ 17

TABLE 4: WHO PROCEDURE ......................................................................... 19

6.2.4 ADDITIONAL NURSING CARE FOR CHILDREN ON WHO VIA NASALCANNULAE ........................................................................................... 28

6.2.5 TRANSPORTING CHILD WHILE ON FISHER & PAYKEL WHO

CURCUIT .............................................................................................. 29

TABLE 5: PROCEDURE FOR TRANSPORT ................................................... 29

6.2.6 CLEANING WHO ................................................................................... 30

6.2.7 TROUBLESHOOTING FOR WHO ......................................................... 30

6.3 FACE MASK ..................................................................................................... 316.3.1 PROCEDURE FOR FACE MASK APPLICATION .................................. 31

6.4 PARTIAL RE-BREATHER ................................................................................ 32

6.4.1 PARTIAL RE-BREATHER PROCEDURE .............................................. 33

6.5 NON RE-BREATHER BAG .............................................................................. 33

6.5.1 NON RE-BREATHER BAG PROCEDURE ............................................ 33

6.6 VARIABLE CONCENTRATION MASK ............................................................. 34

6.6.1 VARIABLE CONCENTRATION MASK PROCEDURE ........................... 35

6.7 BLOW OVER OXYGEN.................................................................................... 35

6.8.1 BLOW OVER OXYGEN PROCEDURE ................................................. 35

6.8 TRANSPORT OXYGEN VIA PORTABLE CYLINDER ...................................... 36

7. WEANING ................................................................................................................ 36

8. EQUIPMENT CHECK ............................................................................................... 37

9. DOCUMENTATION .................................................................................................. 37

DEPARTMENT OF HEALTH CIRCULARS ...................................................................... 38

AREA POLICIES .............................................................................................................. 38

AUTHOR & CONSULTATION .......................................................................................... 38

REFERENCES ................................................................................................................. 39

APPENDIX 1. DETERMINING FiO2 DELIVERED FROM THE OUTLET FLOW ............... 40

APPENDIX 2. AIR / OXYGEN BLEND FOR WHO ........................................................... 41

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DEFINITIONS / ABBREVIATIONS:

BP Blood pressure

BTF Between the Flags

CXR Chest x-ray

ED Emergency Department

FiO 2 Fract ion of insp ired oxyg en (%)

HR Heart rate

HFNP - 8 High-f low nasal pron g to 8 L/min l imit

ICU Inten sive Care Unit

IV or IVT Intrav enous Therapy

JHCH John Hunter Children’s Hospital

LOC Level of consc iou sness

L/kg L i t res of gas f low p er k i logram of b ody weight per

minute

L/min L i t res of gas f low per minute

NBM Ni l by mo uth

NICU Neonatal Inten sive Care Unit

NPA Nasoph aryngeal A spirate

MO Medical Off icer

O 2 Oxygen

PaO 2 Part ia l pressur e of oxyg en in arter ia l bloo d

Resps Respiratory rate

RDS Respiratory Distress Score

RR Respiratory rate

SaO 2

Oxygen saturat ion

SOP Stand ard Operat ing Procedure

SPOC Stand ard Paediatr ic Observat ion Chart

WHO Warmed Humid if ied Oxygen

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1. OUTCOMES:

To maintain adequate oxygenation to body tissues to ensure:

1. Hypoxia is minimised

2. Optimal respiratory status is achieved and maintained.

3. Safe and effective administration of oxygen is delivered.

NOTE:

In order to increase the fraction of inspired oxygen concentration (FiO2) available to

a patient, a variety of oxygen delivery devices are employed to administer medical

oxygen. The oxygen should be administered with humidity if possible.

Oxygen is a drug and should be given only when ordered by a medical officer, or by

a registered nurse as a nurse initiated order in an emergency situation. A nurse

initiated order for oxygen can be given as an intervention whilst patient is reviewed.

Oxygen is to be ordered on the intervention section of an age appropriate Standard

Paediatric Observation Chart (SPOC).

Oxygen therapy is given to maintain oxygen saturations above 95% unless altered

calling criteria are documented on the SPOC.

2. INDICATIONS:

Hypoxia.

Increased work of breathing, increased heart rate with progressive decrease inSaO2.

3. PRECAUTIONS:

In patients with chronic carbon dioxide retention whose stimulus to breathe is adecreased partial pressure of oxygen in arterial blood (PaO2), oxygen

administration may depress respiratory drive. Careful monitoring of these patients

for hypoventilation is required during oxygen therapy1.

Persons with severe lung disease need to be maintained at the prescribed oxygen

saturation range.

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4. OXYGEN THERAPY PROCEDURE:

4.1 OBSERVATIONS:

Children’s oxygenation status should be assessed in a well-lit room if possible by

assessing clinical signs and symptoms and recording baseline observations.

Observations must be recorded on an age appropriate NSW Health Standard

Paediatric Observation Chart (SPOC) with the times entered as the observations

are completed.

The response of the nurse assessing the child will depend on the clinical

assessment, level of deterioration and which zone the observations are recorded in.

See Kaleidoscope Recognition of the Deteriorating Paediatric Patient Guideline,

Number 3.19.

In the acute presentation, frequent observations should be attended and recorded.

The first set of observations must be initiated within 10 minutes of the child’s

deterioration then half hourly to hourly depending on the condition of the child2.

Patients who are stable with ongoing treatment of oxygen need hourly heart rate,

respiratory rate, SaO2, and gas flow. Temperature and BP can be attended fourth

hourly if child stable.

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4.1.1 SIGNS AND SYMPTOMS OF RESPIRATORY DISTRESS:

Neurolog ical Status - Anxiety

- Restlessness initially progressing to

agitation, confusion, disorientation

and loss of consciousness.

Increased Work o f Breathing - Apnoea

- Change in pattern of breathing including;

respiratory rate, rhythm and effort.

- Nasal flaring

- Grunting

- Mouth breathing

- Use of accessory muscles and recession

Vital Sign s - Tachycardia

- Hypertension

- Tachypnoea

- Bradypnoea may indicate further

deterioration

- Decreasing O2 saturation

Skin Colour - Mild hypoxia initially as pale colour due to

peripheral vasoconstriction.

- Clammy

- Later signs progressing to bluish grey

[cyanosis] most easily seen as lip

discolouration3.

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4.1.2 OBSERVATIONS TO ASSESS THE SIGNS AND SYMPTOMS OF

RESPIRATORY DISTRESS INCLUDE:

a) Respiratory rate.

b) Respiratory effort and work of breathing as above.

c) Heart rate.d) SaO2 (in any amount of O2).

An oximetry reading:

95% in room air is desirable unless an altered calling criterion is

documented on the SPOC.

90-95% indicates a need for increased observation and report to the

nurse in charge as per SPOC zone protocol.

< 90% requires a rapid response as per SPOC zone protocol.

The response to the SaO2 reading is dependent:

On the child’s normal baseline observation. Children with chronic

illnesses such as congenital heart disease, chronic obstructive pulmonary

disease, pulmonary hypertension, cystic fibrosis and bronchopulmonary

dysplasia should be assessed individually as their oxygen requirements

may be different. An altered calling criterion will need to be documented

on the SPOC if a child’s stable baseline observations are outside the

accepted values.

On work of breathing and heart rate and not just a decrease in SaO2

alone.

e) Oxygen – Flow rate of gases and device.

f) Capillary refill.

g) Blood pressure.

h) Level of consciousness.

i) Pain score.

j) Temperature.

k) Blood glucose level if necessary.

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4.1.3 TABLE 1: NORMAL RANGES for ARTERIAL BLOOD GAS4

Measurement ArterialBlood

Clinical Notes

Acid-base status(pH)

7.35 – 7.45 Most important acid-base value; detectsacidosis or alkalosis

Partial pressureof carbon dioxide(PaCO2)

35 – 45mm Hg

Measures adequacy of ventilation andrespiratory contribution of acid-baseabnormality (respiratory acidosis)

Partial pressureof oxygen (PaO2)

(sea level)

80 – 100mm Hg

Indicates driving pressure that causes oxygen-hemoglobin binding; varies with age and

barometric pressure.

Bicarbonate(HCO3)

21 – 28mEq/L

Measures metabolic contribution to acid-baseabnormality (metabolic acidosis); calculatedfrom pH and Pco2

Base excess (BE) -2 to +2 Reflects deviation of bicarbonate concentrationfrom normal

Saturation ofhemoglobin withoxygen (SaO2)

96 – 98% Indicates abnormality of oxyhemaglobinassociation and dissociation; may bemeasured directly or calculated from Po2, pHand body temperature

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5. NURSING CARE FOR ALL CHILDREN ON OXYGEN

THERAPY:

Oxygen is a drug and should be given only when ordered by a medical officer, or by

a registered nurse as a nurse initiated order in an emergency situation. A nurse

initiated order for oxygen can be given as an intervention whilst patient is reviewed.

Observations as above per guideline.

All children on oxygen therapy MUST be connected to the Massimo System

Patients who are stable with ongoing treatment of oxygen need hourly heart rate,

respiratory rate, SaO2, and gas flow. Temperature and BP can be attended fourth

hourly if child stable.

Oxygen therapy is given to maintain oxygen saturations above 95% unless an

altered calling criterion is documented on the SPOC.

Children who receive oxygen therapy via the Fisher and Paykel Humidifier at

a flow rate of 1L/kg/min with a ratio of oxygen to air of 1:1, which equates to

an approximate FiO2 of 60% oxygen, can be nursed in the paediatric wards of

JHCH.

Team leader should be notified BEFORE an increase in oxygen concentration

or flow rate is given.

A medical review should be attended after an increase in oxygen concentration or

flow rate is given.

Patient delivery device position is important as dislodgement will result in a loss of

respiratory support

If feeding is required, respiratory status should be observed closely

If child is NBM, IV fluid replacement or NG therapy should be commenced

Oral and nasal hygiene and normal saline drops as necessary.

Suctioning as required with caution. If suctioning is indicated there should be two

nurses with child for this procedure with emergency equipment ready to use

therefore checked prior to commencement of the procedure.

Document all changes in oxygen administration on the SPOC.

Oxygen is to be ordered on the intervention section of the SPOC.

Document all interventions on patient’s notes.

All other observations and interventions are to be documented on the paediatric

respiratory observation chart.

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6. DELIVERY SYSTEMS:

The choice of delivery system is to be determined by the rate of oxygen

required as calibrated against the clinical assessment of work of breathing,

heart rate, oximetry reading and the age of the child.

It is to be determined by flow rate and FiO2 required (See Appendix 1)

The concentration of oxygen delivered is variable and depends on gas flow

rate, fit of the device, ventilatory pattern and anatomic dead space5.

The devices used to deliver oxygen are:

6.1 Nasal Cannulae

6.2 Nasal Cannulae with warmed humidified oxygen (WHO) via the

Fisher & Paykel ® Humidification System6.3 Simple Mask

6.4 Partial Rebreather Mask

6.5 Non – Rebreather Mask

6.6 Variable Concentration Mask (Venturi Or Air-Entrainment Mask)

6.7 “Blow over ” oxygen

6.8 Transport oxygen via portable cylinder

6.1 NASAL CANNULA:

L/Min FiO2

0.125 – 2 1L/min = 24% and 2L/min = 28%

Nasal cannulae from wall oxygen are the delivery method of choice for infants,

toddlers, older children and adolescents, who require a flow rate up to 2 L/min.

Nasal cannulae deliver a maximum of 28% FiO2. One litre of oxygen will deliverapproximately 24% FiO2 (See Appendix 1).

Do not deliver a flow rate greater than 2 L/min from wall oxygen as it is

uncomfortable for the child. If a higher flow rate is required an alternate delivery

system should be considered.

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6.1.1 NASAL CANNULAE PROCEDURE:

1. Obtain the appropriate size nasal cannulae (ie infant, intermediate infant, child

or adult).

2. AQUAPAK humidifier is to be used when a child is having oxygen directly

from the wall. Attach AquaPakTM

to the wall outlet.3. Attach an appropriate (high, low or ultra-low flow) oxygen meter to wall oxygen

and ensure it is working.

4. Explain the procedure to the child and parents.

5. Assess adequacy of oxygen delivery via the child’s nasal passages.

6. Clean nares as needed.

7. To minimise skin irritation place thick Duoderm on the cheeks before securing

the prongs to the face with Hyperfix. Measure and cut Hyperfix ready for use.8. Attach the nasal prongs to the flow meter; adjust the oxygen flow to the required

amount of oxygen ordered.

9. Gently fit the prongs into the nostrils making sure the curves of the prongs follow

the contour of the nasal passage.

10.Ensure the tubing is under or over the child’s ears and behind their head.

Anchor the tube by sliding the plastic ring up until the tubing is sitting

comfortably around the child’s head.

11. Secure prongs to Duoderm with the premeasured Hyperfix. Nasal prongs should

be changed when necessary or at least weekly.

12. Connect child to Massimo System for continual monitoring

13. Check every four hours:

Integrity of nasal passages and skin area under prongs

The prongs are inserted into the nostrils correctly

Kinking or twisting does not obstruct the flow of oxygen.

6.1.2 ADDITIONAL NURSING CARE FOR CHILDREN ON WALL OXYGEN VIA

NASAL CANNULAE: (Also See Section 5 – Nursing Care for All Children On

Oxygen Therapy)

A maximum of 2 L/ minute via nasal prongs. A higher flow may cause discomfort

for the child unless a Fisher & Paykel ® Humidification System is used.

If child is requiring more that 28%, wall oxygen delivery system needs to be

changed.

Nasal prong position is important as dislodgement will result in a loss of

respiratory support.

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Observe nares for drying, cracking or bleeding of nasal mucosa when attending

cares. Nasal toilets should be attended and normal saline drops as necessary

6.2 NASAL CANNULA WITH WARMED HUMIDIFIED OXYGEN (WHO) VIA

THE FISHER & PAYKEL ® HUMIDIFICATION SYSTEM

Each Fisher & Paykel Humidifier Circuit has its own corresponding set of nasal prongs.

The different circuits and nasal prongs are not interchangeable. There are three (3) circuits

that may be used at John Hunter Children’s Hospital. These circuits are to be used with

the MR850 heated humidifier. See Table 1 below:

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Table 1: Fisher & Paykel Humidifier Circuits, Corresponding Prongs and Use

Circuit Prongs Use Gas Flow FiO2 Weight

RT329 Circuit -

nfant Respiratory

Care System

BC Range of

Cannula

(See Table 2)

Prem infant – Paediatric

Original circuit used at JHCH

Circuit of choice for routine WHO

2 – 8 L/min

Max 1L/kg/min

in ward

Variable.

Dependent on gas

flow which is made

of oxygen / air

blend. (See

Appendix 2)

Maximum FiO2 is

60%, which equates

to a ratio of oxygen

and air of 1:1 can be

nursed in paediatric

wards

Prem

infant to

>5kgs

RT330 Circuit -

Optiflow Tubing

it

Optiflow

Nasal

Cannula.

(See table 3)

Premature infant – Paediatric

New Circuit Released in June 2012

Used for patients on the Bronchiolitis HFNP WHO RCTrial

Can be used for sicker older children (up to 22kgs) needing flows

>8L/min in the ward

1 – 20 L/min

Max 20L/min

for children

enrolled in

the trial

1kgs –

20kgs

RT203 Adult

Optiflow Circuit

MaxVenturi

Oxygen System

Small,

medium and

large adult

prongs.

OPT542

This circuit is used in ICU and not generally in the ward.

If a bigger child is in need of flows >25L/min this system may be

considered.

The setup of this system is outside the scope of this guideline. See

HNE Health Guideline and Procedure: Humidified Oxygen Delivery via

the MaxVenturi Oxygen Diluter with MR850 heated Humidifier in

Intensive Care Adults)

10 - 60L/min

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6.2.1. WARMED HUMIDIFICATION:

One of the complications of oxygen therapy, even for relatively short periods of

time, is the drying of the upper airway, which causes secretions to be thicker and

harder to expectorate6, 7

.

Humidification minimizes this inflammation, mucosal drying and retention ofsecretions

6, 8.

When there is not enough humidity in the inspired gas, nasal passages become dry

and painful. There is also a higher risk of the development of atelectasis or

infection6, 8

.

Oxygen is to be humidified for comfort of the infant or child using the Fisher &

Paykel ® Humidification system if possible.

Warmed humidification is advantageous during oxygen administration as cold, dry

inspired gas causes detrimental physiological changes within the airway such as

moisture and heat loss from the mucosa, airway secretions with decreased volume

and abnormal rheology, decreased mucociliary clearance, and inflammatory

reactions due to thermal injury or fluid imbalance9. Additionally extra energy is

required to warm the gases in the airways.

Normal mucosal function is needed to maintain airway patency and lung

compliance9.

The inspired gas flows are heated to near body temperature (37.1°) and are fully

saturated with water vapour 10

.

Warmed humidification oxygen / air flow is only used in conjunction with the Fisher

& Paykel ® MR850 Humidification System at present.

The Fisher & Paykel ® Humidification System is used at the discretion of the

nursing team leader and medical team.

The minimum and maximum gas flow rate through a Fisher & Paykel ®

Humidification system changes depending on the circuit and prongs used. See

Table 1 for Fisher & Paykel Humidifier Circuits, Corresponding Prongs and Use

Children who receive oxygen therapy via the Fisher and Paykel Humidifier at a flow

rate of 1L/kg/min with a ratio of oxygen to air of 1:1, which equates to an

approximate FiO2 of 60% oxygen, can be nursed in the paediatric wards of JHCH.

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A child can be transferred from Emergency Department to the ward if the child is

stabilised on WHO of 1L/kg/min with a ratio of oxygen to air of 1:1, which equates to

a FiO2 of 60% oxygen.

To calculate the flow rate of 1L/kg/min on the WHO, the child’s weight will need to

be rounded up or down to the closest whole number. . For example a child weighing

3.3 kgs will be managed as a 3 kg child; an 11.8 kg child will be managed as a 12

kg child.

Children are NOT to be nursed in the wards if the gas flow rate exceeds 1 L/kg/min

with a ratio of oxygen to air of 1:1, which equates to a FiO2 of 60% oxygen unless

special precautions are initiated.

For babies <4kgs an oxygen analyzer is to be used with WHO.

The oxygen analyzer becomes less accurate when the gas flow decreases as air is

entrained diluting the oxygen concentration.

The oxygen analyzer is to be removed when gas flows are weaned as the reading

will be incorrect.

6.2.2 WHO EQUIPMENT

Fisher and Paykel provide three (3) humidifier circuits that are used with the Fisher

& Paykel Humidifier base (MR850).

Each humidifier circuit has its own corresponding prongs. Humidifier circuits and

prongs are not interchangeable.

Any of these circuits may be used in the JHCH wards.

The choice of circuit will depend on child’s size, weight and flow requirements.

Ensure you have corresponding nasal prongs and circuit suitable to the child’s

weight and flow requirements. See Table 1 for details.

If using Fisher and Paykel Optiflow nasal cannulae, Duoderm and Hyperfix are not

necessary as this product comes with adhesive (WigglepadTM

) attached to the

prongs.

If the WigglepadTM

adhesive is loose or does not adhere replace WigglepadTM

.

DO NOT STICK OPTIFLOW NASAL CANNULAE TUBING TO FACE WITH

HYPERFIX.

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Table 2: FISHER AND PAYKEL BC RANGE NASAL CANNULA SIZE SELECTION TO

USE WITH CIRCUIT RT329 INFANT RESPIRATORY CARE SYSTEM10

Cannula Description Minimum flow Maximum patient flow

BC2425 Premature 2L/min 6L/min

BC2435 Neonate 2L/min 6L/min

BC2745 Infant (term newborn) 2L/min 7L/min

BC2755 Intermediate infant

(<5 kg)

2L/min 7L/min

BC3780 Paediatric

(> 5 kg)

2L/min 8 L/min

Table 3: FISHER AND PAYKEL OPTIFLOW JUNIOR NASAL CANNULA SIZE

SELECTION TO USE WITH CIRCUIT RT330 OPTIFLOW TUBING KIT11

The following codes should be used as per the current manufacturer’s instructions andshould be utilized as a guide when selecting nasal cannula.

Colour

Code

Product Item

Code

Approx

Weight Range

Max Flow Rate

(L/Min)

Wigglepad

Item CodeRed Premature Size OPT312 <2kg 8 OPT010

Yellow Neonatal Size OPT314 1 – 8kg 8 OPT012

Purple Infant Size OPT316 3 – 15kg 20 OPT012

Green Pediatric Size OPT318 12 – 22kg 25 OPT012

6.2.3 ASSEMBLE WHO EQUIPMENT

Fisher & Paykel Healthcare ® Humidifier base (MR850) on IV stand.

Choose circuit and prongs appropriate to the child’s condition, weight and flow

requirements.

o Fisher & Paykel Healthcare ® RT329 Infant Respiratory Care System.

Discard short piece of blue tubing as it is not used in the set-up.

o Appropriate size BC range nasal cannula. See Table 2: Fisher and Paykel

BC Range Nasal Cannula Size Selection.

OR

o Fisher & Paykel Healthcare ® RT330 Circuit - Optiflow Tubing Kit.

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o Appropriate size Optiflow nasal cannula. See Table 3: Fisher And Paykel

Optiflow Junior Nasal Cannula Size Selection To Use With Circuit RT330

Optiflow Tubing Kit.

Fisher & Paykel Temperature / flow probe (900MR868)

Fisher & Paykel Heater wire adaptor (900MR801)

One (1) piece of green tubing approximately 1m – 1.3m long

Two (2) pieces of green tubing approximately 70cm long

Y connector

Analyzer if child weighs 3 – 4 kgs

Pathology bag to hold blue cap if analyzer is being used

1 litre bag of water for irrigation.

15L/min Oxygen flow meter x 2

15L/min air flow meter

Oximeter and appropriate size disposable probe. (See Kaleidoscope Guideline 6.4,

Paediatric Oximetry).

Ensure correct, functional emergency equipment (including suction catheters) are

available.

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TABLE 4: WHO PROCEDURE

Photos by HNE Health Medical Photography Department.

PROCEDURE ADDITIONAL INFORMATION

EQUIPMENT REQUIRED. Ensure you have corresponding nasal prongs

and circuit suitable to the child’s weight and flow

requirements. (See Table 1, F & P Humidifier

Circuits, Corresponding Prongs And Use).

WHO Set ups can be assembled in advance

except for puncturing the water bag.

Set up in treatment room and not next to patient

area

Not all children need an oxygen analyser

however smaller infants weighing 3 to 4 kgs

should have an analyser connected to the

humidifier.

The set up for both RT329 and RT330 are the same

RT329 Infant Respiratory Care

System

RT330 Circuit - Optiflow

Tubing Kit.

CONNECT HUMIDIFIER BASE TO IV POLE:

Place Humidifier Base on metal bracket and

attach to the IV pole.

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FIT THE CHAMBER:

Depress the light blue finger guard above the

temperature readout.

Slide the water chamber onto the humidifier base.

HANG THE WATER BAG:

Hang the 1 litre water bag from the IV pole.

Remove the blue protector caps from top of water

chamber.

Unwind the waterfeed set from white storage

frame.

Spike the waterbag and water will automatically

feed into the chamber.

The bag should be at least 50cm above the

chamber.

CONNECT THE CIRCUIT:

DISCARD SHORT PIECE OF BLUE TUBING

from RT329 circuit set-up as it is not used.

Connect the elbow of the blue inspiratory circuit

to the chamber.

50cmbetweenbag andchamber

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Connect the yellow end of the heater wire

adaptor plug into the yellow socket on side of

machine.

Ensure the arrows on the plug line up with the

arrow on the machine.

Connect the 3 way plug of the heater wire

adaptor to the blue inspiratory circuit which has

been attached to the humidifier.

Connect the blue end of the temperature probe

into blue socket on the side of the humidifier.

Ensure the arrows on the plug line up with the

arrow on the machine.

Connect the middle plug of the temperature

probe into circuit on humidifier.

Be careful of the prongs as the temperature

probe is fragile and breaks easily.

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Connect the end of the temperature probe to

the patient end of the circuit.

Hang circuit from IV stand to keep clean while

you continue with set up.

RT329 Circuit

RT330 Circuit

Connect the white pressure manifold with 3

ports to the chamber. The ports are:

1. Top blue port is the pressure pop off

valve

2. The small middle nipple is a pressure

port for pressure lines, which we do not

utilize.

3. Lower port with blue cap is the oxygen

analyzer port.

DO NOT DISCARD THIS BLUE CAP IF REMOVED

(see below for instructions)

SET UP OXYGEN TUBING:

Take the two shorter pieces of green tubing

(approx. 70cm) and connect to the two top

sections of the Y connector.

Take the longest piece of green tubing (approx.

1m – 1.3m) and connect to the lower end of the

Y connector.

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Take the longest piece of oxygen tubing which

is attached to the end of the Y connector and

connect it to the top of the white pressure

manifold.

Hang green tubing from IV stand to keep clean

while you continue with set up.

CONNECT NASAL CANNULA TO CIRCUIT:

Push distal end of nasal cannula onto blue

inspiratory circuit.

If using RT329 Circuit connect

a nasal cannula from the BC

size selection

If using RT330 Circuit connect

a nasal cannula from the

Optiflow Junior size selection.

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COMPLETE CIRCUIT:

The humidifier may be turned on before it is

attached to wall gas outlets however the

humidifier will not reach its desired temperature

without gas flow.

RT329 Circuit

RT330 Circuit

CONNECT HUMIDIFIER TUBING TO THE WALL

OXYGEN AND AIR SUPPLY:

Take humidifier to bedside.

Add a two way oxygen connector to the wall

oxygen meter before connecting green tubing.This allows O2 high flow meter to be available

for emergency use.

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GAS FLOW:

Connect the two pieces of green tubing to the

oxygen and air flow meters.

Record the air and oxygen flows on the

paediatric respiratory observation chart.

POSITION OF HUMIDIFIER:

Do not set up the WHO under vents or in adraught.

o Cold air on circuit will cause increased

condensation11

.

Ensure humidifier and chamber are positioned

lower than the patient.

o This allows any condensation to collect in

the tubing away from the patient.

TURN HUMIDIFIER ON:

The humidifier will take 10-15 minutes to reach

37.0ºC.

The humidifier needs flow from the wall to reach

desired temperature.

Humidifier must be warmed to at least 30º C before

connecting child to high flow. If the high flow gas is

cool and dry it is uncomfortable for the child.

The button on the right hand side of the humidifier

changes the mode. Keep the humidifier at the

default setting which is Invasive Mode. This is the

recommended setting to provide optimal

humidification for WHO.

Aim is to deliver optimal humidity 37°C (44mg/L

H2O). Temperature readout on humidifier will

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fluctuate between 35-40°C to achieve this.

SAFETY ALERT:

Do not touch the metal heater disk of the base unit

or the bottom of the humidifier chamber as both

become very hot and will burn if the unit is turned

on.

Ensure there is not excessive condensation (water

pooling) in the tubing or cannula. Check that the

tubes are not kinked or tangled.

ATTACHING AN OXYGEN ANALYSER:

An oxygen analyser should be used on infants

3 –4 kgs.

Older children do not require an oxygen

analyser.

To attach an analyzer remove blue plug from

the lower port of the white pressure manifold.

DO NOT DISCARD BLUE PLUG.

Place blue plug in a pathology plastic bag and

attach to the IV stand for safe keeping so it can

be used again once analyser is removed.

Calibrate analyser to room air before placing

oxygen analyser sensor into port

Stand oxygen analyser on patient self

CONNECT CHILD TO WHO:

NOTE:

Connect child to Masimo System for continual

monitoring.

The nasal cannula size should be approximately

half the diameter of the nares (no seal should

be created).

Ensure at least a 2mm gap to the septum2.

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If an occlusive seal is formed between the

prongs and nares excessive pressure may be

generated2.

1. Gel hands.

2. Humidifier must be warmed to at least 30o Celsius

before connecting child to the gas flow as cool dry

gas is uncomfortable for child.

3. Explain the procedure to the child and parents.

4. Clean nares as needed.

5. If using the RT329 Circuit, the BC range of nasal

prongs will need to be taped to cheek.

6. Place a piece of thick Duoderm along each cheek.

(aids protection of skin from pressure) Measure

and cut Hyperfix ready for use.

7. If using the RT330 Circuit, the Optiflow range of

nasal prongs have tape already attached.

8. Remove the adhesive cover of the WigglepadTM

9. Ensure the gas flow is on

10. Ensure the prongs are the correct size for the age

of the child.

11. Gently fit the prongs into the nostrils making sure

the curves of the prongs follow the contour of the

nasal passage.

12. Secure prongs to Duoderm with the premeasured

Hyperfix or remove Wigglepad

TM

backing andsecure to cheeks.

13. DO NOT STICK OPTIFLOW NASAL CANNULAE

TUBING TO FACE WITH HYPERFIX.

14. If the WigglepadTM

adhesive is loose or does not

adhere replace WigglepadTM

.

15. Ensure the tubing is under or over the child’s ears

and behind their head.

16. Nasal prongs should be changed when necessary

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or at least weekly

17. Check every four hours:

Integrity of nasal passages and skin area under

prongs

Integrity of skin on face, ears and head from

metal ringed tubing if using Optiflow Junior

nasal cannula.

The prongs are inserted into the nostrils

Correctly.

Kinking or twisting does not obstruct the flow of

Oxygen10

.

6.2.4 ADDITIONAL NURSING CARE FOR CHILDREN ON WHO VIA NASAL

CANNULAE: (Also See Section 6 – Nursing Care for All Children On

Oxygen Therapy)

The minimum gas flow rate through a Fisher & Paykel RT329 Circuit is 2L/min and

maximum 8L/min.

The minimum gas flow rate through a Fisher & Paykel RT330 Circuit is 1L/min to a

maximum 20L/min.

The maximum gas flow rate for a child on the ward is 1L/kg/min.

The maximum oxygen flow rate for a child on the ward is 60%.

Hourly observation of circuit, water level and prong position

If the child’s oxygen / air flow requirements increase beyond 1 L/kg/min of

flow or 60% oxygen the child needs urgent review +/- transfer to ICU

An oxygen analyzer is to be used on infants 3-4kgs

Be aware that if an oxygen analyzer is used on flows < 1L/kg/min, the read out may

be less accurate due to the child entraining air.

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6.2.5 TRANSPORTING CHILD WHILE ON WHO CURCUIT

To transfer paediatric patients within JHCH who are on WHO take humidifier with

patient.

Transfer the patient with the Fisher & Paykel MR850 turned off. This should be

done when transfer is imminent. The circuit will be warm enough to warm the

oxygen during the transfer. Transfer the patient with an oximeter with appropriate

alarm limits set, an ambu bag/mask, and emergency equipment as appropriate

TABLE 5: PROCEDURE FOR TRANSPORTING PATIENT ON WHO

Obtain an oxygen cylinder for transport and

check that it is full enough to support the

duration of transfer.

Check cylinder for appropriate flow meter

(capable of delivering 2L/min).

Disconnect the long piece of green tubing

from the bottom of the Y connector and

attach it to the flow meter on the oxygen

cylinder.

The end of this piece of tubing will remain

attached to the humidifier manifold for

transfer.

Set flow while flow meter is vertical.

Oxygen Cylinders may be laid on side with

flow meter always kept in upright position

to read accurately.

Adjust flow to 2L/min

Transfer child with Fisher & Paykel MR850

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6.2.6 CLEANING OF WHO

Each circuit, nasal prong and water supply line is disposable.

Y piece is re-usable alcohol wipe reuse oxygen tubing after cleaning with alcohol

wipes

For long term patients, change each circuit after 7 days.

Clean the humidifier base, small grey heater lead with yellow connectors, and stand

with large alcohol wipes after use.

Leads are thoroughly wiped over with alcohol wipes and re set up to decrease the

risk of cross infection and damage. The grey leads are not disposable.

Set up the unit for the next patient.

6.2.7 TROUBLESHOOTING FOR WHO

With the RT329 circuit, gas flows < 0.5 L/m may cause the humidification alarm to

be triggered – increase the gas flow.

Temperature alarms triggered - The blue probes must be pushed into the circuit

carefully and completely in order to monitor the humidity and temperature in the

circuit. Ensure that the connections are firmly matched to each other. The humidifier

base will light up the area of concern on its diagram.

Also refer to Fisher & Paykel Healthcare ® Reference cards attached to the

humidifier unit.

Watch for “rain-out” in the clear prong tubing as this can cause a lavage into the

infant if tubing is raised above the level of the child’s face. This may result in

aspiration.

Watch for condensation in the blue tubing. To remove the condensation from the

tubing, hold up the blue tubing above where you can see the condensation or the

pool of water forming and drain the fluid back into the water chamber.

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6.3 FACE MASK

L/Min FiO2 5 – 10 45 – 60%

The face mask is applied over the mouth and nose. This increases the size of the

oxygen reservoir so that a higher flow rate can be administered.

Improper mask fit may allow room air to dilute oxygen concentration excessively

The vent holes in the mask allow room air to be inspired in addition to the oxygen

being delivered, and the exhaled carbon dioxide to be released.

A minimum gas flow of 5 L/min must be maintained in order to prevent

accumulation of carbon dioxide with subsequent re-breathing

For patient comfort, humidification should be used6,12

.

6.3.1 PROCEDURE FOR FACE MASK APPLICATION:

1. Obtain appropriate size mask and oxygen tubing.

2. Attach 15 litre flow meter to the oxygen outlet on the wall and ensure it is working

3. Explain procedure to the child and family.

4. Securely attach the oxygen tubing to the gas source and set the oxygen to the flowrate required. (To determine the FiO2 that is being delivered from a flow rate see

Appendix 1).

5. Check for gas flow through the device before placing mask on patient.

6. Place the mask over the child’s mouth and nose. Mold the metal strip on the bridge

of the nose portion of the mask to fit the patient’s face ensuring a snug fit to create

a seal.

7. Slip elastic strap over head and above or below both ears and adjust to ensure a

secure but comfortable fit. Gently pull the ends of the strap until the mask is secure

and comfortable

8. Observe child closely:

Connect child to Massimo System for continual monitoring

Continuous monitoring and hourly recording of child’s work of breathing and

observations

Monitor child’s compliance with mask.

9. Do not use for children who are vomiting or have excess secretions due to risk of

aspiration.

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10. If the patient’s oxygen requirements increase consider a partial re-breather or non

re-breather bag and mask.

6.4. PARTIAL RE-BREATHER

L/Min FiO2 6 - 15 35 – 70%

The partial re-breathing bag is similar to the face mask but with the addition of an

oxygen reservoir bag and side ports.

By increasing the oxygen reservoir, the oxygen concentration can be increased to

70%.

The side ports are covered with one-way discs to prevent room air entering the

mask on inspiration and subsequently reducing the FiO213

.

The reservoir bag must remain inflated on inspiration and the oxygen flow rate

regulated so that it is sufficient enough to only deflate the bag by ⅓ on

inspiration6,12

.

When the child inspires, the air is drawn from the bag and through the holes in themask.

On expiration the first ⅓ of air is blown back into the reservoir bag. This air comes

from the anatomic dead space and is still rich in oxygen, humidification and

contains very little carbon dioxide.

On the next inspiration the child inhales part of the previously exhaled air together

with 100% oxygen. This system results in less dilution by room air . 6

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Recommended flow rate is minimum 8 to 15 litres (90-99% FiO2).

The valves between the mask and the reservoir should rise on inspiration and

lower on exhalation. Valves located on external mask surface should open

during exhalation.

6.6. VARIABLE CONCENTRATION MASK

(VENTURI OR AIR-ENTRAINMENT MASK)

L/Min FiO2

12 15 L/min Colour coded jets are attached to mask to deliver desired amount of

oxygen

Blue = 24%; Yellow = 28%; White = 31%; Green = 35%;

Pink = 40%; Orange = 50%

Colour and percentage of oxygen can change between different

manufacturers. Check product information on pack when usung.

Delivers a more accurate concentration of Oxygen than Hudson masks, and is able

to be calibrated with the device and easily monitored.

Requires a minimum flow rate of at least 5 litres / min and is dependent upon the

Oxygen concentration required.

Venturi mask (also called an air-entrainment mask) uses a nozzle to accelerate the

oxygen flow and mix it with air in a precise ratio. The venturi mask can deliver from

24% to 50% oxygen by using different adapters with different sized nozzle openings

varying the size of the opening where the room air enters the system (called

entrainment ports)5.

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6.6.1 VARIABLE CONCENTRATION MASK PROCEDURE:

Follow steps 1 through 10 as per face mask procedure.

Additional Steps

Adjust oxygen flow as per chart using correct colour attachment to deliver required

oxygen %.

6.7 BLOW OVER OXYGEN

This practice is designed for short periods only.

Can be used if child is requiring small amounts of oxygen to correct transient

respiratory compromise.

Can be used when the child is receiving nasal cannula oxygen and has increased

oxygen requirements with feeding or physical activity.

Owing to dilutional effects of ambient air, the effective FiO2, which is the

hypopharyngeal, may be low and is unpredictable14

.

Blow over oxygen is a transient measure and oxygen supplementation is to be

administered by other means if child remains unstable.

The Fio2 cannot be measured.

6.7.1 BLOW OVER OXYGEN PROCEDURE:

Connect oxygen tubing to 100% oxygen.

Adjust flow meter to deliver oxygen at 5 to 10 L/min.

Hold tube with or without mask attached above child’s nose and mouth.

Deliver oxygen by:

- Oxygen mask. Deliver oxygen close to the infant's face. Allow some oxygen to

escape around the mask.

- If using oxygen tubing on its own cup hands around tubing and hold over the

infant's face.

- Once the infant is pink, withdraw the oxygen gradually until the infant remains

pink on room air.

- If the child remains compromised trial child on nasal prongs, mask, or bag and

mask depending clinical assessment15

.

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6.8 TRANSPORT OXYGEN VIA PORTABLE CYLINDER

No need for humidification as only used for short periods

Cylinders may be laid on side

Flow meters must always be kept in upright position to read accurately

Check cylinder for fullness

Check cylinder for appropriate flow meter.

Attach oxygen tubing and delivery device

Adjust flow and place on child

7. WEANING

If the child is under the care of the specialist paediatric respiratory team the

weaning of oxygen is per order of the specialist.

To be commenced when child’s clinical condition is improving as evidenced by

decreased work of breathing and normal respiratory rate, normal cardiovascular

parameters and O2 saturations >95% or as stated in the altered calling criteria.

Infants enrolled in the HFNP WHO Randomised Control Trial (July 16th 2012 –

August 31st 2014 or trial closeout) are to be weaned according to the trial standard

operating procedure (SOP) No.6 – HFNP WHO RCT Procedure Manual.

8. EQUIPMENT CHECK

Care must be taken that all connections are secure and are tight, otherwise a

reduced volume or concentration will be administered.

Check the oxygen is flowing through the flow meter by turning the oxygen supply on

and placing finger at the outlet to feel flow.

Flow meters must be vertical to be read accurately.

Is the tubing twisted, kinked or blocked in some way? Check that all tubing is

connected securely and not kinked at any place.

Ensure the child’s mouth or nose is not obstructed by food, secretions or other

articles.

Ensure the regulator/flow meters are on the correct setting as ordered by the

medical officer6.

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9. DOCUMENTATION

Document the initiation of oxygen therapy, changes in therapy, and the effect

and tolerance of therapy.

All “continuous” and “prn” oxygen therapy must be documented at least once per

shift in the patient’s chart. The following is required documentation

Usage of therapy (continuous or prn)

Mode of delivery

Device

FIO2 and/or liter flow

SpO2

Indication12

Oxygen therapy must be documented on the SPOC hourly.

All other observations and interventions are to be documented on the oxygen chart.

REFERENCES:

1. Warren G. Maguson Clinical Centre: National Institute of Health. Oxygen therapy

procedure. Bethesda, USA

2. Clinical Excellence Commission (2010). Between the flags, keeping patients safe:

Paediatric clinical emergency response system (CERS).

3. Aylott, M. (2006). Observing the sick child: Part 2a respiratory assessment.

Paediatric Nursing, 18, 9 ,38-44.

4. McCance, K., & Huether, S.E. Pathophysiology: The biological basis for disease in

adults and children. 4th Ed. Mosby, Missouri, USA.

5. Pruitt, W. and Jacobs, M. (2003). Breathing lessons: Basics of oxygen therapy.

Nursing 33, 10. 43-45.

6. The Children’s Hospital at Westmead. (2008) Oxygen therapy and delivery devices

procedure.

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7. Sim, M., Dean, P., Kinsella, J., Black, R., Carter, R., and Hughes, M. (2008)

“Performance of Oxygen Delivery Devices when the breathing pattern of respiratory

failure is simulated”. Anaesthesia, 63(9), 938 -940

8. Fell, H. and Boehm, M. (1998) “Easing the discomfort of oxygen therapy”, Nursing

Times, 94(38), 57-58.9. Williams, R., Rankin, N., Smith, T., Galler D. and Seakins, P. (1996). Relationship

between the humidification and temperature of inspired gas and the function of the

airway mucosa. Critical Care Medicine 24(11)

10. Fisher & Paykel Healthcare Product Literature. RT329 Infant Oxygen Therapy

usage System. 2008

11. Fisher & Paykel Healthcare Product Literature. (2012). Optiflow Junior: Easy care,

effective flow.12.Jevon, P. (2007). “Respiratory Procedures” Nursing Times, 103(32), 26 – 27

13. Mayo Health Care, Australia. Product information

http://www.mayohealthcare.com.au/products/Resp_oxygen_variableconcent_

mask.htm

14. Frey, B. and Shann, F. (2002). Oxygen administration in infants. Arch Dis Child

Fetal Neonatal Ed, 88. F84-F88

15. Princess Margaret Hospital for Children. (2010). Paediatric Nursing Practicemanual: 7.2.3 Humidified High Flow Nasal Cannula Therapy for Infants. Perth

DEPARTMENT OF HEALTH CIRCULARS:

NSW Health, (2006) Policy Directive: newborn Infants – Safe oxygen administration

AREA POLICIES:

3.19 Recognition of the deteriorating paediatric patient

6.8 Fisher & Paykel ® Humidification System

6.4 Paediatric Oximetry

The Upper Hunter Emergency Guidelines: July 2004

John Hunter Neonatal Unit Oxygen Therapy Policy: May2003

The New Children’s Hospital, Westmead Oxygen Policy: 2000.

AUTHOR:

Bernadette Goddard – Paediatric General Respiratory Clinical Nurse Consultant

http://www.mayohealthcare.com.au/products/Resp_oxygen_variableconcent_mask.htm





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CONSULTATION:

Dr Bruce Whitehead – Director of Tertiary services / Respiratory Staff specialist JHCH

Linda Cheese – Paediatric Respiratory Clinical Nurse Consultant

Dr Larry Roddick – Paediatric Staff SpecialistDr Mark Lee – Paediatric Emergency Staff Specialist

Elizabeth Kepreotes – Clinical Improvement Coordinator

Leanne Lehle – H1 NUM

Elizabeth Newham – Paediatric Nurse Educator

APPROVED: CPGAG 16th July 2012

KGN Quality and Safety Committee – 24

th

July 2012

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Appendix 1: Determining FiO2 Delivered from the Outlet Flow

OXYGEN DELIVERY DEVICE OUTLET FLOW RATE

[LITRES / MIN ]

FiO2

Nasal Cannulae 1

2

24%

28%

Simple Mask 5

6

7

89

10

45%

50%

55%60%

60-65%

Partial Rebreather 6

8

10

12

15

35%

50%

60%

60-65%

65-70%

Non – Rebreather

10

12

15

70-80%

80-85%

85-90%

Venturi Mask Flow rate as indicated on

entrainment device

24%, 28%

30%, 35%40%, 50%

Disposable infant head box

‘Foldadome’

10

15

up to 50%

over 50%

If available confirm with oxygen

analyser

FiO2 is influenced by patient inspiratory demand. FiO2 amounts are derived from the

manufacturer’s product information and are approximations for the adult population.

THESE FIGURES ARE A GUIDE AND WILL DIFFER FOR THE PAEDIATRIC POPULATION. The exception is Venturi mask FiO2 figures which should remain constant regardless of

inspiratory demand.

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Appendix 2: Air and Oxygen Blends for WHO Fisher & Paykel Healthcare ® (2012)

FiO2O2 Flow

L/min

Air Flow

L/min

TOTAL

Flow L/minFiO2

O2 Flow

L/min

Air Flow

L/min

TOTAL

Flow L/min

21% 0 2

2

21% 0 7

7

30% 0.2 1.8 30% 1 6

40% 0.5 1.5 40% 2 5

50% 0.7 1.3 50% 3 4

60% 1 1 60% 3.5 3.5

21% 0 3

3

21% 0 8

8

30% 0.5 2.5 30% 1 7

40% 0.8 2.2 40% 2 6

50% 1 2 50% 3 5

60% 1.5 1.5 60% 4 4

21% 0 4

4

21% 0 9

9

30% 0.5 3.5 30% 1 8

40% 1 3 40% 2 7

50% 1.5 2.5 50% 3.5 5.5

60% 2 2 60% 4.5 4.5

21% 0 5

5

21% 0 10

10

30% 0.5 4.5 30% 1 9

40% 1 4 40% 2.5 7.5

50% 2 3 50% 3.5 6.5

60% 2.5 2.5 60% 5 5

21% 0 6

6

30% 0.5 5.5

40% 1.5 4.5

50% 2.5 3.5

60% 3 3

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Air and Oxygen Blends for WHO Fisher & Paykel Healthcare ® (2012)

FiO2O2 Flow

L/min

Air Flow

L/min

TOTAL

Flow L/minFiO2

O2 Flow

L/min

Air Flow

L/min

TOTAL

Flow L/min

21% 0 11

11

21% 0 16

16

30% 1 9 30% 2 14

40% 3 8 40% 4 12

50% 4 7 50% 6 10

60% 5.5 5.5 60% 8 8

21% 0 12

12

21% 0 17

17

30% 1.5 10.5 30% 2 15

40% 3 9 40% 4 13

50% 4.5 7.5 50% 6 11

60% 6 6 60% 8.5 8.5

21% 0 13

13

21% 0 18

18

30% 1.5 11.5 30% 2 16

40% 3 10 40% 4.5 13.5

50% 5 8 50% 6 12

60% 6.5 6.5 60% 9 9

21% 0 14

14

21% 0 19

19

30% 1.5 12.5 30% 2 17

40% 3.5 10.5 40% 4.5 14.5

50% 5 9 50% 7 12

60% 7 7 60% 9.5 9.5

21% 0 15

15

21% 0 20

20

30% 1.5 13.5 30% 2 18

40% 3.5 11.5 40% 5 15

50% 5.5 9.5 50% 7.5 12.5

60% 7.5 7.5 60% 10 10

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