Download Oxygen Therapy in Newborns

Title:
Oxygen Therapy in Newborns
NEONATAL CLINICAL
PRACTICE GUIDELINE
1.0
Pages:
1 of 4
Supercedes:
HSC #80.275.554
SBH #119
PURPOSE AND INTENT:
1.1
2.0
Approval Date:
March 2015
Approved by:
Neonatal Patient Care Teams, HSC & SBH
Child Health Standards Committee
To provide a process for the therapeutic use of oxygen for neonates in the neonatal units (includes
Neonatal Intensive Care Units and Intermediate Care Nursery).
PRACTICE OUTCOME
2.1
Oxygen is a drug with potentially significant dangerous side effects. Avoiding hypoxia is important, but
prolonged hyperoxia leads to oxidative stress and injury. There is no evidence that very low birth weight
infants need to be managed with an FIO2 that leads to surface oxygen saturation levels (SpO2) of 95% to
100%. These levels are harmful.
Note: All recommendations are approximate guidelines only and practitioners must take in to account
individual patient characteristics and situation. Concerns regarding appropriate treatment must be
discussed with the attending neonatologist.
3.0
GUIDELINES
3.1
Provide therapeutic oxygen at < 100% to neonates requiring resuscitation at the time of delivery or
shortly after according to the guidelines found in the Neonatal Resuscitation Program (NRP) from the
Canadian Pediatric Society.
3.2
For all newly born infants who require resuscitation with positive pressure ventilation begin using room
air.
EXCEPTION: In infants with a high risk of underlying lung disease it is acceptable to start with an
increased oxygen concentration at the discretion of the resuscitating physician. Usually this should not
exceed an FiO2 of 0.40
3.3
In the delivery area, if supplemental oxygen is required after 15 minutes of age, initiate nasal prongs or
nasal continuous positive pressure and maintain as defined in the General Guidelines contained in this
document. Determine the exact oxygen requirements using the “Low Flow Oxygen FiO2 calculator”, or
consult a Respiratory Therapist.
3.4
For neonates requiring positive pressure ventilation (PPV) or resuscitation in newborn areas, , provide
oxygen during PPV/resuscitation according to the following guidelines:
3.4.1
Presently on room air; initiate PPV/resuscitation with positive pressure ventilation using room
air (FiO2: 0.21). Increase oxygen as needed as defined in section 2.4.
3.4.2
Presently receiving oxygen therapy; initiate resuscitation with positive pressure ventilation
using the FiO2 the patient is presently on (ordered oxygen therapy). Increase oxygen as
needed as defined in section 2.4.
3.4.3
Mechanical ventilation; initiate resuscitation with positive pressure ventilation using the FiO 2
the patient is presently on (ordered oxygen therapy). Increase oxygen as needed as defined in
section 2.4.
3.5
Initiate O2 saturation monitoring within the first minute after birth.
3.6
Adjust inspired Oxygen concentration used during resuscitation according to the following guidelines:
3.6.1
If using a flow inflating bag (i.e. Jackson Reese):
Oxygen Therapy in Newborns
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3.6.2
If heart rate <100 after 60 seconds of PPV at the starting FiO2 increase the FiO2 by 0.2 every
60 seconds until the heart rate is >100. I.E. oxygen starting at room air would then jump to 0.4 0.6 - 0.8 – 1.0 with an increase every 60 seconds of poor response. Once heart rate is >100,
FiO2 should be adjusted according to O2 saturation.
If using a self-inflating bag without blended oxygen (i.e. Laerdal):
Increase the FiO2 to 1.00 by turning on oxygen. Remove the reservoir to attain approximately
40% oxygen.
3.7
Initiate O2 saturation monitoring for all infants receiving supplemental O2.
3.8
For patients on oxygen with a Masimo® monitor, report the histogram obtained from the monitor daily
during morning rounds and as requested by attending physician. The goal for the histogram is for the
infant to spend 80% of time in the target range.
3.9
Deliver nasal prong O2 using a low-flow meter / O2 blender
3.10
Assess nasal prongs for patency at least once a shift and prn when there is suspicion of blocked prongs
from copious nasal secretions or there is unexplained need for increased flow. Assess patency using the
“bubble test” where the prongs are removed from the patient and placed under the surface distilled
water in a cup.
3.11
Ensure a resuscitation bag is available at the bedside at all times.
3.11.1 For patients requiring respiratory support connect a Jackson Reese bag to the blender with a
“Y-type” connector in order to deliver O2 at the same level as the nasal prongs are set.
3.11.2 For patients not requiring respiratory support use a Laerdal bag with reservoir connected to a
flow meter.
3.12
When initiating nasal prongs on infants previously intubated or on nasal CPAP, set the O 2 blender to the
same percentage as was set on the previous mode of support.
3.13
For nasal prongs set the low flow meter at 0.5 lpm unless otherwise ordered by the physician.
3.14
Follow the target oxygen saturation range and alarm limits as outlined in APPENDIX A.
3.15
For infants with frequent, non-clinically significant low saturation alarms, set the lower alarm limit lower
with a physician’s order. The lowest setting is 80. The target range remains the same.
3.16
When adjusting oxygen to meet target O2 saturation range do not exceed .05, or 5% above or below
previous level. (ie. If O2 set at 30%, adjust up to 35% or down to 25%). Adjustments may be smaller
than .05.
3.16.1 When the saturation levels drop below the target range, assess ventilation before adjusting
oxygen
3.16.2 Observe O2 saturation every 1-2 minutes and make O2 adjustments until the saturation level is
stable for 3- 5 minutes.
3.16.3 If O2 is increased wean back down as early as possible after adequate oxygenation is
established.
3.17
When the O2 blender is set at FiO2 1.0 and the infant’s O2 saturation remains below the target range
increase the flow from the flowmeter by 0.1 lpm every 1-2 minutes until it reaches 1.0 lpm or the O2
saturation is within the target range for that infant and notify physician/NNP/CA.
3.18
If the O2 saturation does not reach the target range with an increase in 10% with respiratory support, or
20% if on nasal prongs, notify physician/NNP/CA.
3.19
For infants who fluctuate frequently between room air and small amounts of oxygen set the alarm limits
as outlined in 3.8 if the infant requires oxygen for longer than 30 minutes.
3.20
Attempt weaning oxygen when saturation levels are within the target range.
Oxygen Therapy in Newborns
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3.21
4.0
PRIMARY AUTHORS
6.1
6.2
6.3
6.4
5.0
Discontinue nasal prongs when the flow meter is at 0.5 lpm and the FiO2 is 0.21 with the O2 saturation
stable within the target range.
Respiratory Therapy Clinical Specialists: John Minski (HSC), Joe Millar (SBH)
Neonatal Intensive Care Unit, Assistant Medical Directors: Dr. John Baier (HSC), Dr. Ruben Alvaro
(SBH)
Neonatal Intensive Care Unit, Clinical Nurse Specialists: Barbara Wheeler (SBH), Doris SawatzkyDickson (HSC)
Neonatal Intensive Care Unit, Nurse Educators: Karen Bodnaryk (HSC) Tanya Tichon (HSC), Ceceile
Porter (SBH)
REFERENCES
7.1
American Heart Association, Canadian Paediatric Society, American Academy of Pediatrics (2006).
th
Neonatal Resuscitation Program 5 Edition, John Kattwinkel (ed.)
7.2
Anderson, C.G., Benitz, W.E., & Madan, A. (2004) Retinopathy of prematurity and pulse oximetry: a
national survey of recent practices. Journal of Perinatology, March 24 (3), 164-8.
7.3
Askie, L.M., Henderson-Smart, D.J., Irwig, L., & Simpson, J.M. (2003) Oxygen-Saturation Targets and
Outcomes in Extremely Preterm Infants. New England Journal of Medicine, 349 (10), 959-67.
7.4
Askie, L.M. & Tin, W. (2003) The Use of Oxygen in Neonatal Medicine: Half a Century of Uncertainty
Neonatal Reviews, 4 (12), E340-48.
7.5
Canadian Pediatric Society (2006). Addendum to the 2006 NRP Textbook.
7.6
Chow, L.C., Wright, K.W., & Sola, A. (2003) CSMC Oxygen Administration Study Group. Can changes
in clinical practice decrease the incidence of severe retinopathy of prematurity in very low birth weight
infants? Pediatrics, February 111 (2), 339-45.
7.7
Polin, R.A. & Bateman, D. (2013). Oxygen-saturation targets in preterm infants. The New England
Journal of Medicine 22, 2141 – 2142.
7.8
Ramji, S., Saugstad, O.D., & Jain, A. (2015). Current concepts of oxygen therapy in
neonates. Indian Journal of Pediatrics 82(1), 46 - 52.
7.9
Saugstad, O.D. & Aune, D. (2013). Optimal oxygenation of extremely low birth weight infants: a
meta-analysis and systematic review of the oxygen saturation target studies. Neonatology 105, 55 63.
7.10
Saugstad, O.D. (2001) Is Oxygen More Toxic Than Currently Believed? Pediatrics, 5 (8), 1203-05.
7.11
Synnes, A. & Miller, S.P. (2015). Oxygen therapy for preterm neonates: the elusive optimal
target. JAMA Pediatrics, 9 Feb 2015, E1 – E2.
7.12
Newnam, K.M. (2014). Oxygen saturation limits and evidence supporting the targets. Advances in
Neonatal Care 14(6), 402 – 409.
7.13
Tin, W., Milligan, D.W.A., Pennefather, P., & Hey, E. (2001) Pulse oximetry, severe retinopathy, and
outcome at one year in babies of less than 28 weeks gestation. Archives of Disease in Children: Fetal
and Neonatal Edition, (84), F106-10.
7.14
Richmond, S.,Goldsmith, J.P. (2006) Air or 100% oxygen in neonatal resuscitation? Clinics in
Perinatology 33(1), 11-27.
7.15
Kamlin, C.O., O’Donnell, C.P.F., Davis, P.G., Morley, C.J. (2006) Oxygen saturation in healthy infants
immmediately after birth. Journal of Pediatrics 148(5), 585-589.
7.16
Rabi, Y., Yee, W., Chen, S.Y., Singhal, N. (2006) Oxygen saturation trends immediately after birth.
Journal of Pediatrics, 148(5), 590-594.
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APPENDIX A
Oxygen Saturation Goal Range and Alarm Limits
Health Sciences Centre:
Infant Description
O2 Saturation Range
Alarm Limits (low-high)
Term and Preterm
88-92%
85 - 94
Chronic Respiratory Disease >37
88-92% ors per
85 - 94
weeks PMA
physician/NNP/CA order
Infant with Pulmonary Hypertension
88-92% or as per
physician/NNP/CA order
Cyanotic congenital heart disease
per physician/NNP/CA
85 – 94 (usually preductal)
per physician/NNP/CA order
order
Any infant on room air
N/A
85 - 101
Infant Description
O2 Saturation Range
Alarm Limits (low-high)
Term and Preterm > 32 wks
90 - 94%
87 – 95
Acute Preterm ≤ 32 wks
88-92%
85 - 95
Chronic Preterm > 32 wks PCA
90-94%
87 - 95
Infant with Pulmonary Hypertension
As per physician/NNP order
Any infant on room air
N/A
No need for high alarm
Cyanotic congenital heart disease
per physician/NNP/CA order
per physician/NNP/CA order
St. Boniface Hospital