OXYGEN THERAPY FOR CHILDREN

Children with lung disease can have low levels of oxygen in their bodies and some need to use extra (supplemental) oxygen in order to bring their oxygen levels up to a healthier level. Children with lung diseases such as bronchopulmonary dysplasia (BPD) or cystic fibrosis (CF) may require oxygen therapy. Extra oxygen protects their bodies from the effects of low oxygen levels, helps them to function better, and allows them to stay more active.

Why do some children need oxygen therapy? Oxygen is a basic need for all humans. The air we breathe contains about 21 percent oxygen at sea level. This amount is enough for children who have healthy lungs and many with lung disease. However, some children with lung disease are unable to get enough oxygen in their bodies through normal breathing. They require extra oxygen to maintain normal function. How do I know if my child needs oxygen? A healthcare provider will figure out if your child needs oxygen therapy by testing the level of oxygen in his or her blood. This test is called an arterial blood gas (ABG). Blood is drawn from an artery (usually in the wrist). Your childs oxygen level (oxygen saturation or O2 Sat) can also be measured with a small device called a pulse oximeter. This device can be clipped painlessly on to your childs finger, toe or earlobe. With this device, O2 sats can be checked over a period of time, for example, during sleep or exercise. The general goal is to keep your

childs oxygen at a level that meets the bodys need for oxygen, usually 90% O2 sat or higher. How much oxygen should my child take? Oxygen is a medical treatment. A healthcare provider writes a prescription for the amount of oxygen needed. The provider will prescribe an oxygen setting or flow rate. You may need to use a different setting or flow rate for different activities, for example during exercise, eating, and sleep. It is very important that you use the oxygen exactly as it has been prescribed. Using too little may stress your childs brain and heart, resulting in fatigue, memory loss or changes in heart function. Too much oxygen can also be a problem at times, especially for the lungs. Will my child need oxygen during sleep? During sleep, people slow down their breathing and may not breathe as deeply. If a person has a low oxygen level while awake, usually he or she will have lower levels during sleep. In some cases, children who may not sleeping. need extra oxygen while awake may need oxygen while The healthcare provider will help you figure out

if and how much oxygen your child should use at night. Will my child need oxygen during physical activity? During any physical activity, a person breaths in faster and deeper to get more oxygen. To find out how much oxygen is needed during physical activity, the provider can have your child do a walk test while

measuring his or her oxygen saturation. Young children and infants can be observed during play activities and feeding.

How many hours per day will my child need oxygen? Some children only need to use extra oxygen when they are active or while sleeping. However, in some cases, a child needs extra oxygen 24 hours a day. At times, your child may seem fine to you. Your child may not appear to be low in oxygen or have blue skin or lips. However, this does not always mean his or her bodys oxygen level is ideal. It is best to have your childs oxygen level checked if you are not sure how much oxygen is needed. Sometimes a pulse oximeter is sent home for you to use. Will my child always need to use oxygen? Many children who require extra oxygen to treat their chronic lung problem will need to continue their oxygen therapy. Some children may need to use extra oxygen only during a disease flare-up or infection. They may be able to reduce or stop its use if their condition improves. You should never reduce or stop your childs oxygen therapy on your own. Talk to your childs health care provider if you think a change in your childs oxygen therapy is needed. What are the different kinds of oxygen systems? Oxygen can be delivered from three types of sources: An oxygen concentrator, liquid oxygen system, or oxygen pressurized in a metal cylinder (tank). The right choice for your child depends on how much is needed, and your childs daily activities. Other things to keep in mind are where you live, costs, and insurance restrictions. What are oxygen concentrators?

An oxygen concentrator produces oxygen by concentrating the oxygen that is already in the air and removing other gases. The concentrator is powered by electricity. What is liquid oxygen? Liquid oxygen is made by super-cooling oxygen gas, changing it to a liquid form. When in liquid form, oxygen takes up much less room and can be stored in a special container. What are oxygen cylinders? Oxygen is compressed into a metal cylinder (also called a tank) under high pressure. Oxygen may be stored in either large or small cylinders. What is a nasal cannula? A nasal cannula is a tube that has two prongs to go in the nose passages (nostrils) . The tube is attached to the oxygen system. Different sizes of nasal cannula are available and some tubes are softer than others. What are oxygen conserving devices? Oxygen conserving devices make the delivery of oxygen more efficient, and reduce the amount of oxygen that is wasted. There are several types of oxygen conserving devices, however, they cannot be used by many younger children. How do I help my child be comfortable using oxygen? Some children resist wearing nasal cannula or a mask on their face. Sometimes it helps to let them play with a spare mask, see it on another child, or put one on a favorite stuffed animal. Praise the child for keeping the tube or mask on his or her face. If your childs nose gets irritated from the nasal cannula, you can switch to a face mask.

Remember that there is more leak of oxygen around the mask so the lowest level of oxygen flow used with a face mask is 5 liters. If you use a very high flow with nasal cannula, it can be more irritating to the nose. If more than that is needed, you should switch to a face mask. Using a humidifier to help keep the oxygen moist can help prevent nose irritation from dry air. What should I watch out for while my child uses oxygen therapy? If your child is very drowsy or tired, has morning headaches, or seems short of breath, you need to contact your doctor. If your child or infant on oxygen seems tired, less active, is breathing harder, or has blue lips or nail beds, call your childs doctor. Do I have to worry about oxygen exploding or burning? Oxygen alone will not explode and does not burn, but oxygen will make a flame hotter and burn stronger. Never smoke around oxygen devices or a person using oxygen. Keep oxygen at least 6 feet (2 meters) away from any open flame. Stabilize all cylinders by placing carts in a safe place or by securing them to a wall. Remember: oxygen is safe and helpful if it is used according to directions. What do we need to do when my child travels? Your child can travel even on oxygen therapy. However, travel with oxygen requires careful planning well in advance of your trip. Check with your transportation company (airline, train, bus, boat) about its policies for travel with oxygen. Contact your oxygen company to arrange for your oxygen supply during your trip. Make sure that you have plenty of oxygen in case of delays or emergencies. Keep a copy of your childs oxygen and

medicine prescriptions with you. You should keep emergency numbers handy (healthcare provider, oxygen supply company, and get names of local doctors and hospitals where you are traveling to) just in case.

OXYGEN THERAPY
Oxygen therapy is the administration of oxygen as a medical intervention, which can be for a variety of purposes in both chronic andacute patient care. Oxygen is essential for cell metabolism, and in turn, tissue oxygenation is essential for all normal physiological functions. High blood and tissue levels of oxygen can be helpful or damaging, depending on circumstances and oxygen therapy should be used to benefit the patient by increasing the supply of oxygen to the lungs and thereby increasing the availability of oxygen to the body tissues, especially when the patient is suffering from hypoxia and/or hypoxaemia.

Indications for use Oxygen is used as a medical treatment in both chronic and acute cases, and can be used in hospital, pre-hospital or entirely out of hospital, dependant on the needs of the patient and their medical professionals' opinions.

Use in chronic conditions A common use of supplementary oxygen is in patients with chronic obstructive pulmonary disease(COPD),the occurrence of chronic bronchitis or emphysema, a common long term effect of smoking, who may require additional oxygen to breathe either during a temporary worsening of their condition, or throughout the day and night. It is indicated in COPD patients with PaO2 55mmHg or SaO2 88% and has been shown to increase lifespan. Oxygen is often prescribed for people with breathlessness, in the setting of end-stage cardiac or respiratory failure, advanced cancer or neurodegenerative disease, despite having relatively normal blood oxygen levels. A 2010 trial of 239 subjects found no significant difference in reducing breathlessness between oxygen and air delivered in the same way.

Use in acute conditions Oxygen is widely used in emergency medicine, both in hospital and byemergency medical services or advanced first aiders. In the pre-hospital environment, high flow oxygen is definitively indicated for use in resuscitation, major trauma, anaphylaxis, major haemorrhage, shock, activeconvulsions and hypothermia. It may also be indicated for any other patient where their injury or illness has caused hypoxaemia, although in this case oxygen flow should be moderated to achieve target oxygen saturation levels, based on pulse oximetry (with a target level of 9498% in most patients, or 8892% in COPD patients).

For personal use, high concentration oxygen is used as home therapy to abortcluster headache attacks, due to its vaso-constrictive effects. Storage and sources

Gas cylinders containing oxygen to be used at home. When in use a pipe is attached to the cylinder's regulator and then to a mask that fits over the patient's nose and mouth.

A home oxygen concentrator in situ in anemphysema patient's house.

Oxygen can be separated by a number of methods, includingchemical reaction and fractional distillation, and then either used immediately or stored for future use. The main types sources for oxygen therapy are: Liquid storage Liquid oxygen is stored in chilled tanks until required, and then allowed to boil (at a temperature of 90.188 K (182.96 C)) to release oxygen as a gas. This is widely used at hospitals due to their high usage requirements, but can also be used in other settings. SeeVacuum Insulated Evaporatorfor more information on this method of storage. Compressed gas storage the oxygen gas is compressed in a gas cylinder, which provides a convenient storage, without the requirement for refrigeration found with liquid storage. Large oxygen cylinders hold 6,500 litres (230 cu ft) and can last about two days at a flow rate of 2 litres per minute. A small portable M6 (B) cylinder holds 164 or 170 litres (5.8 or 6.0 cu ft) and weighs about 1.3 to 1.6 kilograms (2.9 to 3.5 lb). These tanks can last 46 hours when used with a conserving regulator, which senses the patient's breathing rate and sends pulses of oxygen. Conserving regulators may not be usable by patients who breathe through their mouths. Instant usage The use of an electrically powered oxygen concentrator or a chemical reaction based unit[8] can create sufficient oxygen for a patient to use immediately, and these units (especially the electrically powered versions) are in widespread usage for home oxygen therapy and portable personal oxygen, with the advantage of being continuous supply without the need for additional deliveries of bulky cylinders.

Delivery

Various devices are used for administration of oxygen. In most cases, the oxygen will first pass through a pressure regulator, used to control the high pressure of oxygen delivered from a cylinder (or other source) to a lower pressure. This lower pressure is then controlled by a flowmeter, which may be preset or selectable, and this controls the flow in a measure such as litres per minute (lpm). The typical flowmeter range for medical oxygen is between 0 and 15 lpm with some units able to obtain up to 25 liters per minute. Many wall flowmeters using a Thorpe tube design are able to be dialed to "flush" which is beneficial in emergency situations.

Supplemental oxygen Many patients require only a supplementary level of oxygen in the room air they are breathing, rather than pure or near pure oxygen, and this can be delivered through a number of devices dependant on the situation, flow required and in some instances patient preference. A nasal cannula (NC) is a thin tube with two small nozzles that protrude into the patient's nostrils. It can only comfortably provide oxygen at low flow rates, 2 6 litres per minute (LPM), delivering a concentration of 2440%. There are also a number of face mask options, such as the simple face mask, often used at between 6 and 12 LPM, with a concentration of oxygen to the patient of between 28% and 50%. This is closely related to the more controlledairentrainment masks, also known as Venturi masks, which can accurately deliver a predetermined oxygen concentration to the trachea up to 40%.

In some instances, a partial rebreathing mask can be used, which is based on a simple mask, but featuring a reservoir bag, which increases the provided oxygen rate to 4070% oxygen at 5 to 15 LPM. Non-rebreather masks draw oxygen from an attached reservoir bags, with one-way valves that direct exhaled air out of the mask. When properly fitted and used at flow rates of 10-15 LPM or higher, they deliver close to 100% oxygen. This type of mask is indicated for acute medical emergencies. Demand valves or oxygen resuscitators deliver oxygen only when the patient inhales, or, in the case of an apnic (non-breathing) victim, the caregiver presses a button on the mask. These systems greatly conserve oxygen compared to steadyflow masks, which is useful in emergency situations when a limited supply of oxygen is available and there is a delay in transporting the patient to higher care. They are very useful in performing CPR, as the caregiver can deliver rescue breaths composed of 100% oxygen with the press of a button. Care must be taken not to over-inflate the patient's lungs, and some systems employ safety valves to help prevent this. These systems may not be appropriate for unconscious patients or those in respiratory distress, because of the effort required to breathe from them. High flow oxygen delivery In cases where the patient requires a flow of up to 100% oxygen, a number of devices are available, with the most common being the non-rebreather mask (or reservoir mask), which is similar to the partial rebreathing mask except it has a series of one-way valves preventing exhaled air from returning to the bag. There should be a minimum flow of 10 L/min. The delivered FIO2 of this system is 6080%, depending on the oxygen flow and breathing pattern. High flows of warmed and humidified air/oxygen blends can also be delivered via a nasal cannula,

allowing the patient to continue to talk, eat and drink while still receiving the therapy. In specialist applications such as aviation, tight fitting masks can be used, and these also have applications in anaesthesia, carbon monoxide poisoningtreatment and in hyperbaric oxygen therapy

Positive pressure delivery Patients who are unable to breathe on their own will require positive pressure to move oxygen in to their lungs for gaseous exchange to take place. Systems for delivering this vary in complexity (and cost), starting with a basic pocket maskadjunct which can be used by a basically trained first aider to manually deliverartificial respiration with supplemental oxygen delivered through a port in the mask. Many emergency medical service and first aid personnel, as well as hospitals, will use a bag-valve-mask (BVM), which is a malleable bag attached to a face mask (or invasive airway such as an endotracheal tube or laryngeal mask airway), usually with a reservoir bag attached, which is manually manipulated by the healthcare professional to push oxygen (or air) in to the lungs. This is the only procedure allowed for initial treatment of cyanide poisoning in the UKworkplace. Automated versions of the BVM system, known as a resuscitator or pneupac can also deliver measured and timed doses of oxygen direct to patient through a facemask or airway. These systems are related to the anaesthetic machinesused in operations under general anaesthesia that allows a variable amount of oxygen to be

delivered, along with other gases including air, nitrous oxide andinhalational anaesthetics.

As a drug delivery route Oxygen therapy can also be used as part of a strategy for delivering drugs to a patient, with the usual example of this being through a nebulizer mask, which delivers nebulizable drugs such as salbutamol or epinephrine into the airways by creating a vapor-mist from the liquid form of the drug.

Filtered oxygen masks Filtered oxygen masks have the ability to prevent exhaled, potentially infectious particles from being released into the surrounding environment. These masks are normally of a closed design such that leaks are minimized and breathing of room air is controlled through a series of one-way valves. Filtration of exhaled breaths is accomplished either by placing a filter on the exhalation port, or through an integral filter that is part of the mask itself. These masks first became popular in the Toronto (Canada) healthcare community during the 2003 SARS Crisis. SARS was identified as being respiratory based and it was determined that conventional oxygen therapy devices were not designed for the containment of exhaled particles. Common practices of having suspected patients wear a surgical mask was confounded by the use of standard oxygen therapy equipment. In 2003, the HiOx80 oxygen mask was released for sale. The HiOx80 mask is a closed design mask that allows a filter to be placed on the exhalation port.

Several new designs have emerged in the global healthcare community for the containment and filtration of potentially infectious particles. Other designs include the ISO-O2 oxygen mask, the Flo2Max oxygen mask, and the O-Mask. The use of oxygen masks that are capable of filtering exhaled particles is gradually becoming a recommended practice for pandemic preparation in many jurisdictions. Because filtered oxygen masks use a closed design that minimizes or eliminates inadvertent exposure to room air, delivered oxygen concentrations to the patient have been found to be higher than conventional non-rebreather masks, approaching 99% using adequate oxygen flows. Because all exhaled particles are contained within the mask, nebulized medications are also prevented from being released into the surrounding atmosphere, decreasing the occupational exposure to healthcare staff and other patients. Negative effects Many EMS protocols indicate that oxygen should not be withheld from any patient, while other protocols are more specific or circumspect. However, there are certain situations in which oxygen therapy is known to have a negative impact on a patients condition. Oxygen should never be given to a patient who is suffering from paraquat poisoning unless they are suffering from severe respiratory distress or respiratory arrest, as this can increase the toxicity. (Paraquat poisoning is rare for example 200 deaths globally from 1958 to 1978). Oxygen therapy is not recommended for patients who have suffered pulmonary fibrosis or other lung damage resulting from bleomycin treatment.

High levels of oxygen given to infants causes blindness by promoting overgrowth of new blood vessels in the eye obstructing sight. This is retinopathy of prematurity (ROP). Oxygen has vasoconstrictive effects on the circulatory system, reducing peripheral circulation and was once thought to potentially increase the effects ofstroke. However, when additional oxygen is given to the patient, additional oxygen is dissolved in the plasma according to Henry's Law. This allows a compensating change to occur and the dissolved oxygen in plasma supports embarrassed (oxygen-starved) neurons, reduces inflammation and post-stroke cerebral edema. Since 1990, hyperbaric oxygen therapy has been used in the treatments of stroke on a worldwide basis. In rare instances, hyperbaric oxygen therapy patients have had seizures. However, because of the aforementioned Henry's Law effect of extra available dissolved oxygen to neurons, there is usually no negative sequel to the event. Such seizures are generally a result ofoxygen toxicity, although hypoglycemia may be a contributing factor, but the latter risk can be eradicated or reduced by carefully monitoring the patient's nutritional intake prior to oxygen treatment. Oxygen first aid has been used as an emergency treatment for diving injuries for years. Recompression in a hyperbaric chamber with the patient breathing 100% oxygen is the standard hospital and military medical response todecompression illness. The success of recompression therapy as well as a decrease in the number of recompression treatments required has been shown if first aid oxygen is given within four hours after surfacing. There are suggestions that oxygen administration may not be the most effective measure for the treatment of decompression illness and that heliox may be a better alternative.

Chronic obstructive pulmonary disease Care needs to be exercised in patients with chronic obstructive pulmonary disease, such as emphysema, especially in those known to retain carbon dioxide (type II respiratory failure). Such patients may further accumulate carbon dioxide and decreased pH (hypercapnation) if administered supplemental oxygen, possibly endangering their lives. This is primarily as a result ofventilation perfusion imbalance (see Effect of oxygen on chronic obstructive pulmonary disease). In the worst case, administration of high levels of oxygen in patients with severe emphysema and high blood carbon dioxide may reduce respiratory drive to the point of precipitating respiratory failure, with an observed increase in mortality compared with those receiving titrated oxygen treatment. However, the risk of the loss of respiratory drive are far outweighed by the risks of withholding emergency oxygen, and therefore emergency administration of oxygen is never

contraindicated. Transfer from field care to definitive care, where oxygen use can be carefully calibrated, typically occurs long before significant reductions to the respiratory drive. A 2010 study has shown that titrated oxygen therapy (controlled administration of oxygen) is less of a danger to COPD patients and that other, nonCOPD patients, may also, in some cases, benefit more from titrated therapy.

Fire risk Highly concentrated sources of oxygen promote rapid combustion. Oxygen itself is not flammable, but the addition of concentrated oxygen to a fire greatly increases its intensity, and can aid the combustion of materials (such as metals) which are relatively inert under normal conditions. Fire and explosionhazards exist

when concentrated oxidants and fuels are brought into close proximity; however, an ignition event, such as heat or a spark, is needed to trigger combustion. A wellknown example of an accidental fire accelerated by pure oxygen under pressure occurred in the Apollo 1 spacecraft in January 1967 during a ground test; it killed all three astronauts. A similar accident killed Soviet cosmonaut Valentin Bondarenko in 1961. Combustion hazards also apply to compounds of oxygen with a high oxidative potential, such as peroxides, chlorates, nitrates, perchlorates,

and dichromatesbecause they can donate oxygen to a fire. Concentrated O2 will allow combustion to proceed rapidly and

energetically. Steel pipes and storage vessels used to store and transmit both gaseous andliquid oxygen will act as a fuel; and therefore the design and manufacture of O2systems requires special training to ensure that ignition sources are minimized. Highly concentrated oxygen in a high-pressure environment can spontaneously ignite hydrocarbons such as oil and grease, resulting in fire or explosion. The heat caused by rapid pressurization serves as the ignition source. For this reason, storage vessels, regulators, piping and any other equipment used with highly concentrated oxygen must be "oxygen-clean" prior to use, to ensure the absence of potential fuels. This does not apply only to pure oxygen; any concentration significantly higher than atmospheric (approximately 21%) carries a potential risk. Hospitals in some jurisdictions, such as the UK, now operate no -smoking policies, which although introduced for other reasons, supports the aim of keeping ignition sources away from medical piped oxygen. Other recorded sources of ignition of medically prescribed oxygen include candles, aromatherapy, medical

equipment, cooking, and unfortunately, deliberate vandalism. Smoking pipes, cigars and cigarettes are of special concern. This does not entirely eliminate the risk of injury with portable oxygen systems, especially if compliance is poor.

Oxygen therapy while on aircraft In the United States, most airlines restrict the devices allowed on board aircraft. As a result passengers are restricted in what devices they can use. Some airlines will provide cylinders for passengers with an associated fee. Other airlines allow passengers to carry on approved portable concentrators. However the lists of approved devices varies by airline so passengers need to check with any airline they are planning to fly on. Passengers are generally not allowed to carry on their own cylinders. In all cases, passengers need to notify the airline in advance of their equipment. Effective May 13, 2009, the Department of Transportation and FAA ruled that a select number of portable oxygen concentrators are approved for use on all commercial flights. The list of approved portable oxygen concentrators includes the Respironics EverGo, the Invacare XPO2, the Invacare Solo 2 and others.