Dr. Subhasis Roy: Consultant, Sisu Sanjiban Hospital, Salt Lake, Kolkata

Presented By :
Dr. SUBHASIS ROY ,

CONSULTANT, SISU SANJIBAN HOSPITAL ,
SALT LAKE , KOLKATA
THE HISTORY
1774 – J. Priestly produced O2 – “Dephlogisticated Air”

1776 – A. L. Lavoisier termed this vital air – OXYGEN
Late 1800 – Bonnaire gave O2 to preterm “Blue Baby”
with success .
1907 – A. Lane invented NASAL CATHETER
1919 – L. Hill developed O2 TENT.
1920 - O2 therapy became routine for “SICK NEW BORN”
O2 THERAPY IN NEONATE VS OLDER CHILDREN

In Neonate –
 O2 reserve less
 O2 requirement / kg. higher.
 Small change in Fi O2 – large change in Pa O2
 Unrestricted O2 therapy – produce pulmonary / extra

pulmonary hazards.
MORE CAUTION REQUIRED IN NEONATAL O2 THERAPY

NEW BORN RESUSCITATION – HOW IMPORTANT O2 IS
CURRENT RECOMMENDATION – 100% O2 IN NRP

BUT
A GROWING OPINION THAT RA CAN BE USED IN PLACE OF O2
Approx 100 million babies born annually, globally
- 10 million need resus ! .
Cochrane review :
RAR group shorter time to first breath and first cry.
RAR group – only 25% required 100% backup O2 facility.
RAR group – Marginally lower overall mortality.
No evidence of HARM in using RA
BUT
INSUFFICIENT DATA TO RECOMMEND RA OVER 100% O2
NEW BORN RESUS. IS A SCIENTIFIC PROTOCOL BUT MORE AN “ART”

THAN A “SCIENCE” IN DEVELOPING COUNTRIES WITH RESOURCE
CONSTRAINTS. NOT TO PANIC IF O2 SUPPLY IN LABOUR ROOM IS
RESTRICTED OR NOT AVAILABLE.
ASSESSMENT OF NEED OF O2 THERAPY
DURING AND JUST AFTER RESUSCITATION IN NEWBORN
Only clinical –  Cyanosis
 Heart rate i.e bradycardia
 Resp effort
 Muscle tone
 Response to stimuli
LATER PART OF THE NEW BORN LIFE
Clinical –  Cyanosis
 Heart rate
 Pattern of breathing i.e. apnoea/Periodic breathing
Monitoring -  ABG – PaO2 < 50 mm.Hg.
 Trans cutaneous oxygen monitoring
 Pulse oximetry - SpO2 < 85 %
MODES OF OXYGEN DELIVERY
SOURCE
O2 cylinder
O2 concentrator - max 5 – 8 lit / min. of

90 – 92% O2
Pipeline - Cheapest

MODES OF OXYGEN DELIVERY…
DELIVERY DEVICE
LOW FLOW DEVICE
Nasal Canula – Max flow 2 – 3 lts./min.

in new born.
Nasopharyngeal Catheter
 Insert a length – Alae nasai to Tragus
 Check for blockage with mucus plug
 FiO2 difficult to measure/control
 Better if changed 24 hrly.
 Not more than 3 lit. / min. O2 in new born
 Every lit. of O2 -  FiO2 by 4
MODES OF OXYGEN DELIVERY…
HIGH FLOW DEVICE
 Mask
 mask with 5 lit / min O2 can give 40 – 60% O2
require a minimum O2 flow to prevent rebreathing
of CO2
 Enclosure system
 O2 hood - > 7 lit./ min of 100% O2 required initially to
wash out CO2
FiO2 can be 0.21 – 1.
WHAT TO EXPECT FROM ADEQUATE OXYGEN THERAPY
A. Clinical Monitoring:
 No cyanosis
 No apnoea or periodic breathing
 Stable heart rate
B. Non Invasive Monitoring:
 Pulse Oximetry
 Alarm set 85 – 96% SpO2
 Target range 88 – 95% SpO2 Except PPHN 
SpO2 >97%
 Unable to detect hyperoxia reliably
 Plenty of other limitation
WHAT TO EXPECT FROM ADEQUATE OXYGEN THERAPY..
 Trans centaneous O2 monitoring

 Not accurate in term babies with thick skin
 Not used in prematures < 27 wks.
 Heat related problems – skin heated to 44oc

C. Invasive monitoring
 ABG
 Gold standard
 8 – 12 hourly – may be required
 PaO2 – 50 – 80 mm Hg.
 PaO2 – 100 – 120 mm Hg acceptable in PPHN
NON RESPONDERS TO OXYGEN THERAPY
 CCHD - COMMONEST
 LARGE INTRAPULMONARY SHUNT - UNCOMMON
METHAEMOGLOBINAEMIA - RARE
HYPEROXIA TEST
FiO2 0.21 FiO2 1.0 x 10 min
NORMAL 70 (95) >200(100)
CCHD <40 (<75) <70(<85)
PULMONARY 50 (85) >150(100)

MARKERS OF O2 MONITORING
 PiO2 = (760 – 47) x 0.21 = 150 mmHg.
 FiO2 = 0.21
 PAO2 = 100 mmHg
 PaO2 = 90 mmHg
 SaO2 – O2 saturation derived from arterialised

cap. Blood.
 SpO2 – O2 saturation by puls. ox
THUMB RULE: FiO x 5 = PaO

UNWANTED EFFECTS OF O2 THERAPY
IMMEDIATE – Some neonate on hypoxic drive going to apnoea.

LATE -  ROP – Persistent  PaO2 - main contributary factor
 CLD
Free radical damage due to O2 therapy.
 HIE
 HOME O2 DEPENDANCE AND REHOSPITALISATION

 NOSOCOMIAL INFECTION
EFFECTS OF NOT ENOUGH OXYGEN
  Pulm Vasc. Resistance
  Airway Resistance
  Risk of SIDS in Infant with CLD
 ? Limitation in Growth
 ? Sleep Disorder
O2 – HOW COSTLY IT IS ?
 COMMONLY USED – SIZE F CYL. – CAP – 1320 lit.

 Refilling cost – Rs. 140.00
 5 lit./ min. = 300 lit./ hr. = 4.5 hr. / CYL. = 6 CYL./day
= Rs. 800.00 (approx) , without making any profit
 PIPED O2 – CYL. USED – CAP – 7100 – 7500 lit.

 Refilling cost – Rs. 220.00
 Institutions charge – Rs. 400 – 800/day, irrespective

of usage/ day. !
KEY POINTS
 New born Resus
 If O2 not available – Room Air may be enough in 90% cases.
 To save life – Do not think of ROP, Short term PaO2 acceptable.
 Beyond EMERGENCY period
 Strict monitoring of PaO2 necessary.
 To Detect ROP Eye exam from 4-6 weeks & 2–4 weekly in<32 wk. <
1250 gm.
 Max O2 flow through nasal catheter - do not exceed 3 lit./ min.
 O2 hood – initial flow of 7 lit./ min. required.

KEY POINTS….
 Keep PaO2 50 – 80 mm. Hg. , SpO2 88 - 95 %
 O2 is a DRUG only should be used  Documented hypoxia

 Resp. Distress
 Cynosis
 When prescribing O2 – specify -  Dose

 Device
 Duration
 Monitoring
 Take care of devices judiciously to prevent – NOS. INFECTION

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Dr. Subhasis Roy: Consultant, Sisu Sanjiban Hospital, Salt Lake, Kolkata

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Presented By :

Dr. SUBHASIS ROY ,

1774 – J. Priestly produced O2 – “Dephlogisticated Air”

 Unrestricted O2 therapy – produce pulmonary / extra

MORE CAUTION REQUIRED IN NEONATAL O2 THERAPY

CURRENT RECOMMENDATION – 100% O2 IN NRP

NEW BORN RESUS. IS A SCIENTIFIC PROTOCOL BUT MORE AN “ART”

O2 concentrator - max 5 – 8 lit / min. of

Nasal Canula – Max flow 2 – 3 lts./min.

 Trans centaneous O2 monitoring

 Heat related problems – skin heated to 44oc

FiO2 0.21 FiO2 1.0 x 10 min

NORMAL 70 (95) >200(100)

CCHD <40 (<75) <70(<85)

PULMONARY 50 (85) >150(100)

 PiO2 = (760 – 47) x 0.21 = 150 mmHg.

 PAO2 = 100 mmHg

 SaO2 – O2 saturation derived from arterialised

THUMB RULE: FiO x 5 = PaO

IMMEDIATE – Some neonate on hypoxic drive going to apnoea.

 HOME O2 DEPENDANCE AND REHOSPITALISATION

  Pulm Vasc. Resistance

  Risk of SIDS in Infant with CLD

 COMMONLY USED – SIZE F CYL. – CAP – 1320 lit.

 PIPED O2 – CYL. USED – CAP – 7100 – 7500 lit.

 Institutions charge – Rs. 400 – 800/day, irrespective

 If O2 not available – Room Air may be enough in 90% cases.

 To save life – Do not think of ROP, Short term PaO2 acceptable.

 Beyond EMERGENCY period

 Strict monitoring of PaO2 necessary.

 Max O2 flow through nasal catheter - do not exceed 3 lit./ min.

 O2 hood – initial flow of 7 lit./ min. required.

 Keep PaO2 50 – 80 mm. Hg. , SpO2 88 - 95 %

 O2 is a DRUG only should be used  Documented hypoxia

 When prescribing O2 – specify -  Dose

 Take care of devices judiciously to prevent – NOS. INFECTION

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