What are the options for oxygen delivery devices in neonates?

Oxygen Delivery Devices in Neonates: A Comprehensive Guide

Nasal cannulas are the most widely used and preferred oxygen delivery device for neonates due to their convenience, safety, and tolerability, especially in the ambulatory setting. 1 The selection of appropriate oxygen delivery devices for neonates should be based on the infant's clinical condition, oxygen requirements, and care setting.

Primary Oxygen Delivery Devices for Neonates

1. Nasal Cannula

• Standard Low-Flow Nasal Cannula

  • Most widely used device for oxygen delivery in neonates 1
  • Advantages: Convenient, safe, well-tolerated, allows mobility 1
  • Flow rates: Typically 0.25-2 L/min for neonates
  • Delivered FiO₂: Varies based on flow rate, infant size, respiratory rate, and respiratory effort 1
  • Best practice: Use lowest possible flow with 100% oxygen to minimize variability in oxygen delivery 2
  • Most centers recommend humidification of oxygen to prevent mucosal drying 1

• High-Flow Nasal Cannula (HFNC)

  • Increasingly used in critically ill neonates with respiratory failure 3
  • Flow rates: Typically 2-8 L/min
  • Advantages: Provides mild CPAP effect, comfortable, easy to set up, low incidence of nasal trauma 3
  • Can deliver more precise FiO₂ when used with air-oxygen blender

2. Oxygen via Tracheostomy

• Tracheostomy collar most widely used for chronic oxygen delivery in tracheostomized neonates 1
• Enhanced humidification strongly recommended 1
• Modified designs available to minimize size and appearance 1

3. Face Tents and Head Hoods

• Acceptable for enhanced oxygen and humidity delivery 1
• Limitations:
  • Restrict mobility and visibility
  • Risk of CO₂ buildup with insufficient flow rates
  • Temperature and moisture buildup can be problematic 1
  • Not ideal for long-term use

4. Oxygen Masks

• Simple oxygen masks: Provide 30-50% oxygen concentration for spontaneously breathing neonates 1
• Non-rebreathing masks: Deliver higher oxygen concentration when used with 15 L/min flow to maintain reservoir bag inflation 1
• Less commonly used in neonates due to fit issues and restriction of movement

Oxygen Concentration Guidelines

For Preterm Neonates (<35 weeks gestation):

• Start with lower oxygen concentration (21-30%) rather than higher (60-100%) 1
• Titrate oxygen using pulse oximetry to maintain target saturations 1
• Avoid FiO₂ >0.3 unless necessary to maintain target saturations 4

For Term/Late-Preterm Neonates (≥35 weeks):

• Start with 21% oxygen (room air) 1, 4
• Avoid starting with 100% oxygen due to potential toxicity 1, 4
• Titrate based on pulse oximetry readings 4

Practical Considerations for Oxygen Delivery

Calculating Effective FiO₂ with Nasal Cannula

• Effective FiO₂ can be calculated using the formula:

  FiO₂ = 20 + (4 × oxygen flow in L/min)

  or more precisely:

  FiO₂ = 0.21 + [(oxygen flow × (FO₂ - 0.21))/minute ventilation]

  where minute ventilation = tidal volume × respiratory rate 5, 6

• For accurate estimation, assume tidal volume of approximately 5.5 mL/kg 5

Monitoring and Titration

• Use pulse oximetry to guide oxygen titration 4
• Target oxygen saturation ≥94% once circulation is restored 1
• Wean FiO₂ for saturations of 100% to avoid hyperoxia while maintaining saturation ≥94% 1
• For infants at risk of retinopathy of prematurity, more careful oxygen targeting is required 1

Common Pitfalls to Avoid

1. Unintentional Room Air Delivery: Some infants receive oxygen concentrations and flow rates that deliver an effective FiO₂ equivalent to room air (0.21) 6

   • Solution: Calculate effective FiO₂ routinely to prevent unnecessary oxygen therapy

2. Unstable Oxygen Delivery: FiO₂ varies with changes in the patient's breathing pattern 2

   • Solution: Use lowest possible flow rate with higher oxygen concentration (up to 100%) to maximize stability 2

3. Inadequate Humidification: Can lead to mucosal drying and thickening of pulmonary secretions 1

   • Solution: Always humidify oxygen when possible 1

4. Excessive Peak Inspiratory Pressures: Can cause gastric inflation and interfere with ventilation 1

   • Solution: Deliver each breath over approximately 1 second when providing assisted ventilation

Special Considerations for Travel

Air Travel with Oxygen-Dependent Neonates

• Commercial aircraft maintain cabin altitudes between 6,000-8,000 ft, reducing inspired PO₂ 1
• Increased oxygen requirements during flight due to lower barometric pressure 1
• Contact airline well in advance to arrange oxygen supply 1
• Consider hypoxic challenge testing before travel to predict oxygen needs 1

Oxygen Delivery Systems for Travel

• Options include compressed gas, liquid oxygen, and concentrators 1
• Key considerations: securing oxygen source, ensuring sufficient supply, and ability to monitor infant during travel 1

By selecting the appropriate oxygen delivery device and following evidence-based guidelines for oxygen administration, clinicians can optimize respiratory support for neonates while minimizing risks associated with both hypoxia and hyperoxia.