In an infant needing nebulized medication, should the nebulizer be driven with supplemental oxygen or with room air when the infant’s oxygen saturation is adequate (≥92%)?

Nebulizer Administration in Infants: Oxygen vs. Room Air

Direct Recommendation

When an infant has adequate oxygen saturation (≥92%), nebulized medications should be driven by compressed room air with supplemental oxygen delivered concurrently via nasal cannula at 2-6 L/min to maintain SpO2 ≥92%. 1

Clinical Algorithm for Nebulizer Gas Selection

For Infants with Normal Oxygen Saturation (≥92%)

• Use compressed air to drive the nebulizer with supplemental oxygen by nasal cannula at 2-6 L/min to maintain appropriate saturation levels 1
• This approach prevents unnecessary oxygen exposure while ensuring adequate oxygenation during treatment 1
• The infant should be changed back to their usual oxygen delivery device when nebulizer therapy is complete 1

For Infants with Hypoxemia or Respiratory Distress

• Use oxygen as the driving gas at 6-8 L/min when the infant is at risk of hypoxemia or has oxygen saturation <92% 1
• Oxygen is the preferred gas source for nebulization in acutely ill infants requiring bronchodilator therapy 1

Critical Physiological Considerations

Why This Matters

• Bronchodilator therapy can cause pulmonary vasodilation leading to increased ventilation-perfusion (V/Q) mismatch, which paradoxically reduces blood oxygen levels during treatment 1
• Studies show arterial oxygen saturation can fall by 2-6% during or after nebulized bronchodilator treatment, particularly in younger children 2
• These desaturation episodes occur on the steep part of the oxygen dissociation curve where small changes in saturation represent clinically significant drops in oxygen delivery 2

Transient Nature of Oxygen Benefits

• When oxygen is used as the driving gas, arterial oxygen saturation improves and heart rates remain stable during treatment 2
• However, after treatment completion, oxygen saturation falls and heart rates rise to values similar to those seen with air-driven nebulization 2
• This means the benefits of oxygen-driven nebulization are transient, and continued oxygen supplementation may be needed after the nebulized medication is completed 2

Practical Implementation

Equipment Requirements

• Use an air-driven nebulizer with electrical compressor when oxygen cylinders cannot deliver adequate flow rates (>6 L/min) 1
• Ensure availability of nasal cannula for concurrent oxygen delivery 1
• Maintain continuous pulse oximetry monitoring throughout nebulizer treatment 1

Monitoring During Treatment

• Do not allow hypoxemia to occur while administering nebulized treatments 1
• For hypoxemic patients, oxygen therapy should continue during nebulized treatments regardless of the driving gas used 1
• Place pulse oximetry probe on the right upper extremity (preductal location) for accurate monitoring 1

Common Pitfalls and How to Avoid Them

Risk of Hypoxemia

• Younger infants and those who fall asleep during treatment are at higher risk for desaturation 2
• The level of oxygen saturation before treatment does not predict who will desaturate 2
• Always maintain continuous monitoring rather than relying on pre-treatment saturation values 2

Avoiding Unnecessary Oxygen Exposure

• In infants with adequate baseline saturation, using oxygen to drive the nebulizer delivers unnecessarily high FiO2 1
• This is particularly important for premature infants or those at risk for retinopathy of prematurity, where excessive oxygen exposure should be minimized 1
• The air-driven approach with supplemental nasal cannula oxygen allows precise titration to maintain target saturations without excessive exposure 1

Special Population: Infants with Chronic Lung Disease

• For infants with chronic lung disease of infancy (CLDI), target oxygen saturation should be maintained at ≥95% to prevent pulmonary hypertension and provide a buffer against desaturation 1
• These infants require more consistent oxygenation during feeding and handling, which nasal cannula delivery provides better than masks or hoods 1
• Multiple determinations should be made during rest, sleep, feeding, and activity states 1