Oxygen therapy is used to treat neonatal and pediatric patients with low blood oxygen levels caused by RSV, which has been a major driver of pediatric hospitalizations in 2022 and 2023.

By Bill Pruitt, MBA, RRT, CPFT, FAARC

Oxygen therapy is often used in neonatal and pediatric patients for a variety of conditions that cause low oxygen levels in the blood (hypoxemia). The 2022-2023 winter season has shown a strong resurgence in pulmonary infections especially with neonatal and pediatric patients, and infections with respiratory syncytial virus (RSV) has been one of the leading issues in these two populations. Oxygen therapy is frequently required to treat hypoxemia. This article will take a close look at RSV in the neonatal and pediatric population and discuss various aspects of oxygen therapy in these patients.

Respiratory Syncytial Virus Overview

RSV infection is an acute infection of the airways and occurs in all ages. By age one, half of infants have symptoms of RSV infection and by the age of two, almost all children will have had RSV.1 It is the most common cause of lower respiratory tract infection in children less than 1 year of age.2 RSV infection in healthy adults occurs several times through their lifetime and the symptoms are usually limited to the upper respiratory tract. Although individuals can be infected with RSV more than once, subsequent infections usually are milder whether they occur in the same season or in different year. However, in immunocompromised adults and those over 50 years of age, RSV is “an important and often unrecognized cause of LRTI (lower respiratory tract infection)” and becomes an important factor as the cause of death in these patients.2 

Generally, RSV occurs in during the fall-winter months (October-May) with peak infections landing in January-February. The COVID-19 outbreak brought in steps to reduce its transmission (ie, use of masks, social distancing, school closures, hand-washing) that also reduced transmission of RSV. With the relaxation of these practices, RSV has had a strong return in infecting the population and has shown an increase in activity outside its usual season (ie, occurring in spring and early summer).2 Research published in 2022 showed that bronchial asthma was a risk factor for prolonged oxygen therapy and that summertime infections of RSV was a risk factor for progression to more severe cases.1 Globally, in infants from 28 to 364 days of age, RSV is thought to cause more deaths than any other infection (with malaria being the only exception).2

There is a host of risk factors for RSV. In infants and children, these include being born during the RSV season, attending daycare, having older siblings, underlying lung disease, prematurity, congenital heart disease, and secondhand smoke exposure. In adults, risk factors include having cardiopulmonary disease, living at altitudes > 2,500 m (8,200 ft), being institutionalized, and having chronic pulmonary disease or functional disability. In all patients, persistent asthma increases the risk.2 Symptoms appear between 4 to 6 days after exposure but some 40% of cases are asymptomatic.

RSV has subtypes A and B, with both occurring during most outbreaks. Subtype A is usually more severe. Transmission occurs by inoculation of the nasopharynx or eyes after contact with infected secretions or some object or clothing that has been contaminated with RSV. Large droplet aerosols (such as those produced by sneezing or coughing) have also been implicated in transmitting RSV. After establishing itself in the nasopharynx, the virus moves distally via infection of bronchiolar epithelium and eventually infects types 1 and 2 alveolar pneumocytes with LRTI appearing within one to three days.2 The infection causes epithelial cell necrosis, airway obstruction, air trapping, atelectasis,  hypoxemia (and sometimes hypercapnia), and increased airway resistance with wheezing heard on auscultation.2-3 In infants and children, the LRTI can result in bronchiolitis (RSV is the leading cause for this condition), bronchospasm, pneumonia, apnea, and acute respiratory failure (both hypoxemic and hypercapnic). Severity diminishes with subsequent infection. Around 2% to 3% of first infection in children results in hospitalization.2 In older children and adults with upper respiratory tract infection, symptoms include cough, rhinorrhea, conjunctivitis, fever, myalgia (muscle pain) and coryza (stuffy nose and sneezing).2,4

In diagnosing RSV, symptoms support a clinical diagnosis and laboratory confirmation may be done by taking a sample via nasal wash, nasopharyngeal swab, or midturbinate nasal swab. Positive polymerase chain reaction (PCR)-based assays or rapid antigen detection tests (RADTs) can be used however incidence of false negative results are higher with RADT. PCR assays can have results in a little as 3 hours where RADT results are ready in less than 30 minutes.2

Care for Neonatal/Pediatric Patients with Respiratory Syncytial Virus

RSV calls for supportive care to provide humidified oxygen (if hypoxemic), antipyretics, nutritional support, and hydration. Is cases of more severe infection with hypoxemia and hypercapnia, continuous positive airway pressure (CPAP), Bi-level positive airway pressure (BiPAP), and oxygen therapy via high-flow nasal cannula (HFNC) have been utilized.3 If acute respiratory failure occurs, intubation and mechanical ventilation is utilized.3-4 A preventive medication is available (Palivizumab) but this drug will not treat RSV once it has been contracted.4 

Oxygen Therapy in the Neonatal/Pediatric Respiratory Syncytial Virus Patient

Oxygen therapy is needed to address hypoxemia. O2 therapy can be provided by a variety of devices and is classified as low-flow or high-flow. With a low-flow device, 100% oxygen from a source (ie cylinder, hospital oxygen system, etc) flows through tubing to the patient. As the patient inspires, room air (21% oxygen) is mixed with the pure oxygen by entrainment, so the precise fraction of inspired oxygen  (FiO2) is variable. High-flow devices provide flow at higher rates so that no room air is entrained and the FiO2 is constant. The gas source may be the same as the low-flow system, or may be delivered through a blender that mixes air and O2 based on the desired set FiO2 set by the operator.5 (See Table 1 for details on oxygen delivery devices.) 

Table 1. Oxygen Delivery Devices

Nasal cannulaLow-flow. Uses different sized nasal prongs in the nares.Delivers estimated FiO2 from 22% to 60%. Patient can eat or talk without interruption of O2 therapyMost commonly used device. Lowest cost device. FiO2 will vary based on patient tidal volume and/or respiratory rate. Needs added humidification. Maximum flow < 6 LPM.
Simple maskLow-flow. Uses various sizes of mask over mouth and nose. Held in place by elastic strap.Delivers estimated FiO2 from 35% to 60%. May interfere with O2 delivery to eat or talkFiO2 will vary based on patient tidal volume and/or resp rate. Needs added humidification. Flow is needed at minimum of 6 LPM. to flush out CO2. Approximate flow rate set at 6 to 10 LPM. Must remove mask to eat.
Partial rebreathing mask with reservoir bagLow-flow. Uses various sizes of mask over mouth and nose. Held in place by elastic strap and has reservoir bag that fills with 100% O2 plus patient’s exhaled gas.Delivers approximate FiO2 of 40% to 80%; Good for short-term therapy in children who need higher concentrations of
oxygen. May interfere with O2 delivery to eat or talk.
FiO2 will vary based on patient tidal volume and/or resp rate.  Oxygen flow rate of 10 LPM. is typically needed to keep the reservoir bag from collapsing. Monitor patient for hypercarbia. Can dry out airway. Must remove mask to eat.
Non-rebreathing mask with reservoir bagLow-flow. Uses various sizes of mask over mouth and nose. Held in place by elastic strap and has reservoir bag that fills with 100% O2. Bag has valve at entrance point and mask has one or two valves in place to prevent entrainment of room airCan deliver FiO2 of 80% to 95%. Used in patients who need highest amount of oxygen (usually for short periods) without intubation.Oxygen flow rate of > 10 LPM. is typically needed to keep the reservoir bag from collapsing. Monitor patient for hypercarbia. Can dry out airway. Must remove mask to eat.
Venturi mask (Air-entrainment mask)High-flow. Mask sits on face and over mouth and nose and has air-entrainment port with elastic strap. Uses various removable O2-air mixing valves (or is adjustable) to alter FIO2Precise delivery of FiO2 concentrations from 24% to 40, not affected by patient’s inspired air flow.Can dry out airway. Must remove mask to eat.
Oxygen hoodHigh-flow. Clear plastic box covers infant’s head. Oxygen can be delivered via either blender or nebulizer.For neonates or infants who need oxygen. Provides high concentration of oxygen, FiO2 up to 100%. Must have humidified, warm gas.Monitor the child for signs of hypercarbia. High flow is needed to achieve appropriate oxygen concentrations and decrease hypercarbia. Nasal cannula may be needed when infant is removed from the hood for feeding or other nursing care. Temperature needs to be monitored in tent. Creates moist environment. May have issues with noise.
High-flow nasal cannulaHigh-flow. Delivers FiO2 with oxygen titrated from a flow rate of 4 LPM in infants up to 40 LPM or more in adolescents.Used when a higher FiO2 Often delivers some low level positive end-expiratory pressure (PEEP). Used when ventilation is adequateFlow rate can be adjusted based on the child’s respiratory effort. Needs training and knowledge to operate and adjust. Note: In some 25% of patients tried on HFNC with moderate to severe respiratory distress another, higher level of support will be needed.5
Continuous Positive Airway Pressure (CPAP)High-flow. Uses a nasal mask, nasal prongs, oronasal mask, or sealed hood. Delivers continuous positive pressure with variable fixed FiO2 for spontaneously breathing patients.By recruiting alveoli and preventing atelectasis, the FiO2 needed to maintain adequate oxygenation may be reduced.Must be discontinued to eat. Needs training and knowledge to operate and adjust.
Bi-level Positive Airway Pressure (BiPAP)High-flow. Uses an oronasal mask, or sealed hood. Delivers continuous airway positive pressure with variable fixed FiO2 plus pressure-support during inspiration for spontaneously breathing patients.By recruiting alveoli and preventing atelectasis, the FiO2 needed to maintain adequate oxygenation may be reduced. With added pressure support, reduces patient’s work of breathing, increases tidal volume, and helps reduce CO2Equipment costs are higher than CPAP, needs more training and knowledge to operate and adjust.
Mechanical ventilatorHigh-flow. Delivers support for oxygenation and ventilation. May be noninvasive ventilation (via mask) or invasive (via ETT or tracheotomy tube)Similar to CPAP, BiPAP regarding oxygenation. Provides some or most support for ventilation and management of CO2 Highest equipment and supplies cost. Heated, humidified gas needed. Needs high level training and knowledge to operate and manage.
Adapted from ref. 5:  Elsevier Clinical Skills website, Oxygen Therapy and Oxygen Delivery (Pediatric)

Bulk oxygen systems and other sources such as cylinders etc. deliver dry, cold gas. Humidification and warming of oxygen therapy must be included whenever supplemental O2 is delivered to infants and children. As stated by Walsh and Smallwood, “Often, children who require oxygen therapy are experiencing respiratory distress with an increased minute ventilation and suffer from some form of dehydration. Providing dry oxygen may treat their hypoxemia but set them up for other complications.”6 These complications include mucociliary malfunction, mucus obstruction, mucosa dryness, ulceration, and can also induce bronchospasm.7

In neonatal and pediatric patients, the interface with the patient (cannula, mask, etc) may cause skin tears or breakdown. Skin integrity must be monitored and steps taken to avoid this issue. The patient may also have trouble tolerating the interface — time to become accustomed to the device may be needed, or if possible, changing to another interface may help. Masks with elastic straps are also a concern for skin breakdown and need to be monitored. 

RSV can cause hypoxemia and hypercarbia by interfering with alveolar exchange and reducing ventilation due to inflammation and bronchoconstriction. Hypoxia may appear due to higher metabolic demand, fever, inadequate circulation for O2 delivery, anemia, etc. O2 therapy has been routinely started when the PaO2 drops to <60 mmHg (or a noninvasive SpO2 of 90%). 6 Patient indications for needing supplemental oxygen include cyanosis, confusion, tachycardia, retractions, nasal flaring, and expiratory grunting. 6 Keep in mind that tissue hypoxia is not the same as hypoxemia. Issues with hemoglobin, oxygen extraction, and oxygen/metabolic demand may cause hypoxia despite high oxygen delivery.6 Supplemental oxygen may be contraindicated in patients with congenital heart disease and have ductal-dependent lesions. Also, in premature babies, a lower SpO2 may be considered to reduce the toxic effects of oxygen (ie, retinopathy of prematurity, bronchopulmonary dysplasia).6

Hyperoxia (generally defined as having a PaO2 around 120 to 150 mmHg (or higher)) has become another concern for oxygen therapy. Oxygen toxicity, oxidative stress, and high oxygen delivery during cardiopulmonary resuscitation (CPR) are some of the issues being examined by researchers. Many studies have compared using room air versus 100% oxygen, and according to three meta-analysis of the data, the conclusion was that using room air in CPR had a significant reduction in the risk of neonatal mortality.6 This topic is still being debated and studied and as there is no consensus, the American Heart Association Pediatric basic and advanced life support guidelines (2020) state that it is reasonable to ventilate initially with 100% O2 and wean the oxygen to target a SpO2 between 94% and 99%.8

Oxygen Supply Issues

As a final note, with the COVID-19 epidemic and the high demands placed on hospitals to provide oxygen to a host of patients, oxygen supply became an issue. Supplies were not available, and some hospital bulk oxygen systems were too small, or the massive draw of oxygen from a liquid system caused piping systems in older facilities to break. The growing use of high-flow nasal cannulas (running at flow rates of 40 to 60 LPM) also stressed many hospital delivery systems.9 With the high number of RSV, influenza, COVID-19, and other respiratory illnesses occurring during the 2022-2023 winter season, a shortage of oxygen supply has become a concern in many states. This has been an issue in the US and globally. Hospitals are taking a hard look at their infrastructure, supply chain, and possible need for a triage plan should this concern become a reality.9


RSV has been a major issue in infants and pediatrics for a long time and has come on with vigor in the 2022-2023 season (along with continued COVID-19, influenza, and pneumonia cases). Oxygen therapy is a prime component of care for these patients, and careful administration is needed to match the right device and correct FiO2 to meet the patients’ need. Humidification and warming of delivered gas is needed to avoid causing harm, and avoidance of hyperoxygenation should be part of the plan. Oxygen supply is also being examined and corrective actions are happening to avoid an oxygen crisis in the hospital. Research is continuing to provide insight into the best delivery of O2 therapy and innovations are coming forward that open more possible means of providing safe, effective supplemental oxygen to all patients.


Bill Pruitt, MBA, RRT, CPFT, FAARC, is a writer, lecturer, and consultant. He has over 40 years of experience in respiratory care, and has over 20 years teaching at the University of South Alabama in Cardiorespiratory Care. Now retired from teaching, he continues to provide guest lectures and write. For more info, contact [email protected].


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  8. From the AHA website: https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/pediatric-basic-and-advanced-life-support. Accessed January 2023.
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