Oxygen therapy is a primary treatment for managing acute respiratory conditions in children across both clinical and home care settings. However, pediatric patients require special care due to their unique physiological needs and increased sensitivity to oxygen levels.
Bill Pruitt, MBA, RRT, CPFT, FAARC
Hypoxemia (low oxygen in the blood) over time results in hypoxia (low oxygen in the tissues). Hypoxia causes various organ systems to be stressed and may bring system dysfunction and may lead to death if it is severe and prolonged. Pediatric hypoxia is a frightening experience for parents but often with supplemental oxygen, hypoxia can be treated.
Oxygen therapy is a primary intervention for managing acute respiratory conditions in children across both clinical and home care settings. However, pediatric patients require special care due to their unique physiological needs and increased sensitivity to oxygen levels. Patient monitoring, appropriate oxygen delivery methods, and individual care plans are essential to ensure safe and effective treatment while minimizing potential complications such as oxygen toxicity or delayed detection of underlying conditions.
Common Conditions and Indications
Neonatal patients can have hypoxia due to respiratory distress syndrome, birth asphyxia, transient tachypnea of the neonate, pneumonia, prematurity, and apnea, etc.1 In children, hypoxia is most often associated with acute lower respiratory tract infections—namely pneumonia and bronchiolitis—and may also be seen in acute asthma, meningitis and sepsis.1 Chronic lung diseases may also cause hypoxia and call for long-term support with supplemental oxygen.
Clinical signs of hypoxia include cyanosis (a blue coloring) in the gums or fingernail beds, nasal flaring, grunting with every breath, drowsiness or lethargy, high respiratory rate (70 or more breaths/min), and chest wall retractions.1
Many clinicians use an oxygen saturation of <90% to be the threshold for initiating oxygen therapy, with the goal to reach a range of 90% to 98%, confirmed via pulse oximetry. (The recommendation from the American Heart Association’s guidelines 2020 Pediatric Advanced Life Support targets a SpO2 between 94% and 99%.)1-2
Special Care for Pediatric Patients
Oxygen therapy can be administered to pediatric patients through a number of device types, from nasal cannula to masks to oxygen hoods. (See Table 1: Oxygen delivery devices.)
Flow rates with infants are often much lower than with older patients and call for using low-flow O2 flowmeters that can be set in units of 0.01 to 0.25 LPM flow. Oxygen from the source (hospital oxygen system, cylinder, or concentrator) is delivered as a dry gas. Humidification is not recommended in children if gas flow is <4 LPM (for infants the threshold is 1 LPM). Bubble humidifiers are most often used to humidify oxygen in higher flow settings with the exception of high-flow nasal cannula (HFNC) applications which call for a heated humidifier.2 HFNC use flow rates starting at 2 LPM /kg and are often used in children with moderate to severe bronchioloitis.2
One issue with providing supplemental oxygen involve hyperoxia (having too much oxygen in the blood/tissues—generally defined as a PaO2 of > 120 mmHg). This can lead to oxygen toxicity which can affect the cardiovascular and central nervous systems. Too much oxygen in the lungs can displace nitrogen and cause issues with absorption atelectasis. Infants exposed to too much oxygen are at risk for developing retinopathy of prematurity and/or bronchopulmonary dysplasia.3
An air/oxygen blender may be needed to provide a precise dose of oxygen and when using a HFNC system. These devices usually require a 50 PSI gas source for air and for oxygen and can provide an FiO2 ranging from 0.21 to 1.0 with flow rates from <1 LPM to 60 LPM (depending on the flowmeter and capability of the blender). Air/O2 blenders are almost exclusively used in the hospital setting due to the required air/oxygen sources, and pressures needed to run the device.
Infants (and children) can also have skin breakdown and pressure-related injury related to devices such as nasal cannulas or masks. Devices need to be properly sized and should not be attached too tightly to avoid pressure-related injury. Regular inspection of the nares, nasal septum, behind the ears and neck is a necessary precaution and use of a hydrocolloid dressing or other appropriate dressing should be used under delivery devices to protect the skin. If possible, oxygen devices should be repositioned at the time of inspection (every 4 hours).4
Home Pediatric Oxygen Therapy
Home oxygen therapy is recommended for use in pediatric patients who have chronic lung diseases and severe chronic hypoxemia. This may occur in cases such as cystic fibrosis, bronchopulmonary dysplasia, sleep-disordered breathing, sickle cell disease, interstitial lung disease, and pulmonary hypertension.5 Careful, thorough family education is needed to allay their fears and to provide a safe environment when using oxygen at home. How to apply/change the interface, setting flow rates, monitoring oxygenation with a pulse oximeter, and risks of smoking, use of oil-based products, and avoiding open flames in the home are important points to cover in education of caregivers.5 Age-appropriate devices and supplies should be provided.
Home oxygen is most often supplied by oxygen concentrators and cylinder back-up supplies should be provided in case of electrical outage or malfunction of the concentrator. As the pediatric patient grows and matures, the need for home oxygen therapy may resolve and a plan should be established on how to wean and discontinue the therapy if appropriate.5
Conclusion
Pediatric oxygen therapy is appropriate and needed to treat hypoxemia and hypoxia but involves special care to be safe and effective due to the size and delicate nature of these patients. Guidelines are available for providing care and although there are some areas of disagreement, these documents provide valuable information for handling oxygen therapy in infant and pediatric patients. Special care is needed to avoid issues with giving supplemental oxygen (ie, hyperoxia) to pediatric patients. Home oxygen may be needed to provide support for chronic illnesses and care should be taken to ensure that care givers are educated and that the appropriate supplies and services are available.
RT
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 the department of Cardiorespiratory Care. After retiring from teaching, he continues to provide guest lectures and write professionally. For more information, contact [email protected].
References
- World Health Organization, 2016. Oxygen therapy for children: a manual for health workers. https://www.who.int/publications/i/item/9789241549554.
- Napolitano N, Berlinski A, Walsh BK, Ginier E, Strickland SL. AARC clinical practice guideline: management of pediatric patients with oxygen in the acute care setting. Respiratory Care. 2021 Jul 1;66(7):1214-23. https://www.aarc.org/wp-content/uploads/2021/08/management-of-pediatric-patients-with-oxygen-in-the-acute-setting.pdf
- Malhotra A. Adverse effects of supplemental oxygen. UpToDate. Published Nov 2024. https://www.uptodate.com/contents/adverse-effects-of-supplemental-oxygen.
- Oehlke S. Skin Care Guide for Non‐Invasive Oxygen Delivery Systems. Children’s Hospital and Clinics of Minnesota. Published Feb 2012. https://www.childrensmn.org/departments/webrn/pdf/practice-update-non-invasive-oxygen-delivery-systems-feb-2012.pdf
- Krivchenia K, Hawkins SM, Iyer NP, Hayes Jr D, Deterding RR, et. al. 2019 Clinical Practice Guideline Summary for Clinicians: Home Oxygen Therapy for Children. Annals of the American Thoracic Society. 2019 Jul;16(7):781-5.
Table 1: Oxygen Delivery Devices
| System | % Oxygen Delivered* | Indications | Comments |
|---|---|---|---|
| Blow by | < 30% | For spontaneously breathing children who need a low oxygen dose and do not tolerate a mask | Flow rate >10 L/minute using a reservoir held close to face (i.e., a simple mask or Styrofoam up with oxygen tubing inserted through the bottom). |
| Low flow nasal cannula (1-4 LPM) | 25 to 40% | Delivers low dose oxygen to spontaneously breathing patients | % O2 delivered is affected by respiratory rate, tidal volume, and open/closed mouth. Limit flow to < 2 L/min to avoid delivering inadvertent positive pressure in children |
| High Flow nasal cannula | 21-100% | Delivers fully humidified oxygen to spontaneously breathing patients | For patients with severe respiratory distress or hурохеmiа. Cannulas come in various sizes. Uses a blender and a heated humidifier. May also deliver some level of positive pressure. |
| Simple mask | 35-50% | Same as low flow N/C | % O2 delivery affected by mask fit and respiratory rate |
| Small diffuser (OxyMask) | 25-80% | Delivers low to high dose oxygen to spontaneously breathing patients | Delivery of O2 % varies with flow (i.e. 25% at 1.5 L/min to >80% at > 15 L/min.) Open-mask design may be better tolerated by children. |
| Partial rebreather mask | 50-60% | Use to conserve oxygen | |
| Non-rebreather mask | 65-95% | Delivers high dose oxygen to spontaneously breathing patients | Tight mask fit required to deliver higher concentrations of oxygen |
| Hood | 30-90% | Use in infants < one year of age | Noisy for patient |
| Oxygen tent | 25-50% | Use in children who need < 30% oxygen delivered | Mist may obscure the view of the patient. May be noisy for patient. The environment may become too warm. Low-flow nasal cannula or mask preferred |
| Self-inflating bag with mask | 95-100% with reservoir | Use to deliver assisted ventilation with oxygen | Not to be used for blow by |
| Flow-inflating ventilation bag | 100% | Use to provide assisted ventilation with oxygen | May use to provide blow by. Requires experience to use reliably. |
| *Actual % O2 delivered may vary depending on manufacturer, flow rate used to drive the device, and mask fit (when using a mask). All patients should be monitored with pulse oximetry. | |||
- *Actual % O2 delivered may vary depending on manufacturer, flow rate used to drive the device, and mask fit (when using a mask). All patients should be monitored with pulse oximetry.
- Adopted from:
- Nagler J. Continuous oxygen delivery systems for the acute care of infants, children, and adults. UpToDate. Updated July 2023.
- Nagler J. High-flow nasal cannula oxygen therapy in children. UpToDate. Updated May 2023.
