This document discusses oxygen therapy for pediatric COVID-19 patients. It outlines the indications for oxygen therapy including hypoxemia and shock. It then describes the various oxygen delivery systems and methods including nasal cannulas, masks, tents, and positive pressure ventilation. Factors determining the appropriate method are also discussed. The document provides guidance on dosage, monitoring response, and managing complications of oxygen therapy.

1. Oxygen therapy
in management of COVID-19 pediatric patients
Noha El-Anwar
ICU consultant – 57357CCHE
Lecturer of pediatrics – Cairo university

2. • INDICATIONS
• THE OXYGEN DELIVERY SYSTEM
• METHODS OF OXYGEN DELIVERY
• ADJUNCTS TO OXYGEN DELIVERY
• OXYGEN DOSAGE
• EVALUATION OF RESPONSE TO OXYGEN THERAPY
• COMPLICATIONS ASSOCIATED WITH OXYGEN THERAPY

3. Indications
The main indication is arterial hypoxemia.
Severe acute anemia
Shock states
Acute brain insults (convulsions, coma, increased intracranial pressure)

4. The oxygen delivery system:
a) Oxygen source
b) Oxygen flow meter
c) Oxygen humidifier
d) Oxygen delivery equipment
e) Oxygen analyzer

5. Methods of Oxygen delivery
Oxygen delivery system can be divided into:
A) Positive ventilation (passive) VS negative ventilation (active)
B) Low flow systems (variable performance) VS High flow systems
(fixed performance)

7. The method used depends on:
1- patient age
2- patient comfort
3- desired oxygen concentration
4- need to measure the inspired oxygen concentration

9. 1- Nasal Cannula
• Consist of 2 short soft plastic prongs which are inserted in to
the ant. Nares and O2 is delivered into the nasopharynx.
• Up to 4 L/min of O2 can be used
• Does not provide humidified oxygen.
• Indications: low to mod. O2 required, mild or no distress, long term O2 therapy
requirement.
• Contra indication: Poor resp. effort, Apnea, severe hypoxia, mouth breathing.
• Advantage: Simplicity of use, Patient acceptance, Ability to eat and talk
• Disadvantage : does not deliver high O2 conc.

11. 2- Reservoir systems

12. 2A-Simple Oxygen mask
• Minimum oxygen flow of 6L/min should be used
• Deliver 35% to 60% oxygen with flow rate of 6 to 10 L/ min
• Indications: Medium flow O2 desired, mild to mod. RD
• Contra indication: Poor resp. effort, Severe hypoxia, Apnea
• Advantage: less expensive
• Disadvantage : does not deliver high conc. O2 , Interferes with eating
and talking.

14. 2B- Partial re-breathing mask
• Simple face mask + reservoir bag
• Oxygen flow of 10 to 12 L/min is generally required
• Reliable to provide oxygen concentration of 50% to 60 %
• Indications: relatively high O2 requirement .
• Contra indication: Poor resp. effort, Severe hypoxia, Apnea
• Advantage: inspired gas not mixed with room air
• Disadvantage : more O2 flow does not increase O2 conc., Interferes with
eating and talking.

16. 2C- Non re-breathing mask
• Face mask + reservoir bag+ A valve incorporated into the exhalation port (A valve placed
between reservoir bag and mask)
• Oxygen flow into the mask is adjusted to prevent collapse of bag
• Inspired concentration of oxygen of 95% can be achieved by 10 to 12L/min of oxygen
• Well sealed face mask is used
• Indications: delivery of high conc. Of O2
• Contra indication: Poor resp. effort, Apnea
• Advantage: high conc. O2 without intubation
• Disadvantage : expensive, Interferes with eating and talking.

18. 3- Face tent
• Also known as face shield
• High flow soft plastic bucket
• Well tolerated by children then face mask
• Up to 40% of oxygen can be delivered with 10 to 15 L/min of oxygen
flow
• Access for suctioning is achieved without interrupting the oxygen
flow.

19. 4- Oxygen tent
• Clear plastic shell that encloses the child’s upper body
• Provide more then 50% of O2
• Not reliable
• Limits access to patient
• Cannot be used in emergency situation

20. 5- Nasal catheter
• Flexible, lubricated oxygen catheter with multiple
holes in distal 2 cm
• Advanced posteriorly into the pharynx through nostril
• No advantage over nasal cannula
• Hemorrhage and gastric distension can occur

22. 1- Venturi- type mask
• Reliable
• Provide controlled low to moderate
(25% to 60%) of inspired oxygen concentration
• Indications: desire to deliver exact amount of O2
• Contra indication: Poor resp. effort, Severe hypoxia, Apnea
• Advantage: fine control of FIO2 at a constant flow
• Disadvantage : expensive, can not deliver high O2 conc. Interferes
with eating and talking

23. 2- Oxygen hood
• Clear plastic shell with covers the patient’s head
• Well tolerated by infants
• Allows access to chest, trunk and extremities
• Permits control of inspired oxygen concentration, temp. and humidity
• Flow of oxygen- 10-15 L/min
• 80 to 90 % of oxygen conc. can be achieved
• Can be used in neonates and infants only.

24. 3- High Flow Nasal Cannula (HFNC)

25. • Significant improvement in measures of
RD along with improved gas exchange
• High flow nasal O2 creates positive pressure in nasopharynx.
• It could act like PEEP to prevent collapse of alveoli at the end of
expiration
• It avoids intubation and mechanical ventilation

26. 4- Bag Valve Mask Ventilation
• Two hands must be used :
One hand- head tilt- chin lift maneuver
Other hand- compress ventilation bag
•A neutral sniffing position is maintained.
• Hyperextension of head is avoided to maintain the optimum position for airway
patency.
• Distention of stomach frequently occurs. It should be avoided to prevent
aspiration.

27. 5- Tracheostomy Collar/ Mask
• Inserted directed into trachea
• Is indicated for chronic O2 therapy need
• O2 flow rate 8 to 10L
• Provides accurate FIO2
• Provides good humidity.
• Comfortable ,more efficient

28. 6- T-Piece
• The T-piece is a T-shaped adapter used to provide oxygen to either an
endotracheal or Tracheostomy tube.
• The flow rate should be at least 10 L/min with humidification.
• Flow can also be provided by a ventilator.
• Used to provide a high-enough flow rate to ensure that there is a
minimal amount of entrained room air.

29. Oropharyngeal Airway
• Indicated in in unconscious pt. if procedure to open
airway fail to provide and maintain a clear,
unobstructed airway.
• Size: corner of mouth to angle of jaw.
• Insertion…
Adjuncts to Oxygen Delivery

30. Oxygen Dosage
• In emergency situations (eg. acute cyanosis, shock states), 100%
oxygen should be immediately given by a tight non rebreathing face
mask or by assisted ventilation with the bag and mask attached to
100% oxygen.
• In less urgent situations (eg. RD, arterial hypoxemia), treatment
usually starts with an oxygen concentration between 40-60%.

31. • Oxygen should be given continuously. Interrupted oxygen therapy is
physiologically harmful especially to sick infants and children.
• Dosage of oxygen can be changed (increased or decreased) according to
the response. Changes in dosage are usually made by increaments or
decrements of 10% per time.
• Oxygen therapy should be used for the least possible time. Starting from
few hours to several days or several weeks.
• Oxygen should be withdrawn gradually. With concentrations above 40%
decrements by 10% per time are appropriate. With concentrations below
40% decrements should be by 5% per time

32. Evaluation of response to oxygen therapy
• Response to oxygen therapy can be evaluated clinically and laboratory
• Measurements of the arterial oxygen saturation (SaO2) and arterial
oxygen pressure (PaO2) are the most reliable parameters for
evaluation

33. • Good response:
SaO2 >90% …. Pulse oximeter ,, PaO2 >90mmHg ….. ABG
• Poor response:
Presistant low SaO2 <85% in spite of 60-70% oxygen
Presistant arterial hypoxemia <60 mmHg in spite of 60-70% oxygen
In this situations of simple oxygen failure, oxygen should be given
through positive pressure support (CPAP or MV)

34. Complications associated with oxygen therapy
1- Lung toxicity:
• Related to both concentration (dosage) and duration of therapy
• PIO2 and not FIO2 is the main responsible factor for toxicity
• Exposure to 100% oxygen is toxic to the lungs in 4 hours, while 70%
oxygen is toxic in 4 days, 40% oxygen is safe for one month.
• It is manifested by cessation of mucociliary activity, destruction of
oxygen sensitive type I pnematocytes with decreased surfactant
production and atelectasia.
• Hyperplasia o type II pnematocytes and interstitial fibrosis eventually
occur.

35. 2- Oxygen dependency and weaning difficults with prolonged oxygen
therapy.
3- Retinal toxicity to premature infants.

36. 4- Other Complications:
• Drying of mucous membranes.
• Skin breakdown
• Suppression of ventilation will lead to increased CO2 and narcosis
• Potential of contamination and infection to patients.
• Absorption atelectasis
• Fire Hazard

37. References
• Pediatric Advance Life Support
• Paramedic: Airway Management 2011
• Pediatric Critical Care Medicine: Basic Science And Clinical Evidence
edited by Derek S. Wheeler, Hector R. Wong, Thomas P. Shanley
• Pediatric critical care, principles of emergency medicine. Edited by
Mohammed El-Naggar, 2009.