1. Presented By : Dr. SUBHASIS ROY, CONSULTANT, SISU SANJIBAN HOSPITAL, SALT LAKE, KOLKATA

2. THE HISTORY 1774 – J. Priestly produced O 2 – “Dephlogisticated Air” 1776 – A. L. Lavoisier termed this vital air – OXYGEN Late 1800 – Bonnaire gave O 2 to preterm “Blue Baby” with success. 1907 – A. Lane invented NASAL CATHETER 1919 – L. Hill developed O 2 TENT. 1920 - O 2 therapy became routine for “SICK NEW BORN”

3. O 2 THERAPY IN NEONATE VS OLDER CHILDREN In Neonate – O 2 reserve less O 2 requirement / kg. higher. Small change in Fi O 2 – large change in Pa O 2 Unrestricted O 2 therapy – produce pulmonary / extra pulmonary hazards. MORE CAUTION REQUIRED IN NEONATAL O 2 THERAPY

4. NEW BORN RESUSCITATION – HOW IMPORTANT O 2 IS CURRENT RECOMMENDATION – 100% O 2 IN NRP BUT A GROWING OPINION THAT RA CAN BE USED IN PLACE OF O 2 Approx 100 million babies born annually, globally - 10 million need resus !. Cochrane review : RAR group shorter time to first breath and first cry. RAR group – only 25% required 100% backup O 2 facility. RAR group – Marginally lower overall mortality. No evidence of HARM in using RA BUT INSUFFICIENT DATA TO RECOMMEND RA OVER 100% O 2 NEW BORN RESUS. IS A SCIENTIFIC PROTOCOL BUT MORE AN “ART” THAN A “SCIENCE” IN DEVELOPING COUNTRIES WITH RESOURCE CONSTRAINTS. NOT TO PANIC IF O 2 SUPPLY IN LABOUR ROOM IS RESTRICTED OR NOT AVAILABLE.

5. ASSESSMENT OF NEED OF O 2 THERAPY DURING AND JUST AFTER RESUSCITATION IN NEWBORN O nly clinical – Cyanosis Heart rate i.e bradycardia Resp effort Muscle tone Response to stimuli LATER PART OF THE NEW BORN LIFE Clinical – Cyanosis Heart rate Pattern of breathing i.e. apnoea/Periodic breathing Monitoring - ABG – PaO 2 < 50 mm.Hg. Trans cutaneous oxygen monitoring Pulse oximetry - SpO 2 < 85 %

6. MODES OF OXYGEN DELIVERY SOURCE  O 2 cylinder  O 2 concentrator - max 5 – 8 lit / min. of 90 – 92% O 2  Pipeline - Cheapest

7. MODES OF OXYGEN DELIVERY… DELIVERY DEVICE LOW FLOW DEVICE  Nasal Canula – Max flow 2 – 3 lts./min. in new born. Nasopharyngeal Catheter  Insert a length – Alae nasai to Tragus  Check for blockage with mucus plug  FiO2 difficult to measure/control  Better if changed 24 hrly.  Not more than 3 lit. / min. O 2 in new born  Every lit. of O 2 -  FiO 2 by 4

8. MODES OF OXYGEN DELIVERY… HIGH FLOW DEVICE Mask  mask with 5 lit / min O 2 can give 40 – 60% O 2  require a minimum O 2 flow to prevent rebreathing of CO 2 Enclosure system  O 2 hood - > 7 lit./ min of 100% O 2 required initially to wash out CO 2  FiO 2 can be 0.21 – 1. O 2 given < 4 lit. min. can be managed without humidifier.

9. WHAT TO EXPECT FROM ADEQUATE OXYGEN THERAPY A. Clinical Monitoring: No cyanosis No apnoea or periodic breathing Stable heart rate B. Non Invasive Monitoring: Pulse Oximetry  Alarm set 85 – 96% SpO 2  Target range 88 – 95% SpO 2 Except PPHN  SpO 2 >97%  Unable to detect hyperoxia reliably  Plenty of other limitation

10. WHAT TO EXPECT FROM ADEQUATE OXYGEN THERAPY.. Trans centaneous O 2 monitoring  Not accurate in term babies with thick skin  Not used in prematures < 27 wks.  Heat related problems – skin heated to 44 o c C. Invasive monitoring ABG  Gold standard  8 – 12 hourly – may be required  PaO 2 – 50 – 80 mm Hg.  PaO 2 – 100 – 120 mm Hg acceptable in PPHN

11. NON RESPONDERS TO OXYGEN THERAPY  CCHD - COMMONEST  LARGE INTRAPULMONARY SHUNT - UNCOMMON  METHAEMOGLOBINAEMIA - RARE HYPEROXIA TEST FiO2 0.21FiO2 1.0 x 10 min NORMAL70 (95)>200(100) CCHD<40 (<75)<70(<85) PULMONARY50 (85)>150(100)

12. MARKERS OF O2 MONITORING  PiO 2 = (760 – 47) x 0.21 = 150 mmHg.  FiO 2 = 0.21  PAO 2 = 100 mmHg  PaO 2 = 90 mmHg  SaO 2 – O 2 saturation derived from arterialised cap. Blood.  SpO 2 – O 2 saturation by puls. ox THUMB RULE: FiO 2 x 5 = PaO 2

14. UNWANTED EFFECTS OF O 2 THERAPY IMMEDIATE – Some neonate on hypoxic drive going to apnoea. LATE -  ROP – Persistent  PaO 2 - main contributary factor  CLD Free radical damage due to O 2 therapy.  HIE  HOME O 2 DEPENDANCE AND REHOSPITALISATION  NOSOCOMIAL INFECTION

15. EFFECTS OF NOT ENOUGH OXYGEN  Pulm Vasc. Resistance  Airway Resistance  Risk of SIDS in Infant with CLD ? Limitation in Growth ? Sleep Disorder

16. O 2 – HOW COSTLY IT IS ? COMMONLY USED – SIZE F CYL. – CAP – 1320 lit.  Refilling cost – Rs. 140.00  5 lit./ min. = 300 lit./ hr. = 4.5 hr. / CYL. = 6 CYL./day = Rs. 800.00 (approx), without making any profit PIPED O2 – CYL. USED – CAP – 7100 – 7500 lit.  Refilling cost – Rs. 220.00  Institutions charge – Rs. 400 – 800/day, irrespective of usage/ day. !

17. KEY POINTS New born Resus  If O 2 not available – Room Air may be enough in 90% cases.  To save life – Do not think of ROP, Short term  PaO 2 acceptable. Beyond EMERGENCY period  Strict monitoring of PaO 2 necessary. To Detect ROP Eye exam from 4-6 weeks & 2–4 weekly in<32 wk. < 1250 gm. Max O 2 flow through nasal catheter - do not exceed 3 lit./ min. O 2 hood – initial flow of 7 lit./ min. required.

18. KEY POINTS…. Keep PaO 2 50 – 80 mm. Hg., SpO 2 88 - 95 % O 2 is a DRUG only should be used  Documented hypoxia  Resp. Distress  Cynosis When prescribing O 2 – specify -  Dose  Device  Duration  Monitoring Take care of devices judiciously to prevent – NOS. INFECTION