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Oxygen administration forneonatal intensive care
Volume 80 Number 6
Brief clinical and laboratory observations
Oxygenadministration
for
neonatal intensive care David W. Deaton, ARIT, David Bentley, and E. Warner Ahlgren, M.D., Dallas, Texas
THE
ADMINISTRATION
Of
oxygen
to neonates and small infants requiring intensive care presents many problems. These problems involve oxygen toxicity (both to lungs and the eyes), a-~ pulmonary hypertension, ~ oxygen humidification, 6 oxygen administration in an incubator environment, 7, s observation of the patient, and nursing care. In essence, all these problems center around the maintenance of a known, consistent oxygen environment. The greater the needs are for oxygen supplementation, the greater are the associated problems. With sophistication of intensive care techniques which include the use of umbilical artery catheters, endotracheal tubes, ventilators, apnea monitors, and other intensive care modalities, oxygen administration with the known, consistent environment has remained a dilemma. Arterial oxygen tension, as determined by blood gases, has become corrtmon place. The precision associated with these blood gases has demanded the additional precision in oxygen administration so that a preselected oxygen environment remains constant2 To deliver a consistent oxygen environment to the neonate in an incubator, especially an open incubator, the "halo" (Patent No. 3,552,391) was developed. DESCRIPTION
OF TIlE D E V I C E
Oxygen is mixed with air in a predetermined percentage in a jet nebulizer. The huFrom the Departments of Anesthesiology and Respiratory Therapy, Children's Medical Center. ~Reprint address: Department of Anesthesiology, Children's Medical Center, 1935 Amelia St., Dallas, Texas 75235.
10 3 9
midified gas mixture is delivered directly by a corrugated hose to the infant's head. The infant's head is enclosed in the halo (Fig. 1), a rigid plastic cylinder (8 inches in diameter, 7 inches high) with an open top and bottom, which has a neck cut-out ( 3 ~ inches high, 3 89 inches wide) and a 2 ml. plastic body trunk sheet. The gas, at a flow of 10 L. per minute, is introduced into the base of the halo 180 degrees from the infant's neck. At the point of introduction into the halo the gas flow is directed at a 90 degree angle from the entry point. Controlled turbulence, vortex flow, is utilized to direct the gas flow along the halo wall laterally. T h e flow then continues up over the infant's head and finally up out the top of the halo. T h e halo by its open-top design permits a controlled oxygen environment which can be monitored intermittently or continuously with an oxygen analyzer. Small slots are provided in the base to allow entry and exit of intravenous administration tubing and nasogastric suctio n tubing. EVALUATION
OF THE HALO
Over a test period of two years the halo has been utilized on more than 200 patients with greater than 1,000 patient days of clinical application. The desired consistent inspired oxygen tension was satisfactorily maintained with all infants; oxygen tensions and carbon dioxide tensions have been measured during this 2 year period. Fig. 2 is a composite graph on one infant which is considered representative. With a t,700 Gm. neonate in the halo, oxygen percentage was adjusted to 40, 60, 80, and maximal. The inspired oxygen tension was measured with an I.M.I. continuous oxygen analyzer (I.M.I. Division of Becton, Dickinson, and Co.) with the electrode attached to the bridge of the infant's nose. Over a 4:0 minute study period the patient's head was turned left to right (point A), simulated airway suction was performed (point B), and simulated insertion of a nasogastric tube (point C). Turning and the other manipulations of the patient with the halo firmly on the mattress and the trunk sheet firmly on the thorax resulted in no appre-
10 4 0
Brief clinical and laboratory observations
The Journal o[ Pediatrics June 1972
!tlll/l'!l!l" I"lllllll
d
Jb
,~-,~ - ~
Fig, 1, a, Open-top halo; b, neck sheath; c, aerosol "T,"' d, intravenous outlets.
10-
~
100 -
0 2 max.
90LtJ
80 t ,,z, 70
_a 8 X 0 Z 6 0 rn ,< ',..3 4 I-Z W {.3 n." 2 Ld (3_
0 -
~x60
oz
0
~_50~ Z
t 0-20 I I
ol
0
t
Start A.
Turned
B.
Simulated
head
~
C02
10 20 30 40 TIME IN MINUTES
t
A left
airway
t
B
t
C
to right suctioning
C. Simulated insertion of nasogastric tube
Fig. 2. "Halo" in open incubator. Infant weight 1,700 Gin. ciable change in oxygen concentrations. With the higher oxygen concentrations there is some increase in percentage variations. The maximal concentration delivered to the infant in this device is 96 per cent. Carbon dioxide tensions were measured with a Harvard Carbon Dioxide Analyzer Model 2050 with the sampling tube also attached to the bridge of the nose. The carbon dioxide remained at 0.2 per cent or less during the study period.
DISCUSSION The provision of adequate oxygen tensions in the arterial blood of infants requiring intensive care demands high oxygen concentrations on many occasions. To deliver these concentrations, oxygen masks and closed hoods have been employed. Previously used devices have been an obstruction to care and have resulted in a decrease in oxygen concentration when removed for care. The oxygen halo is present, zs a device to allow for consistency ygen delivery while providing maximal obse~, ation of the patient and without impeding nursing care procedures because this device does not have to be removed to provide care. The halo, with its uniformly consistent environment, eliminates stresses related to interruption of the oxygen environment. With its open-top design there is no pressure buildup regardless of flow rate. The device is simple and employs the principal of vortex flow. The environmental violation is constant and allows for minimal disruption during all phases of intensive care. The halo is applicable to either the standard closed incubator or the infra-redwarmed open incubator. There i s no absorption of radiant infra-red heat with the openLtop halo as has been reported with the closed hood. 1~ The open-top permits maximum view of the infant's head and presents
Volume 80 Number 6
Brief clinical and laboratory observations
no barrier to patient care. W i t h medical care of the sick i n f a n t being m a i n l y directed to the head, there is no i n t e r r u p t i o n of t h e preselected oxygen e n v i r o n m e n t while providing the care.
5.
6.
REFERENCES
1. A Review: Pathological effects of exposure to high oxygen tensions, N. Engl. J. Med. 275: 1038, 1966. 2. Nichols, C. W., and Lombertson, C. J.: Medical progress--effects of high oxygen pressures on the eye, N. Engl. J. Med. 281: 25, 1969. 3. Balentine, J. D.: Pathologic effects of exposure to high oxygen tension, N. Engl. J. Med. 275: 1038, 1966. 4. Northway, W. H., Jr., Rosan, R. C., and Porter, O. Y.: Pulmonary disease following respiratory therapy of hyaline membrane dis-
7. 8.
9. 10.
1 04 1
ease: Bronchopulmonary dysplasia, N. Engl. J. Med. 276: 357, 1967. Naeye, R. L., and Letts, H. W.: The effects of prolonged neonatal hypoxemia on the pulmonary vascular bed and heart, Pediatrics 30: 902, 1962. Wells, R. E., Perera, R. D., and Kinney, J. M.: Humidification of oxygen during inhalation therapy, N. Engl. J. Med. 268: 644, 1963. Simpson, H., and Russell, D. J.: Oxygen concentrations in tents and incubators in pediatric practice, Br. Med. J. 4: 201, 1967. Adamson, K., Jr., Gandy, G. M., and James, L. S.: The influence of thermal factors upon oxygen consumption of the newborn human infant, J. P~DIATR. 66" 495, 1965. Editorial: Oxygen--a need for a quantitative approach, N. Engl. J. Med. 277: 983, 1967. Indyk, L.: Experience and reason--briefly recorded. A dangerous situation encountered in the administration of oxygen to an infant in a baby warmer, Pediatrics 47: 603, 1971.
Brief clinical and laboratory observations
Oxygenadministration
for
neonatal intensive care David W. Deaton, ARIT, David Bentley, and E. Warner Ahlgren, M.D., Dallas, Texas
THE
ADMINISTRATION
Of
oxygen
to neonates and small infants requiring intensive care presents many problems. These problems involve oxygen toxicity (both to lungs and the eyes), a-~ pulmonary hypertension, ~ oxygen humidification, 6 oxygen administration in an incubator environment, 7, s observation of the patient, and nursing care. In essence, all these problems center around the maintenance of a known, consistent oxygen environment. The greater the needs are for oxygen supplementation, the greater are the associated problems. With sophistication of intensive care techniques which include the use of umbilical artery catheters, endotracheal tubes, ventilators, apnea monitors, and other intensive care modalities, oxygen administration with the known, consistent environment has remained a dilemma. Arterial oxygen tension, as determined by blood gases, has become corrtmon place. The precision associated with these blood gases has demanded the additional precision in oxygen administration so that a preselected oxygen environment remains constant2 To deliver a consistent oxygen environment to the neonate in an incubator, especially an open incubator, the "halo" (Patent No. 3,552,391) was developed. DESCRIPTION
OF TIlE D E V I C E
Oxygen is mixed with air in a predetermined percentage in a jet nebulizer. The huFrom the Departments of Anesthesiology and Respiratory Therapy, Children's Medical Center. ~Reprint address: Department of Anesthesiology, Children's Medical Center, 1935 Amelia St., Dallas, Texas 75235.
10 3 9
midified gas mixture is delivered directly by a corrugated hose to the infant's head. The infant's head is enclosed in the halo (Fig. 1), a rigid plastic cylinder (8 inches in diameter, 7 inches high) with an open top and bottom, which has a neck cut-out ( 3 ~ inches high, 3 89 inches wide) and a 2 ml. plastic body trunk sheet. The gas, at a flow of 10 L. per minute, is introduced into the base of the halo 180 degrees from the infant's neck. At the point of introduction into the halo the gas flow is directed at a 90 degree angle from the entry point. Controlled turbulence, vortex flow, is utilized to direct the gas flow along the halo wall laterally. T h e flow then continues up over the infant's head and finally up out the top of the halo. T h e halo by its open-top design permits a controlled oxygen environment which can be monitored intermittently or continuously with an oxygen analyzer. Small slots are provided in the base to allow entry and exit of intravenous administration tubing and nasogastric suctio n tubing. EVALUATION
OF THE HALO
Over a test period of two years the halo has been utilized on more than 200 patients with greater than 1,000 patient days of clinical application. The desired consistent inspired oxygen tension was satisfactorily maintained with all infants; oxygen tensions and carbon dioxide tensions have been measured during this 2 year period. Fig. 2 is a composite graph on one infant which is considered representative. With a t,700 Gm. neonate in the halo, oxygen percentage was adjusted to 40, 60, 80, and maximal. The inspired oxygen tension was measured with an I.M.I. continuous oxygen analyzer (I.M.I. Division of Becton, Dickinson, and Co.) with the electrode attached to the bridge of the infant's nose. Over a 4:0 minute study period the patient's head was turned left to right (point A), simulated airway suction was performed (point B), and simulated insertion of a nasogastric tube (point C). Turning and the other manipulations of the patient with the halo firmly on the mattress and the trunk sheet firmly on the thorax resulted in no appre-
10 4 0
Brief clinical and laboratory observations
The Journal o[ Pediatrics June 1972
!tlll/l'!l!l" I"lllllll
d
Jb
,~-,~ - ~
Fig, 1, a, Open-top halo; b, neck sheath; c, aerosol "T,"' d, intravenous outlets.
10-
~
100 -
0 2 max.
90LtJ
80 t ,,z, 70
_a 8 X 0 Z 6 0 rn ,< ',..3 4 I-Z W {.3 n." 2 Ld (3_
0 -
~x60
oz
0
~_50~ Z
t 0-20 I I
ol
0
t
Start A.
Turned
B.
Simulated
head
~
C02
10 20 30 40 TIME IN MINUTES
t
A left
airway
t
B
t
C
to right suctioning
C. Simulated insertion of nasogastric tube
Fig. 2. "Halo" in open incubator. Infant weight 1,700 Gin. ciable change in oxygen concentrations. With the higher oxygen concentrations there is some increase in percentage variations. The maximal concentration delivered to the infant in this device is 96 per cent. Carbon dioxide tensions were measured with a Harvard Carbon Dioxide Analyzer Model 2050 with the sampling tube also attached to the bridge of the nose. The carbon dioxide remained at 0.2 per cent or less during the study period.
DISCUSSION The provision of adequate oxygen tensions in the arterial blood of infants requiring intensive care demands high oxygen concentrations on many occasions. To deliver these concentrations, oxygen masks and closed hoods have been employed. Previously used devices have been an obstruction to care and have resulted in a decrease in oxygen concentration when removed for care. The oxygen halo is present, zs a device to allow for consistency ygen delivery while providing maximal obse~, ation of the patient and without impeding nursing care procedures because this device does not have to be removed to provide care. The halo, with its uniformly consistent environment, eliminates stresses related to interruption of the oxygen environment. With its open-top design there is no pressure buildup regardless of flow rate. The device is simple and employs the principal of vortex flow. The environmental violation is constant and allows for minimal disruption during all phases of intensive care. The halo is applicable to either the standard closed incubator or the infra-redwarmed open incubator. There i s no absorption of radiant infra-red heat with the openLtop halo as has been reported with the closed hood. 1~ The open-top permits maximum view of the infant's head and presents
Volume 80 Number 6
Brief clinical and laboratory observations
no barrier to patient care. W i t h medical care of the sick i n f a n t being m a i n l y directed to the head, there is no i n t e r r u p t i o n of t h e preselected oxygen e n v i r o n m e n t while providing the care.
5.
6.
REFERENCES
1. A Review: Pathological effects of exposure to high oxygen tensions, N. Engl. J. Med. 275: 1038, 1966. 2. Nichols, C. W., and Lombertson, C. J.: Medical progress--effects of high oxygen pressures on the eye, N. Engl. J. Med. 281: 25, 1969. 3. Balentine, J. D.: Pathologic effects of exposure to high oxygen tension, N. Engl. J. Med. 275: 1038, 1966. 4. Northway, W. H., Jr., Rosan, R. C., and Porter, O. Y.: Pulmonary disease following respiratory therapy of hyaline membrane dis-
7. 8.
9. 10.
1 04 1
ease: Bronchopulmonary dysplasia, N. Engl. J. Med. 276: 357, 1967. Naeye, R. L., and Letts, H. W.: The effects of prolonged neonatal hypoxemia on the pulmonary vascular bed and heart, Pediatrics 30: 902, 1962. Wells, R. E., Perera, R. D., and Kinney, J. M.: Humidification of oxygen during inhalation therapy, N. Engl. J. Med. 268: 644, 1963. Simpson, H., and Russell, D. J.: Oxygen concentrations in tents and incubators in pediatric practice, Br. Med. J. 4: 201, 1967. Adamson, K., Jr., Gandy, G. M., and James, L. S.: The influence of thermal factors upon oxygen consumption of the newborn human infant, J. P~DIATR. 66" 495, 1965. Editorial: Oxygen--a need for a quantitative approach, N. Engl. J. Med. 277: 983, 1967. Indyk, L.: Experience and reason--briefly recorded. A dangerous situation encountered in the administration of oxygen to an infant in a baby warmer, Pediatrics 47: 603, 1971.