AMERICAN ACADEMY OF PEDIATRICS OCT 2017
THE INS AND OUTS OF HOME OXYGEN
Medically stable babies on supplemental oxygen may go home, provided parents learn the necessary care before discharge. Bronchopulmonary dysplasia (BPD) is the most common condition of babies discharged home on oxygen. With BPD, the lungs are damaged and scarred from long periods on a ventilator and on oxygen. Smaller babies and those born earlier than 32 weeks’ gestation are at the greatest risk for developing this complication. The heart and lungs of a baby with BPD must work particularly hard. Fortunately, as the baby grows, so does new lung tissue—and the damaged lung will become less of the total lung tissue. Other reasons for sending a baby home with oxygen include:
- Evidence of oxygen desaturation when breathing room air while awake, at rest, with activity, or with feedings
- Poor nippling caused by “air hunger” (baby seems to have difficulty catching her breath)
- Apnea or bradycardia that responds to supplemental oxygen
- Poor weight gain
- Airway problems, tracheostomy, or ventilator use
Supplemental oxygen is usually delivered through a nasal cannula—a small tube that fits under your baby’s nose and around the head. Three types of oxygen delivery systems are used in the home:
A very large, non-portable tank is sent directly to your home. A respiratory care practitioner from durable medical equipment (DME) company will show you how to read the gauges to determine when you need to refill your tanks. The length of time between tank refillings depends on how much oxygen your baby uses and on the size of the tank. A portable E cylinder set at 1⁄2 liter of oxygen per minute by nasal cannula, for example, lasts about 20 hours. A smaller D cylinder lasts about 12 hours. The larger H cylinder backup tank at the same setting lasts approximately 175 hours. Larger backup tanks come in a few different sizes as well. Usually, the company exchanges your large tank with a full one when the pressure in it reaches 500 pounds per square inch (psi).
An oxygen concentrator is a device that separates oxygen out of the air and gives it to your baby. Because a concentrator runs on electricity, a portable backup oxygen tank is necessary when your baby is not near an electrical outlet and in the event of a power outage.
Oxygen that has been cooled to a liquid state is called liquid oxygen. It changes to a gas as your baby breathes it. A liquid oxygen tank takes up considerably less space than a large compressed oxygen tank, which contains oxygen in the gaseous form and is used as a backup oxygen tank. As with a compressed oxygen system, a small, portable tank is delivered to the hospital, and a larger, non-portable tank is sent directly to your home. One drawback of liquid oxygen is that it evaporates when not in use. It’s also expensive and may not be covered under insurance provisions. A portable liquid oxygen tank set at 1⁄2 liter of oxygen per minute via nasal cannula lasts approximately eight hours. The larger backup tank at the same setting lasts approximately 500 hours.
Regardless of the type of oxygen system in your home, certain safety precautions must be followed. Because oxygen is a highly flammable substance, there should be no smoking in a room where oxygen equipment is located. When your baby is receiving oxygen, keep her at least six feet away from open flames, such as heaters, fireplaces, or gas appliances with pilot lights. Oxygen tanks themselves should also be kept at least six feet away from an open flame, radiator, or heater. Do not use rubbing alcohol, petroleum jelly, or spray cans near a baby on oxygen. Keep the door to your baby’s room open so the room is well ventilated and not stuffy. Finally, make sure the smoke detectors in your home work well, and periodically review your home fire escape plan with your family. Your instruction in home oxygen use should have begun well before discharge to give you ample opportunity to ask questions and practice operating the equipment.
Rooming in with your baby and the oxygen equipment is an excellent way to achieve these goals. Infants who are oxygen-dependent are often discharged home with an apnea monitor to alert parents of potential signs and symptoms of respiratory distress and/or arrest. Rarely, an oxygen-dependent infant will be discharged home on a pulse oximeter (a machine that measures arterial blood oxygenation). Pulse oximeters are known for frequent false alarms, especially when a baby is active, which limits their usefulness and reliability in the home setting. Therefore, most oxygen-dependent babies will have their oxygenation measured periodically by a respiratory care practitioner (using a pulse oximeter) in the home or in a follow-up clinic with their health care provider or pulmonary specialist. They may also need periodic aerosol breathing treatments (medication inhaled directly into the lungs to open breathing passages) and systemic oral medications at home. Rooming-in also provides you with the opportunity to learn these aspects of your baby’s care.
Lastly, rooming-in is also a good time to take a planned “road-trip,” or walk through the hospital, with your baby in a stroller and the oxygen equipment attached. You will have to travel with your baby by yourself eventually, even if it is only to go to the doctor, and this will give you an opportunity to practice managing all of the equipment attached to the stroller or carried along with your baby. At first it may seem overwhelming, but you will soon become a pro!
Letters from your health care provider will be given to you to send to your telephone company, electric company, and local EMS system, alerting them that you have an infant with special needs in your home. Problems with oxygen-dependent infants can be life-threatening. You need to be able to identify potential problems and then immediately contact your physician, EMS system, or ambulance service.
After discharge, babies on oxygen may receive home health nursing visits or private-duty nursing if medically necessary. The amount and type of home nursing follow-up is determined by your baby’s physician, your individual needs, and your health care coverage. The decision to begin weaning a baby from oxygen depends on many factors. Some physicians begin weaning when the baby’s respiratory effort decreases and oxygen saturation stabilizes. Other physicians keep the baby on oxygen to ensure continued weight gain and attainment of developmental milestones. Studies report fewer respiratory infections in infants on oxygen than in those whose oxygen saturation levels are borderline. Your doctor will take into account these and other factors unique to your baby. Weaning is usually gradual and is accompanied by physical examinations, chest x-rays, and periodic oxygenation measurements (which can be done in your home by a respiratory care practitioner).
If at any time your baby fails to progress in the weaning schedule, she will be evaluated to determine the cause. Your baby will be assessed throughout the weaning process to determine her tolerance for increasingly lower levels of oxygen until the oxygen is finally discontinued. #
Courtesy of the American Academy of Pediatrics, aap.org.