Reprinted from RESPIRATORY CARE (Respir Care 1996; 41(7):637-646)

AARC Clinical Practice Guideline

Selection of an Oxygen Delivery Device for Neonatal and Pediatric Patients


The selection of an oxygen delivery system for neonatal and pediatric patients includes patients with and without artificial airways.


The administration of supplemental oxygen to neonatal and pediatric patients requires the selection of an oxygen delivery system that suits the patient's size, needs, and the therapeutic goals. Oxygen delivery systems are categorized as either low-flow, reservoir, high-flow, or enclosure systems.(1) Low-flow and reservoir systems provide an FDO2 (fractional concentration of delivered oxygen) that varies with the patient's inspiratory flow and are classified as variable-performance oxygen delivery systems.(1) High-flow systems can provide a specific FDO2 at flows that meet or exceed the patient's inspiratory flow requirement and are classified as fixed-performance oxygen delivery systems.(1) Enclosure systems provide a means of controlling oxygen concentration, temperature, and humidity.
2.1 Low-flow systems:
2.1.1 Nasal cannulas consist of two soft prongs that arise from oxygen supply tubing.(2) The prongs are inserted into the patient's nares, and the tubing is secured to the patient's face. Oxygen flows from the cannula into the patient's nasopharynx, which acts as an anatomic reservoir.(3) The fractional concentration of inspired oxygen (FIO2) varies with the patient's inspiratory flow.(1)
2.1.2 Nasopharyngeal catheters are soft tubes with several distal holes. The catheter should be inserted into the patient's nose to a depth equal to the distance from the ala nasi to the tragus(4) or be gently advanced and then withdrawn until it rests slightly above the uvula.(5) The tube, secured to the patient's face, is connected to oxygen supply tubing. Oxygen flows from the catheter into the patient's oropharynx, which acts as an anatomic reservoir.(5) The FIO2 varies with the patient's inspiratory flow.(1)
2.1.3 Tracheostomy oxygen adapters are devices that attach either directly to a tracheostomy tube or to a heat-moisture exchanger (HME), which is then attached to the tube.(6) (HMEs recycle the heat and moisture of respired air.(6)) The oxygen supply tube connected to the adapter provides a blow-by source of oxygen that results in a variable FIO2. These devices are intended for short periods such as brief transports or to increase patient mobility.(7)
2.2 Reservoir systems:
2.2.1 Simple oxygen masks are plastic reservoirs designed to fit over the patient's nose and mouth and be secured around the patient's head by an elastic strap.(8) A reservoir effect is produced by the internal capacity of the mask.(9) Oxygen is delivered through a small-bore tube connected to the base of the mask. Holes on each side of the mask provide an egress for exhaled gases and serve as room-air entrainment ports.(8) The FIO2 varies with the patient's inspiratory flow.(1)
2.2.2 Partial-rebreathing masks are similar to simple oxygen masks but contain a reservoir at the base of the mask.(8) The reservoir receives fresh gas plus exhaled gas approximately equal to the volume of the patient's anatomic dead space.(8) The oxygen concentration of the exhaled gases combined with the supply of fresh oxygen, permits the use of flows lower than those necessary for other devices (eg, non-rebreathing masks), and potentially conserves oxygen use.
2.2.3 Non-rebreathing masks are similar to partial-rebreathing masks but do not permit the mixing of exhaled gases with the fresh gas supply.(8) A series of one-way valves placed at the reservoir opening and on the side ports, ensures a fresh oxygen supply with minimal dilution from the entrainment of room air.(8) This design provides a higher FIO2 than the simple and partial-rebreathing masks and the nasal devices.(1)
2.3 High-flow systems:
2.3.1 An air-entrainment mask is designed to fit over the patient's nose and mouth and contains a short corrugated hose with a jet orifice that is connected to oxygen supply tubing.(8) Oxygen under pressure is forced through a small jet orifice entering the mask. The velocity increases causing a shearing effect distal to the jet orifice, which causes room air to be entrained into the mask.(10) The total flow provided by the mask is determined by the cross-sectional area of the entrainment ports, the diameter of the jet orifice, and the oxygen flow to the jet. The FDO2 is determined by the dimensions of the jet and the entrainment ports. The entrainment mechanism is based on the principles described by Bernoulli.(10) A collar can be attached to the base of the corrugated hose for supplemental humidification,(11) and the device can be adapted to a tracheostomy collar.
2.3.2 Air-entrainment nebulizers are gas-powered, large-volume nebulizers that contain an adjustable air-entrainment port, which determines specific oxygen concentrations.(8,12) In addition to providing particulate water with or without added medication, heated nebulizers can deliver gas saturated with water vapor at body temperature.(13) A corrugated hose serves as a conduit from the nebulizer to an aerosol mask, face tent, tracheostomy collar, or T-piece.(11)
2.4 Enclosure systems:
2.4.1 Oxygen hoods are transparent enclosures designed to surround the head of the neonate or small infant.(8,14) A continuous flow of humidified oxygen is supplied to the hood.(8,14) Transparent enclosures in larger sizes (so-called tent houses or huts) are available for patients who are too big for neonatal-size hoods.(11)
2.4.2 Oxygen tents are electrically powered appliances that incorporate an air circulation system and provide temperature control.(8,14) An oxygen source is connected to a large-volume nebulizer, which provides humidification in the form of particulate water. The nebulizer is connected to a transparent canopy placed over the patient and secured under the mattress of the crib or bed. This provides an oxygen-enriched environment.(8,14)
2.4.3 Closed incubators are transparent enclosures that provide a warm environment for small infants with temperature instability.(8) Supplemental oxygen can be added to incubators but may result in an oxygen concentration.(8) The primary purpose of an incubator is to provide a temperature-controlled environment. Humidification is available through a baffled blow-over water reservoir; however, due to the high risk of infection associated with this humidification system, alternative sources are used.(8) Therefore, the incubator is not further discussed as an oxygen delivery device.(11)


Oxygen delivery devices are used in a number of settings including hospitals, clinics, extended care facilities, the home, and patient transport vehicles.


The selection of an oxygen delivery device is indicated with:
4.1 documented hypoxemia;(15,16)
4.2 an acute situation in which hypoxemia is suspected or in which suspected regional hypoxia may respond to an increase in PaO2. Substantiation of PaO2 is required within an appropriate period of time following initiation of therapy.(15,16)


5.1 No specific contraindications to delivering oxygen exist when indications are judged to be present.(16)
5.2 Nasal cannulas and nasopharyngeal catheters are contraindicated in patients with nasal obstruction (eg, nasal polyps, choanal atresia).(8)
5.3 Nasopharyngeal catheters are contraindicated in the presence of maxillofacial trauma(17) and in patients in whom a basal skull fracture is present or suspected.(18)
5.4 Although opinions vary,(19-21) infants intubated for airway protection should probably be placed on CPAP (ie, physiologic CPAP) for supplemental oxygen rather than on a T-piece because of the loss of physiologic end-expiratory pressure created by an open glottis.


6.1 Physiologic:
6.1.1 The etiology of retinopathy of prematurity, especially the role of oxygen, is controversial. Care should be taken when supplemental oxygen is provided to preterm infants (< 37-weeks gestation). It is suggested that oxygen supplementation should not result in a PaO2 > 80 torr.(22)
6.1.2 The administration of supplemental oxygen to patients with certain congenital heart lesions (eg, hypoplastic left-heart, single ventricle) may cause an increase in alveolar oxygen tension and compromise the balance between pulmonary and systemic blood flow.(23)
6.1.3 The administration of supplemental oxygen to patients suffering from paraquat poisoning or to patients receiving certain chemotherapeutic agents (eg, bleomycin) may result in pulmonary complications (eg, oxygen toxicity and pulmonary fibrosis).(24,25)
6.1.4 The administration of supplemental oxygen to patients with chronic CO2 retention may result in a decrease in respiratory drive.(26)
6.1.5 Stimulation of the trigeminal nerves may cause alterations in respiratory pattern if the gas flow from the oxygen source is cool and is directed at the face of the infant.(27)
6.1.6 Inappropriate selection of FDO2 or oxygen flow may result in hypoxemia or hyperoxemia.
6.2 Equipment-related
6.2.1 Nasal cannulas: Skin irritation can result from material used to secure the cannula(3,28) or from local allergic reaction to polyvinyl chloride.(29) Improper sizing can lead to nasal obstruction or irritation.(3,30) Displacement can lead to loss of oxygen delivery.(3,30) Inadvertent CPAP may be administered depending upon the size of the nasal cannula, the gas flow, and the infant's anatomy.(31) Irritation can result if flows are excessive.
6.2.2 Nasopharyngeal catheters: Improper insertion can cause gagging(5) and nasal or pharyngeal trauma.(5) Excessive flow can produce pain in the frontal sinuses.(8) Pneumocephalus is a rare but possible complication.(32) Excessive secretions and/or mucosal inflammation can result.(5) Skin irritation may result from material used to secure the cannula(3,28) and/or from local allergic reaction to polyvinyl chloride.(29) Occlusion of distal openings may occur.(4) Excessive flow may cause gastric distention.(4)
6.2.3 Masks: Aspiration of vomitus may be more likely when a mask is in place. Irritation may result from tight application.(8) Rebreathing of CO2 may occur if total O2 flow is inadequate.(12,33)
6.2.4 Air-entrainment nebulizers: produce high noise levels in enclosed environments (eg, hoods, incubators) and may induce hearing impairment;(34) when an air-entrainment nebulizer is used in an enclosed environment, the entrainment port should be set on 100% (ie, closed) and the nebulizer powered either by a blender or by compressed air with titration of oxygen to the desired concentration.(11) are susceptible to contamination;(35-37) may cause bronchoreactivity in patients with reactive airways when used with nonisotonic solutions;(38-40) may create unwanted torque and increase the likelihood of inadvertent extubation or decannulation of the patient when used with a T-piece and applied directly to an endotracheal or tracheostomy tube;(11) may not provide particles of desired size range and in a predictable dose;(41) if unheated, may induce cold stress in neonates;(27,42) Condensate in tubing may result in advertent lavage when attached to the endotracheal tube.
6.2.5 Hoods and transparent enclosures: Prolonged exposure to humidfied oxygen may increase risk for cutaneous fungal infection.(43) Inadequate or loss of gas flow may result in hypoxia or hypercapnia. Temperature within enclosures should be closely monitored to reduce the potential for cold stress or apnea from overheating in neonates.(27) Use of an improperly sized hood can result in irritation of the infant's skin.(11)
6.2.6 Oxygen tents: Potential exists for electric shock or fire from electrical or battery-operated devices inside the tent.(8,11) Potential exists for electric shock from static electrical discharge from plastic tent canopies.(8,11) Large-volume nebulizers used to supply oxygen to tents are susceptible to contamination.(35-37) Loss of the air circulation system may result in failure to cool the tent.(11) Potential exists for asphyxiation if the patient becomes lodged between the mattress and the tent.
6.2.7 Tracheostomy oxygen adapters: Adapters may create unwanted torque and increase the likelihood of inadvertent decannulation of the patient, and HMEs may increase work of breathing to an unacceptable level in patients < 8 kg if dead space and resistance are high.(44)
6.3 During laser bronchoscopy, minimal levels of supplemental oxygen should be used to decrease the risk of intratracheal ignition.(16,45)
6.4 Fire hazard is increased in the presence of increased oxygen concentrations.(16)
6.5 Bacterial contamination has been associated with certain nebulization and humidification systems.(35-37)


7.1 Nasal cannulas:
7.1.1 Changes in minute ventilation and inspiratory flow affect air entrainment and result in fluctuations in FIO2.(46,47)
7.1.2 Prongs are difficult to keep in position, particularly with small infants.(3,28,48)
7.1.3 The effect of mouth versus nose breathing on FIO2 remains controversial.(49-52)
7.1.4 Use may be limited by the presence of excessive mucus drainage, mucosal edema, or a deviated septum.(8)
7.1.5 Maximum flow should be limited to 2 L/min in infants and newborns.(46,47,53)
7.1.6 Care should be taken to keep the cannula tubing and straps away from the neck to prevent airway obstruction in infants.
7.1.7 Discrepancies between set and delivered flow can occur in the same flowmeter at different settings and among different flowmeters.
7.1.8 Discrepancies in flow and oxygen concentration between set and delivered values can occur in low-flow blenders at flows below the recommended range of the blender.
7.2 Nasopharyngeal catheters:
7.2.1 Method is in less common use because of the complexity of care.
7.2.2 FIO2 is difficult to control and measure.(46,47)
7.2.3 Effect of mouth versus nose breathing on FIO2 remains controversial.(48-52)
7.2.4 Use may be limited by excessive mucus drainage, mucosal edema, or the presence of a deviated septum.(5)
7.2.5 Catheter should be cleared frequently to prevent occlusion of the distal holes.(4,5) The patient should be observed for evidence of catheter occlusion, and the catheter should be alternated between nares every (8-12) hours and changed daily.(30)
7.2.6 Catheter sizes less than 8 Fr are less effective in oxygen delivery.(4)
7.2.7 Lower oxygen concentrations are delivered if the catheter is placed in the nose rather than in the pharynx.(4)
7.2.8 Low-flow flowmeters (< 3 L/min) should be used.(4)
7.2.9 Discrepancies between set and delivered flow can occur in the same flowmeter at different settings and among different flowmeters.
7.2.10 Discrepancies in flow and oxygen concentration between set and delivered values can occur in low-flow blenders at flows below those recommended by the manufacturer.
7.3 Masks:
7.3.1 provide variable FIO2 depending on inspiratory flow and construction of the mask's reservoir(11) and are not recommended when precise concentrations are required;(15,54)
7.3.2 are confining and may not be well tolerated;(55)
7.3.3 interfere with feeding;(5)
7.3.4 may not be available in sizes appropriate for all patients;
7.3.5 require a minimum flow to avoid possible rebreathing of CO2.(12,33)
7.3.6 The maximum FIO2 attainable with a simple, non-rebreathing or partial-rebreathing mask in neonates, infants, and children has not been well documented.(33)
7.3.7 The performance of air-entrainment masks may be altered by resistance to flow distal to the restricted orifice (resulting in higher FDO2 and lower total flow delivered). The total flow from air-entrainment masks at settings greater than 0.40 may not equal or exceed the patient's inspiratory flow.(8,16)
7.3.8 Performance is altered if the entrainment ports are blocked.
7.4 Air-entrainment nebulizers:
7.4.1 are vulnerable to alterations described in Section 7.3.7;
7.4.2 should have temperature monitored if they are heated (Cool mist is not recommended for newborns because of the potential for cold stress.(27,42) In newborns, the temperature of the gas-aerosol mixture at the patient should be approximately equal to the desired environmental temperature.(42));
7.4.3 may have performance altered by resistance to flow distal to the restricted orifice (resulting in higher FDO2 and lower total flow delivered). The total flow from air-entrainment nebulizers at settings greater than 0.40 may fail to equal or exceed the patient's inspiratory flow.(8,16) However, increasing the oxygen flow to the inlet of the nebulizer may produce a higher delivered total flow.
7.5 Hoods and tents:
7.5.1 O2 concentrations may vary within the hood or tent.(8,11,16) O2 concentrations should be measured as near the nose and mouth as possible.(11) Opening any enclosure decreases the O2 concentration. For infants and children confined to tents, nasal O2 may need to be supplied during feeding and nursing care. Flows g 7 L/min are required to wash out carbon dioxide.(11,12)
7.5.2 Devices can be confining and isolating. Dense fog or excessive condensation can develop, which may frighten the child and limit observation.(11)
7.5.3 Only low-to-moderate concentrations < 0.40 can be achieved in a tent.(11)
7.5.4 Concentration in a hood can be varied from 0.21 to 1.0 and is more stable than in a tent.(9)
7.5.5 Temperature of the gases in the hood should be maintained to provide a neutral thermal environment.(8,16,42)
7.5.6 High gas flows may produce harmful noise levels.(34,56)
7.6 Tracheostomy oxygen adapters provide variable FIO2s. HMEs should have minimum dead-space volume especially when used with neonates.(44,57,58) Resistance within an HMEs can increase when water is absorbed by the hygroscopic inserts(59) or when secretions are coughed into the device.(60)


Need is determined by measurement of inadequate oxygen tensions and saturations by invasive or noninvasive methods(61,62) and/or the presence of clinical indicators as previously described.(16) Supplemental oxygen flow should be titrated to maintain adequate oxygen saturation as indicated by pulse oximetry (SpO2).

8.1 Nasal cannulas and nasopharyngeal catheters are used when the need exists to
8.1.1 provide low-level supplemental oxygen to the infant or child;(46)
8.1.2 feed the infant without interrupting oxygen delivery;(5,63,64)
8.1.3 increase mobility.(5,63,64)
8.2 Simple oxygen masks are used to provide supplemental O2 in the moderate range (0.35-0.50, depending on size and minute ventilation) for short periods of time (eg, during procedures, for transport, in emergency situations).(12,15,16,54)
8.3 Partial rebreathing masks are used to conserve the oxygen supply when higher concentrations (FIO2 > 0.4, < 0.6) are warranted (eg, during transport).(15,16,50,54)
8.4 Non-rebreathing masks are used to deliver concentrations > or = 0.60 or specific concentrations (as from a blender).(15,16,54)
8.5 Air-entrainment masks provide a flow of gas of predetermined precise oxygen concentration (24-40%)(10,46,65,66) that exceeds the patient's inspiratory flow. At the 50% setting, the total flow from the device may not meet the inspiratory flow.(16,54,65,66)
8.6 Air-entrainment nebulizers, although not recommended, can be used when high levels of humidity or aerosol are desired (as with a bypassed upper airway).(40,67) The patient application device can be a tracheostomy collar, face tent, aerosol mask, or blow-by arrangement.(11,16,55)
8.7 Hoods are used to provide
8.7.1 controlled FIO2 in infant and small children;(8)
8.7.2 controlled FIO2 and/or increased heated humidity to patients who cannot tolerate other devices;
8.7.3 controlled FIO2 when the chest, abdomen, and extremities must be accessible to caregivers;(8)
8.7.4 the oxygen concentrations necessary for oxygen challenge (hyperoxia) tests in the spontaneously breathing neonate.
8.8 Tents are appropriate to deliver supplemental oxygen and/or cool, high-humidity gas mixtures to pediatric patients:
8.8.1 with laryngotracheobronchitis,(68,69)
8.8.2 with artificial airways in whom direct attachment of a device to the airway is contraindicated,(68)
8.8.3 who are too big for hoods,(8)
8.8.4 with the need for comfort, without compromising therapy.(69)
8.9 Tracheostomy oxygen adapters, which may or may not be coupled with HMEs, are used to deliver oxygen to a tracheostomy.(44)


Outcome is assessed by determining whether the device selected produces an appropriate increase in oxygen saturation, proves to be appropriate for the patient, allows adequate patient monitoring, and facilitates patient care.


10.1 Equipment
10.1.1 Oxygen source: Cylinder--must meet Department of Transportation (DOT) standards, Compressed Gas Association (CGA) standards, and National Fire Protection Association (NFPA) recommendations, and appropriate regulator and wrenches must be supplied; Concentrators (or enrichers).(70,71) Bulk supplies should meet NFPA standards.
10.1.2 Delivery accessory equipment: oxygen tubing; corrugated aerosol tubing and water trap.
10.1.3 Humidifiers--No subjective or objective evidence supports routine humidification of O2 at flows < or = 4 L/min.(15,70) However, it is not known whether the use of a bubble humidifier with a nasal cannula in the neonate has benefit and the use of a bubble humidifier can verify oxygen delivery at flows < 1 L/min. HMEs with low dead space are appropriate for short-term use in patients with artificial airways.
10.1.4 Blenders-Although blenders have been used in weaning neonates with a nasal cannula from oxygen, it appears that using a very-low flowmeter (0-200 mL) may be more reliable.(72)
10.1.5 Compensated, low-range flowmeters(73) adjustable in increments < 0.125 L/min.(4,47,74)
10.1.6 Oxygen analyzers--Physical and electrical O2 analyzers are suitable for intermittent sampling, and electrochemical analyzers are suitable for continuous sampling.(75)
10.1.7 Noninvasive oxygen monitors--transcutaneous (TcO2) monitor(61,76) or pulse oximeter.(62,77)
10.1.8 Nebulizer solutions--sterile water or sterile normal saline solution.
10.2 Personnel:
10.2.1 Health care providers responsible for delivery of oxygen should have demonstrated and documented knowledge and skills related to: oxygen delivery systems and their limitations; assembly, care, and use of oxygen delivery systems; performance of the necessary subjective and objective assessments in order to determine effectiveness of oxygen therapy; clinical assessment skills to recommend changes in oxygen therapy; provision of comprehensive patient and lay caregiver instruction.
10.2.2 When supplemental oxygen is to be used out of the hospital setting, the patient and/or family member or lay caregiver should: demonstrate proper use and understanding of oxygen delivery device; demonstrate proper assembly, care, and cleaning of oxygen delivery device; demonstrate an understanding of how, when, and what to report to a physician or surrogate.


11.1 Patient:
11.1.1 clinical assessment including but not limited to cardiac, pulmonary, and neurologic status and apparent work of breathing;
11.1.2 assessment of physiologic variables: noninvasive or invasive measurement of oxygen tensions or saturation in any patient treated with oxygen--within 1 hour of initiation for the neonate.(16,22)
11.2 Equipment:
11.2.1 All oxygen delivery systems should be checked at least once each day.(16) More frequent checks by calibrated analyzer are necessary in systems: susceptible to variation in oxygen concentration;(16) applied to patient's with artificial airways;(16) continuous analysis is recommended in hoods.(78) oxygen should be analyzed close to the infant's face.
11.2.3 All heated delivery systems should be continuously monitored for temperature.


12.1 Selection of a device is made at the initiation of therapy, after careful assessment of need and patient characteristics.
12.2 The change from one type of device to another is based on a change in the patient's condition or ability to use a specific device. (Oxygen therapy should be administered continuously unless the need has been shown to be associated only with specific situations eg, exercise, feeding, or other stress.(15,79,80))


13.1 Universal Precautions and measures to limit the transmission of tuberculosis must be adhered to at all times.(81,82)
13.2 Low-flow systems
13.2.1 Under normal circumstances, low-flow oxygen systems do not present clinically important risk of infection and do not require routine replacement on the same patient.(15,16,83)
13.2.2 Nasopharyngeal catheters should be changed every 24 hours.(5)
13.3 Reservoir systems-Under normal circumstances, reservoir systems as defined for this guideline do not present clinically important risk of infection and do not require routine replacement on the same patient.
13.4 High-flow systems
13.4.1 Large-volume nebulizers should be changed every 24 hours when applied to patient's with an artificial airway.(83)
13.4.2 In the absence of definitive studies to support change-out intervals on nonintubated patients, results of institution-specific and patient-specific surveillance measures should dictate the frequency with which such equipment is replaced.
13.5 Enclosure systems-There is no recommendation regarding the frequency of changing mist-tent nebulizers and reservoirs while in use on the same patient,(83) but mist-tent nebulizers are probably as prone to contamination as any other nebulizer and we recommend that they be handled in the same manner.
13.6 Other devices-Between patients, subject equipment (eg, probes, oxygen sensors) to high level disinfection.(83)
13.7 Nebulizer solutions-Use only sterile fluids and dispense them aseptically.(83)

Perinatal-Pediatric Focus Group:

Lynne K Bower RRT, Chairman, Boston MA
Sherry L Barnhart RRT, Cabot AR
Peter Betit BS RRT, Boston MA
Michael P Czervinske RRT, Kansas City KS
Mark J Heulitt MD, Little Rock AR
Joanne Masi-Lynch BS RRT, Salt Lake City UT
Barbara G Wilson MEd RRT, Durham NC


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Interested persons may copy these Guidelines for noncommercial purposes of scientific or educational advancement. Please credit AARC and Respiratory Care Journal.

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