Pediatric Pulmonology 21 :48-51 (1996)

Diagnostic and Therapeutic Methods -

Low Flow Oxygen Delivery via Nasal Cannula to Neonates

Neil N. Finer, MD,
FRCPC,

Rosanne Bates, RRT, and Paula Tomat, RRT

Summary. Neonates with chronic lung disease often require oxygen in the neonatal intensive care unit. The purpose of this study was to determine (1) the actual inspiredoxygen concentration (F,O,) delivered to neonates when using a low-flow flowmeter and a nasal cannula, and (2) the accuracy with which F,Oncould be estimated using a formula that we developed. We studied two groups of infants: 18 infants less than 1,500 g and 13 infants greater than 1,500 g. We measured pharyngeal oxygen levels by sampling pharyngeal gas in infants receiving 100% humidified oxygen by nasal cannula from a low range flow flowmeter. The oxygen flow was increased by 25 mUmin incrementsfrom 25 to 200 mumin. The measured Fi02was compared with the calculated F,Ozusing the formula: F,Opmeasured = oxygen flow (mUmin x 0.79)
VE

+ (0.21 x VE) x 100,

where minute ventilation (VE) equals the minute ventilation in mUmin (VE = V, X respiratory rate). For both groups of infants, increments of 25 mumin of flow produced distinctive changes The calculated F,Ozdid not significantly differ from the actual in F,Ozat all levels ( P < 0.001). F,Opat any flow. The calculated F,Ozwas most predictive when using an assumed tidal volume of 5.5 mUkg. We conclude that an accurate flowmeter connected to 100% humidified oxygen can produce a wide range of predictable F,O,s for neonates, especially those with birthweights of less than 1,500 g. The proposed formula allows useful estimation of the infant's FiOnwhen o 1996 Wiley-Liss, Inc. we assume a tidal volume of 5.5 mUkg. Pediatr Pulmonol. 1996; 21 :48-51. Key words: Inspired oxygen, newborn infant, premature infants, low flow nasal cannula.

INTRODUCTION

With the increasing survival of very small and more critically ill prematurely born infants, there is an increased need for chronic oxygen administration for long periods of time in the newborn intensive care units and at home. Recent reports of the incidence of bronchopulmonary dysplasia vary from as high as 50% to as low as 17% for infants below 1,500 g.'i2The most common mode of administering oxygen to newborn infants is with a nasal cannula. The specific oxygen requirements for the infant are usually determined by oxygen monitoring, using either transcutaneous Po, electrodes or pulse oximetry. If an accurate low flow of oxygen could deliver a known oxygen concentration to the lung, it would remove the need for an oxygen blender and thus simplify oxygen delivery. For the past 3 years we have used a low range flowmeter attached to a 100% oxygen source to deliver humidified oxygen to non-intubated neonates in our intensive care unit and have developed a formula that will
0 1996 Wiley-Liss, Inc.

predict the Fi02 that is delivered to the very small and the full term infant.

MATERIALS AND METHODS

We utilized a low range flowmeter (Model Classic 200, Timeter Corporation, Lancaster, PA) in these studies. This is a pressure-compensated device with a flow range of

From the Department of Newborn Medicine, Department of Pediatrics, Royal Alexandra Hospital, University of Alberta, Edmonton, Alberta, Canada.
Received December 23,1994; (revision) accepted for publication October 15. 1995. Address correspondence and reprint requests to Dr. Neil Finer, UCSD Medical Center, 200 West Arbor Drive, #8774, San Diego, CA 92103-8774.

Neonatal Nasal Oxygen

49

0-200 mL, calibrated at 50 psi and 70F at a barometric The formula used was derived from Wexler et al.? pressure of 760 mmHg. The devices used in this study were recalibrated in our pulmonary function laboratory 0, flow from cannula with a rotameter. The infants were tested while receiving O2flow from ambient total flow 100% humidified oxygen by nasal cannula (No. 1601, Fi02 = total flow Salter Labs, Arvin, CA) using the above flowmeter. The infants oropharyngeal Fi02was measured by an aspirating endtidal oxygen analyzer (Beckman OM- 11, BeckIn order to obtain the amount of the patients VE that man Instruments, Fullerton, CA). The catheter was passed into the oropharynx and a sample was aspirated while was not supplied by nasal cannula flow, the portion of the infant was at rest, either asleep or resting quietly. The the VE supplied by the nasal cannula (in mL/min) was determinations were not performed when the infants were subtracted from the total VE. crying, apneic, or when their regular breathing pattern was interrupted. Hypopharyngeal oxygen concentrations are .anexcellent reflection of tracheal oxygen concentra1 X (Fi02 X O2cannula flow) t i ~ n .For ~.~ the duration of the studies the infants heart + r N R - 0, cannula flow) rate, impedance respiration (HP 78834A, Hewlett Packard, Waltham, MA), and pulse oximetry (N-200, Nellcor (1 X F,02k O2 cannula flow) Inc., Hayward, CA) were continuously monitored. All + VE x 0.21 - 0.21 x o2 cannula flow infants were studied while their pulse oximetry was reading 90-93% saturation. V E (0.79 X Fi02 X O2cannula flow) f V E x 0.21 -

Patients

V E

We studied two groups of infants. Group 1 were infants who weighed less than 1,500 g at the time of the study, and Group 2 were infants who weighed more than 1,500 g at the time of the study. All infants were studied at rest following resolution of antecedent acute respiratory disease and were spontaneously breathing while receiving oxygen via a nasal cannula. All studies were performed after obtaining informed parental consent. Infants were studied while receiving 100% oxygen by nasal cannula and the hypopharyngeal Fi02was measured as the oxygen flow was increased from 25 to 200 mL. The infants were left at each reading for a minimum of 10 minutes until there was a stable reading of the pulse oximeter andor transcutaneous PO2, and the hypopharyngeal oxygen analyzer recorded a stable reading for the determination of the inspired oxygen concentration. Respiratory rate was manually counted for 2 minutes to provide an averaged rate of breathing, and the infants weight on the day of the study was utilized to determine the infants VE. Minute ventilation was calculated from the infants weight in kilograms times an assumed 5.5 mL tidal volume (V,) per kilogram times respiratory rate. The formula for the predicted inspired concentration was as follows: (oxygen flow (mL/min X 0.79)
VE

Different values of VT (from 5.0 to 7.5 mLkg) were substituted to identify empirically the closest approximation to the actual pharyngeal Fi02.

Statistics

Statistical comparison of the calculated vs. measured Fi02,and of the measured Fi02at each flow rate, was performed using a two-way repeated measures analysis of variance. The Student-Newman-Keuls test was used for post hoc testing at all flows for both groups. A P value of less than 0.05 was considered significant. This protocol was approved by the Royal Alexandra Hospital Investigational Review Committee.

RESULTS

Fi02 =

+ (0.21 X V,)

There were 18 infants in Group 1 who ranged in birthweight from 380 to 1,420 g; their postnatal age ranged from 1 to 56 days. When studied, their actual weights ranged from 590 g to 1,315 g. The 13 infants in Group 2 had birthweights from 635 g to 4,100 g, and they were studied at postnatal ages ranging from 4 to 100 days. Their actual weights on the day of the study ranged from 1,580 to 4,020 g. The oropharyngeal F,02was com-

50

Finer et al.
100 1 A I 90 80 e 70 1 0 60 50 30 40 30 20 20 i 0 50 100150200 0

i
1

B
T

50 100 150 200

Oxygen Flow (ml/min)

Oxygen Flow (mllmin)

Fig. 1. Plot of nasal cannula oxygen flow against oropharyngeal measured F,O, (solid circles) and calculated SO2(open squares) for infants of less than 1,500 g (A) and greater than 1,500 g (8). The graph represents mean values f standard deviation.

B
50

e E*
1

40

30
20 0 50 100 150 200
Oxygen Flow (ml/min)

0 50 100 150 200 250

Oxygen Flow (ml/min)

Fig. 2. Correlationbetween nasal cannula oxygen flow rate and measured oropharyngealFi02using assumed tidal volumes per kilogram of body weight from 5.0 to 6.5 mllkg in infants less than 1,500 g (A) and greater than 1,500 g (B). Closed circles indicate actual measured FiOn, open triangles indicate tidal volumes of 5.0 mUkg, open squares indicate tidal volumes of 5.5 mWkg, open circles indicatetidal volumes of 6.0 mlkg, and open diamonds indicate tidal volumes of 6.5 mUkg.

pared with the calculated FiOz (Figs. 1 and 2). For the infants less than 1,500g, each increment in flow produced a statistically significant increment in FiO2 (Fig. 1; P < 0.001). For these infants, the calculated prediction of Fi02was not significantly different from the actual measured Fi02(oxygen concentration) at any of the flows, using an assumed VT of 5.5 mLAcg. For infants greater than 1,500 g, each increment in flow also produced a statistically significant increment in FiO2( P < 0.001; Fig. 2). The calculated FiOzs were not significantly different from the actual measured FiO,s at any flow, and an assumed VTof 5.5 mL/kg or 6.0 mLkg produced equally acceptable predictions of FiOz.
DISCUSSION

When using an accurate low range flowmeter and 100% oxygen via nasal cannula, a wide range of FiOzscan be delivered predictably to neonates. For infants of less than 1,500 g, the actual FiOz varied from 22% to 95%, with a 7-10% increment in F,O, for every 25 mL increase in

flow. For infants of greater than 1,500 g, the highest achievable F,02was approximately 70% with a mean F,02 of 47% at 200 mL/min of flow. For the larger infants in the greater than 1,500 g group (specifically the infants who were over 2,000 g at the time of the study), the highest achievable F,Oz ranged from 47% in the over 2,000 g range to 29% in a 4,100 g infant. The lower F,02s seen in the large infants are due to the large V, in these big infants. Substituting VEs of 300 mWmin and 730 mL/min (the respective averages of our two groups) of 0.47 (<1,500 into the predictive formula yields an F,02 g) and 0.31 (>1,500 g), respectively, at a nasal cannula flow of 100 mL/min. Therefore, one obvious limitation of the low flowmeter is the inability to deliver high, that is, greater than 50%, inspired oxygen concentrations to infants greater than 2,000 kg. The methodology used in this study prevents drying of the nasopharyngeal mucosa associated with high flow rates of oxygen. We have found that the low flow rates are well tolerated by neonates of all weights and gestations, and avoids the need to change the oxygen concentration into the flowmeter. A previous study by Vain et a1,4 utilized different percents of oxygen into a flowmeter with flows from 0.25 to 1 L/min. Flows of 1 L/min are not necessary to achieve a high F,Oz in the small infants and thus the use of a low flowmeter will lessen the risk of drying mucous membranes. In the previous study by Vain et al., the 10 infants studied ranged in weights from 1,780 to 4,090 g. In our study of 31 infants, we have demonstrated that reproducible F,02s can be delivered using accurate low range flowmeters to a wider range of spontaneously breathing neonates, including very low weight infants. Our study has also demonstrated that the use of a predictive formula is reasonably accurate for all infants whenever a VTof 5.5 mL/kg was used. We tried substituting VT values from 5.0 mL up to 7.5 mL (Fig. 2) and found the formula to be the most accurate in both groups when a VTof 5.5 mLkg was assumed, although for infants above 1,500 g an assumed VTof 6.0 mL produced equally acceptable values. The actual value of tidal volume in spontaneously breathing infants tends to vary with the methodology used to measure it. Dolfin et al. demonstrated that the addition of a mask and pneumotachograph increased tidal volume and that when using calibrated respiratory plethysmography the mean tidal volume was 4.6 2 1.1 mL/kg, that is, very close to the values used in the current study. Wexler et al. first described the mathematical model that we used for the calculation of F,O,, and he confirmed its accuracy using a test lung.s It should be noted that the infants true VT can be inserted into this formula, which should provide more accurate estimates of the true F,O,, although we did not test this assumption. Nevertheless, estimates based on the calculated method will provide

Neonatal Nasal Oxygen

51

reasonable estimates over the range of FiO, tested, as can be seen from the figures. Recently, Benaron and Benitz reviewed the vari~us strategies used for the selection of nasal cannula oxygen flows for infants.' Although they did not measure the they conducted a theoretical analysis comparactual Fi02, ing predicted to measured values, based on previous information and the equations used by Vain et a1.4 Their analysis demonstrated that changes in FiO2and cannula flow affect actual FiOzdifferently;increases in cannula oxygen concentrations result in proportional increases in FiOz, whereas increases in cannula flow increase actual FiOz up to the point where cannula flow exceeds the total nasal flow. They demonstrated that the alteration of inspired Fi02 secondary to patient controlled factors such as inspiratory time, VT, and the fraction of nasal breathing was not affected by changes in cannula oxygen concentration and that cannula flow rate was a much more significant determinant of the actual FiOz. On the basis of their results and our observations, we believe that the use of a low range flowmeter and 100% oxygen will provide a simple and reliable method of delivering stable inspired oxygen concentrations to small premature and full-term newborns and that such an oxygen delivery system will simplify the care of infants requiring oxygen. The only adjustment in management that needs to be made is an alteration in the cannula flow rate. While our study did not measure the fraction of nasal breathing in these infants, we did measure the actual FiOz and thus we believe that the predictive formula will be accurate in the prediction of FiOzfor the management of other groups of neonates. Use of the predictive formulas as described by Benaron and Benitz requires a knowledge of fraction of nasal breathing, inspiratory time, and VT. Our own formula, based on an assumed VT, appears to provide reasonably accurate estimates of the FiO2 and does not require the measurement of any additional variables. Vain et a1.4 suggested that nasal cannula flow rates should be used initially at high flow rates with 100%

oxygen and that there should be a step reduction of flow from 1.0 to 0.25 Wmin, followed by a reduction in the oxygen concentration of gas flowing through the cannula. The low flow nasal cannula produces discrete increments in FiOz with 25 mL/min increments in flow, and this approach produces a wide range of F,O,s. While the predictive formula is useful in asessing the actual F,Ozdelivered to the infant, intermittent or continuous monitoring of the infant's oxygen saturation remains the most effective way to determine whether the infant is receiving an appropriateinspired oxygen concentration.
ACKNOWLEDGMENT

We would like to acknowledgethe assistance of Damon Lawson, RRT, of Bicore, San Diego, California.
REFERENCES
1. Parker RA, Lindstrom DP, Cotton RB. Improved survival accounts for most, but not all, of the increase in bronchopulmonary dysplasia. Pediatrics. 1992; 90:663-668. 2. Van Marter LJ, Pagan0 M, Allred EN, Leviton A, Kuban KCK. Rate of bronchopulmonary dysplasia as a function of neonatal intensive care practices. J Pediatr. 1992; 120:938-946. 3. Schacter EN, Littner MR, Luddy P, Beck G. Monitoring oxygen delivery systems in clinical practice. Crit Care Med. 1980; 8:405-409. 4. Vain NE,Prudent LM, Stevens DP, Weeter MM, Maisels J. Regulation of oxygen concentration delivered to infants via nasal cannula. Am J Dis Child. 1989; 143:1458-1459. 5. Wexler HR, Levy H, Cooper JD, Aberman A. Mathematical model to predict inspired oxygen concentration description and validation. C a n Anaesth SOCJ. 1975; 22:410-416. 6. Kaye W, Summers JT, Monast R, McEnany MT. Nasal oxygen sampler. Heart Lung. 1981; 10679-685. 7. Dolfin T, Duffty P, Wilkes D, England S, Bryan H. Effects of a face mask and pneumograph on breathing in sleeping infants. Am Rev Respir Dis. 1983; 128:977-979. 8. Benaron DA, Benitz WE. Maximizing the stability of oxygen delivered via nasal cannula. Arch Pediatr Adolesc. 1994; 148:294-300.