Oxygen Therapy Oxygen delivery devices

Indications
Low Flow System High flow system
Respiratory distress and respiratory failure
Oxygen mask Oxygen Hood
Circulatory compromise / Shock
Nasal cannula Bag and Mask Ventilation
Decreased level of consciousness
Endotracheal Airway
Spo2 - <90%

Low Flow Devices

● Flow is insufficient to meet total inspiratory demand of patient
● Provide FiO2 of 23-50% ( FiO2 Fraction of inspired oxygen )
● Mixing of room air occurs
High Flow devices
● Provide all of the patients inspiratory flow needs
● Mixing of the room air does not occur
● Can deliver either Low/high FiO2
● High-flow system should be used in emergency settings to deliver high inspired O2 concentration

Oxygen Mask
● Low flow device, flow rate of 6-10 L/min
● Deliver 30-60% FiO2
● Indications : Mild-moderate distress, nebulisation
● C/I : Poor respiratory efforts, Severe hypoxia, Apnea
● Disadvantage : Does not deliver high O2 concentration,
Interferes with feeding and suctioning

Nasal Cannula/ Prongs

● Low flow device, flow rate of 5 L/min
● Delivers 30-40% FiO2
● Indications : long term O 2 therapy, CPAP
● C/I : Apnea, choanal atresia, nasal polyp, DNS
● Advantages : better tolerated, leaves mouth free for
nutritional purpose
● Disadvantages : nasal mucosal injury, frequent
displacement, does not provide humidified O 2

Oxygen Hood
● High Flow device : 10-15 L/min
● Delivers 80-90% FiO2
● Well tolerated by neonates and infants
● Both oxygen delivery & humidification can be
provided
● Disadvantages : hypercarbia, cutaneous fungal
infection, difficulty in suctioning and feeding
Bag & Mask Ventilation ( Self inflating bag )

AMBU is Artificial Manual Breathing Unit. An Ambu bag is a self-inflating bag resuscitator.

Indications of Bag & Mask Ventilation - Neonatal Resuscitation

After 30 seconds of Initial steps if

● Baby is not breathing or is gasping
● Heart rate is less than 100 bpm and /or
● Is Cyanotic despite supplemental oxygen
Self inflating bag
● Capacity of bag : 250 - 750 ml
● Delivers 90-100% FiO2 with reservoir and 40% without reservoir
● Safety features : pop-off-valve set to 30-40 cm H 2 O, one way valve prevents rebreathing of
exhaled air
● Pre-requisite : Air-sniffing position

C/I : Meconium aspiration syndrome ( MAS ), Congenital diaphragmatic hernia ( Bochalek hernia )

The pressure is applied to the Lower third

of sternum ( just below an imaginary
horizontal line joining two nipples )
Endotracheal Tube ( ET tube )

Indications :
● When Bag & Mask Ventilation is ineffective or prolonged
● Inadequate CNS control of ventilation
● Functional/anatomic airway obstruction
● Loss of protective airway reflexes
● Surfactant administration
● Suctioning of Non Vigorous MSL Babies

Type of Endotracheal Tubes :

● Cuffed
● Non-Cuffed
Cuffed tube for 8 years or older. In younger children normal anatomic narrowing at the level of
cricoid cartilage provides a functional cuff

Most effective and reliable method of assisted

ventilation:
● The airway is isolated, ensuring adequate
ventilation and O 2 delivery Tube size (mm) Weight (g) Gestational age
● Reduces aspiration chance 2.5 < 1000 < 28 wks

Checking correct placement of Tube 3 1000-2000 28-34

● Chest movements 3.5 2000-3000 34-38
● Auscultation of chest and epigastrium
● Change in appearance of patient 4 > 3000 > 38 wks
● Fogging in tube
● Pulse oximetry
● CXR
● End Tidal CO 2

Laryngoscope

● It has 3 parts - Handle, blade and light source

● 2 types of blade - Straight (Miller) and Curved (Macintosh)
● Straight blade - infants and toddlers
● Curved blade - older children
● Sizes :
00 - preterm neonates
0 - term neonates
1 - infants
2 - children
3 - adolescent
Uses :
Endotracheal intubation
Suction catheter placement
Direct laryngoscopy
Tuberculin syringe

Uses :
1. To administer PPD for montoux test
2. To administer BCG vaccine
3. To administer test dose of drugs
4. To give small doses of drugs such as – insulin in diabetes mellitus, vitamin K in newborn

Tongue depressor

Uses :
1. To examine oral cavity, pharynx and tonsils
2. To see gag reflex
3. Spatula test : bedside diagnostic test for tetanus

Bone Marrow Aspiration & Biopsy needle

Cannula

Trocar / Stylet

Salah Bone
Marrow Aspiration
Needle
Adjustable side guard. This is important part,
which helps in adjusting the depth of penetration
of the needle

Jamshidi Bone
Marrow Biopsy
Needles

Site
● Posterior superior iliac spine PSIS ( > 1 yr )
● Sternum ( only in adults )
● Medial to Tibial tuberosity ( only in infants < 1 yr )
Sternum is not preferred in children
because of associated pain & risk of injury
to underlying vital structures
Procedure : Child positioned Prone with face turned to a side &
pelvis stabilized by folding a sheet below it. If tibia is
aspirated, the leg is slightly flexed at the knee joint

Site cleaned with chlorhexidine & betadine and draped

2 ml of 1% Lidocaine is injected subcutaneously into the periosteum

Needle is advanced perpendicularly into the

identified area with twisting motion till bone is felt

For Aspiration For biopsy

Needle is in bone marrow, remove the stylet & Once the needle is lodged in the bone, remove the
attach a 20 mL syringe, aspirate slowly around stylet & advanced the needle in rotatory motion through
0.5 mL marrow, syringe is disconnected and the marrow space, needle is withdrawn and biopsy
the marrow placed on slides specimen is placed in a vial containing formalin

Indications : Diagnostic Therapeutic

● Leukemia ● Bone marrow transplantation
● Megaloblastic anaemia
● Infections eg. Kala azar
● Storage disorders eg. Gaucher disease
● Idiopathic thrombocytopenic purpura
● Pyrexia of unknown origin
● Aplastic anaemia (dry tap)
If dry tap on aspiration, do BM biopsy
● Myelofibrosis (dry tap)

C/I : Bleeding tendency, DIC, infection at site, very sick baby

Complications : Bleeding and pain at the aspiration site, Bone injury with fracture, subcutaneous
infections or Osteomyelitis
Level of posterior
superior iliac crest
Lumbar puncture needle

Position : Lateral decubitus position

Site : The imaginary line that crosses the

lumbar region of the back joining the
posterior superior iliac crests will cross the L3 L4 L5
L3-L4 interspace

Indications :
Diagnostic
● Meningitis, meningoencephalitis
● Subarachnoid haemorrhage Spinal Needle Stylet

● CNS malignancies
● Demyelinating diseases
Therapeutic
● Intrathecal administration of Anti-cancer drugs Lumbar puncture needle
Complications :
● Post LP headache
● Infection
● Bleeding
● Brainstem herniation
● Back pain

Before LP do Fundus examination if shows Papilledema Raised ICP Brainstem herniation

C/I :
● Raised ICP
● Bleeding tendency
● Skin infection at the site of lumbar puncture
● Deformity of Spine

Acute Bacterial Tuberculous

CSF Normal Viral Meningitis
Meningitis Meningitis
WBC (mm3 ) 0 - 30
1000 1000 500
( Predominant ) ( PMN ) ( lymphocytes ) ( lymphocytes )

Protein (g/L) 0.4 - 0.7 Mildly increased

Glucose (mg/dL) 50 - 80 N

Foley’s catheter
Using 5 mL normal saline
for inflating the balloon of a
Foley catheter

Attach Urobag

Self retaining catheter made up of latex

Indications :

Urinary Non urinary

● To relieve urinary retention ● In epistaxis - to arrest post nasal bleeding
● To monitor urine output in shock and renal failure ● In portal hypertension - to arrest bleeding
● For incontinence of urine from oesophageal varices
● For suprapubic cystostomy ● In Abdominal Sx - to decompress urinary
● In unconcious patients bladder

Complications : Urethral trauma, hematuria, UTI, allergy to latex

C/I : Urethral injuries
Age Size (in French )
0-6m 6
6 m - 11 yr 8
11 yr - 15 yr 10
Urobag

● Bag graduated in ml to increase urine output

● Contains non - return valve
● Conical inlet connector with cap

Umbilical cord clamp

security lock to prevent
accidental opening after
clamping

Grooved clamping area to

prevent slipping of cord

Use : clamping the umbilical cord of new born immediately after birth

Dileys Mucus Extractor / Trap Sputum Trap / Pot

● Capacity : 25 ml
● Pressure : 100 mm Hg
● Suction tube length : 40 cm, 50 cm Suction catheter /
● Uses : Baby end

1. Aspiration of oropharyngeal and nasal

secretions of newborns To suction
2. Mucus specimens for microbiological tubing / Mouth
tests piece

Three way connector

● T-shaped with 2 inlets & 1 outlet

● Advantages - IV fluids & IV antibiotics can be given together
● Uses :
Exchange transfusion
Hemodialysis
Pleural / Ascitic tap
TPN
CVP monitoring
Intra-Venous ( IV ) set

Plastic cannula - to be inserted

into the iv bottle

Murphy’s chamber - regulate the

speed of IV flow : 1 ml = 20 drops

Connector - to be connected to IV
cannula directly or via a three way
Roller clamp / Regulator connector

Clear plastic tubing

Blood transfusion set

Similar to IV set except for the

presence of a Filter in Murphy’s
chamber to remove clots
1 ml = 10 drops

Micro drip set

Murphy's chamber - To regulate Burette chamber - 110 ml

number of drops/min 1 ml = 60 drops

Chamber injection port - to inject

medication into burette chamber

Uses : IV fluid and drug administration, parenteral nutrition

I/V cannula
● Consists of a thin plastic sheath which is guided into the vein by a metallic stillete
● Colour coding according to size ( gauge )
● Bigger the gauge no. smaller is the needle

Orange 14 G Adult

Grey 16 G Adult

Green 18 G Adult

Pink 20 G Adult

Blue 22 G Adult

Yellow 24 G Infants & Neonates

Violet 26 G Neonates

Leucocyte Filter

Leukocyte removal filters are used to reduce

complications associated with transfused white
blood cells

Febrile non-hemolytic transfusion reaction

(FNHTR), caused by cytokines released from blood
donor leukocytes (white blood cells)

Eliminates leucocytes, thereby reducing

non-haemolytic febrile reactions

Trucut biopsy needle

Uses :
● Liver biopsy
● Kidney biopsy
● Lung biopsy - rarely
Liver Biopsy

Indications : Storage disorder - Copper ( Wilson disease), Iron ( Hemosiderosis )

Suspected malignancies ( Primary & Secondary )
Persistent abnormal ( LFT ) Liver Function Test
Diagnosis of Congenital Hepatic Fibrosis
Diagnosis of Parenchymal Liver Disease ( Neonatal hepatitis, Metabolic liver disease )

C/I : Bleeding tendency

Marked ascites
la
Hydatid cyst / Liver abscess Ca
n nu

le
ed
Complications : Hepatic laceration fid
ne
Bi
Gall bladder & intestinal perforation
Pneumothorax
Biliary peritonitis
Vim Silverman Liver
Biopsy Needle

Procedure : Medications that increase risk of bleeding, like aspirin or

NSAIDs, must be stopped 5-7 days prior to procedure,
child nil per oral 5 hrs, placed I.V for sedation & analgesia

Desired area cleaned with spirit, povidone-iodine, draped with sterile linen

Skin, subcutaneous tissue, intercostal muscle are anesthetized with

1% Lidocaine, small skin incision to facilitate entry of biopsy needle

Patient is asked to hold breath at end expiration ( avoid lung injury )

Tru-cut biopsy needle (23 gauge) is inserted perpendicular

to skin at marked site till a sudden feel of resistance is felt
means needle enters the liver

Outer sheath of needle is held firmly, inner cutting needle is inserted quickly, now the
outer sheath is advanced rapidly over the inner cutting needle & thereafter the entire
device is withdrawn, biopsy specimen placed in formalin ( ideal sample is 10-20 mm )

Local pressure applied for few minutes, pressure dressing is

done, monitor vitals and watch for bleeding for next 24 hrs

Transcutaneous route ( intercostal & subcostal approach )

Intercostal : biopsy done at level of 8th or 9th intercostal space in mid-axillary line
Subcostal : when liver is enlarged biopsy can be performed below the costal margin in mid-axillary line

Percussion of lungs near liver, find the liver’s dullness,

once you found it do biopsy one space below it
Kidney Biopsy

Indications : Nephrotic syndrome

Nephritic syndrome
PSGN
Malignancy
Unexplained or persistent hematuria / proteinuria
Systemic disease with renal involvement ( lupus nephritis, systemic vasculitis )

C/I : Uncontrolled bleeding disorders

Uncontrolled hypertension
Uncooperative patient
Single functioning kidney
Polycystic kidney
Shrunken, small kidney

Complications : Hematuria
Perirenal hematoma
Injury to adjacent organs
Transient hypertension
Infection at biopsy site

Site of biopsy : Percutaneous kidney biopsy is done at the angle between the lower end of
12th rib and lateral border of sacrospinalis muscle ( erector spinae )

Infant feeding tube Suction catheter Umbilical catheter

● Closed distal end ● Open distal end ● Open distal end

● Two lateral eyes present ● Two lateral eyes present ● Lateral eyes absent to eliminate
● Soft and rounded tip to ● Soft and rounded tip chances of clot formation
prevent trauma ● Size : 52 cm ● Size : 40 cm
● Size : 52 cm

Suction Catheters

Open distal end

● Flexible, long tubes used to remove secretions from different body parts
● One end is connected to a collection container and a device that generates suction
● The open end is advanced through the airway to remove secretions
● Thumb operated/ non thumb operated
Naso gastric Tubes

Child should be lying supine with head end elevated

Measure the length of tube to be inserted : from the tip of the nose
to the tragus and then to the xiphoid process

Advanced the tube till the mark is reached, then check its position by pushing air into the tube and
simultaneously auscultating over the abdomen ( epigastric area ) to listen the rush of air

Two lateral eyes

present

N.G tube - thin

Closed Ryles tube - thick
distal end

Markings in the body of the tube : 1st : 40 cm ( Gastroesophageal junction )

2nd : 50 cm ( Body of Stomach )
3rd : 60 cm ( Pylorus of stomach)

Indications : Feeding sick and premature infants

Feeding in unconscious child, child with respiratory distress and bulbar palsy
Gastric decompression in case of intestinal obstruction & paralytic ileus
For diagnosis of tracheoesophageal fistula
Gastric lavage in case of poisoning
To administer medication

C/I : Facial trauma

Base of skull fracture
Recent esophageal perforation / repair

Precautions : While removing the NG tube always pinch the outer end to avoid emptying the
contents into pharynx
Stop insertion immediately if child develops respiratory distress, this indicates
wrong insertion into the airway instead of esophagus

N.G tube size ( French, Fr ) = Patient's age ( years ) + 16

2

For an 8-year-old child, the correct size is 12 French ([8 + 16]/2 = 12)
 Lateral eyes absent to eliminate
Umbilical Cannula chances of clot formation

Indications :
Vascular access for I.V fluids and drugs
Exchange blood transfusion
Central venous pressure monitoring
Arterial blood sampling
Open distal end

C/I : Omphalitis ( infection of umbilical stump )

Peritonitis
Necrotizing enterocolitis

Complications :
Vessel perforation
Creation of false luminal tract
Hepatic necrosis or portal hypertension
Catheter-related infection, thrombosis and embolism
Incorrect catheter tip causing cardiac arrhythmia

Placement :
A mark is placed at the length of insertion
expected to place the catheter tip above the
diaphragm but below the right atrium ; this is
calculated as 0.6 times the shoulder-to-umbilicus
distance from the tip of the catheter

Intercostal drainage tube (ICD)

Ductus venosus shunts a portion of
umbilical vein blood flow directly to the
inferior vena cava. Thus, it allows oxygenated
blood from the placenta to bypass the liver.

Indications : C/I : Complications :

Pneumothorax Refractory Coagulopathy Chest tube clogging
Pleural Effusion Diaphragmatic hernia Air leaks
Chylothorax Scarring in pleural space Haemorrhage/ Injury to organs
Empyema or Pyothorax Re expansion pulmonary edema
As a drain after lobectomy Infection
Metered dose inhaler with Spacer

Spacer

Mouthpiece MDI

Inhaler adapter

● Device that delivers fixed amount or metered dose of aerosolized drug into respiratory passage
● Parts : cannister , body and mouthpiece with cap
● 10-12 years child can use it without spacer

● Spacer is a volume holding chamber for the delivered aerosol from MDI
● Children ( usually unable to synchronise MDI with their inhalation ) require spacer
● Up to 3 years, face mask is used with spacer
● Advantage: It extends the space between the inhaler and mouth, allowing the larger particles
get deposited within the device instead of oropharyngeal wall. Hence, the side effect are reduced
Paladai
The paladai is a cup-like utensil with a narrow tip
that has been used traditionally to feed babies in
India when the mother cannot breast feed. It is used
to hold expressed breast milk or other types of liquid
or semi-solids. The baby is held reclining while being
feed

Shakir Tape

Red : Yellow : Green :

< 12.5 cm 12.5 - 13.5 > 13.5 cm
Wasted Border line Normal
 Immunization

National Immunization Schedule

At Birth BCG bOPV-0 HepB-0

6w bOPV-1 Pentavalent-1 Rota-1 fIPV-1 PCV-1

10 w bOPV-2 Pentavalent-2 Rota-2
14 w bOPV-3 Pentavalent-3 Rota-3 fIPV-2 PCV-2

9m PCV-3 MR-1 JE-1

15 m bOPV-B DPT-B1 MR-2 JE-2

5y DPT-B2
11-13 y HPV-1, HPV-2

IAP Immunization Schedule

isd

At Birth y
BCG OPV auh
HepB
Bos o

6w
10 w
Pentavalent-1
Pentavalent-2
OPV-1
OPV-2
(
Rota
Rota
IPV
-
PCV
mee
-]- at
14 w Pentavalent-3 OPV-3 Rota IPV PCV

endum isa
&
9m MR-1 JE-1 PCV-B
16 - 24 m MR-2 JE-2 DPT-B1
OPV-B

Varicella-1
5y DPT-B2

10 y Td-1
16 y Td-2
Typhoid conjugate-B
Varicella-2

bOPV-1 HepB-3
bOPV-2
Vitamin-A
IPV-B HepA-1 HiB-B PCV-B

1st dose at 9 m - 1mL ( 1 Lakh IU )

HepA-2
Every 6 m - 2 mL ( 2 Lakh IU ) till 5 y
Vaccine Strain

BCG Danish-1331

bOPV P1, P3 ( currently bivalent OPV used, P2 strain was globally discontinued in April 16 )

Measles Edmonston-Zagreb

Mumps Jeryl-Lynn

Rubella RA 27 / 3

Varicella OKA