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Avoiding pressure injuries from NIV masks

Artículo

Autor: Uliana Vasilachi

Fecha: 07.12.2022

Prolonged wearing of a NIV mask may lead to patient discomfort and pressure injuries.

Avoiding pressure injuries from NIV masks

What are pressure injuries?

A pressure injury is defined as "localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer . . . [and] occurs as a result of intense and/or prolonged pressure or pressure in combination with shear" (Edsberg et al., 2016).

In order to protect your patient’s skin, you can reduce the risk of pressure injuries (also known as pressure ulcers) during noninvasive ventilation by carefully selecting a suitable NIV mask and by taking precautionary steps.
 

When and where do pressure injuries occur?

These injuries can occur as a result of pressure on the skin over a bony prominence. Patients receiving respiratory support using a mask may develop pressure ulcers on different parts of the face, including the forehead, cheeks, chin, and bridge of the nose, where they are most common.

There are various reasons why a patient may develop pressure injuries: 

  • Incorrect positioning or size of the mask 
  • Skin inspections not thorough or frequent enough
  • Incorrect placement or removal of the mask
  • Insufficient mask seal
  • Over-tightening of the mask straps
  • Increased inspiratory pressure or air volume in the mask
  • Poor patient compliance with the interface
  • The patient’s inability to sense the device and associated pressure on their skin due to sedation, encephalopathy or neurologic disease
  • The patient’s inability to reposition themselves
  • The duration of device use
  • The patient’s latex allergy (occasionally results in florid skin reactions; some patients seem especially prone to mask-related rash even in the absence of allergy)

Severe patient discomfort can be prevented by spotting a pressure injury early in its development. 

Illustration of head with red dots indicating pressure points
Possible pressure points when wearing a mask
Illustration of head with red dots indicating pressure points
Possible pressure points when wearing a mask

How can they be avoided?

Firstly, the patient’s facial anatomy should be assessed. Does the patient have any facial anomalies? Which mask configuration is better suited to the treatment and will promote greater breathing comfort? It is important to select the most suitable size and type of mask for the individual patient. This not only helps prevent leakage, it can also guard against possible pressure injuries. 

During the treatment, the patient’s skin should be kept clean and dry to help reduce friction from the mask. It is crucial to examine the placement of patient’s mask regularly for early signs of pressure points. If there is skin irritation, hydration and moistening of the affected area can speed up the recovery. If the patient can tolerate a break from the oxygen, stop the therapy for 10 minutes. It is also advisable to either reposition the mask or change to a different mask configuration at regular intervals. A different mask configuration  will relieve the pressure from the previous mask and let the wounds heal. It is important to check regularly for the signs: 

  • Assess the facial anatomy
  • Determine the most suitable mask size and configuration for breathing comfort and treatment type
  • Regularly inspect the skin for early signs of pressure points
  • Routinely reposition the mask 
  • Rotate different mask types throughout the treatment

Commonly used types of masks are nasal, full face, or helmet masks. Hamilton Medical offers a wide range of interfaces in different configurations and sizes. 

 



Full citations below: (Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System. J Wound Ostomy Continence Nurs. 2016;43(6):585-597. doi:10.1097/WON.00000000000002811​, Lam UN, Md Mydin Siddik NSF, Mohd Yussof SJ, Ibrahim S. N95 respirator associated pressure ulcer amongst COVID-19 health care workers. Int Wound J. 2020;17(5):1525-1527. doi:10.1111/iwj.133982​, Gefen A, Alves P, Ciprandi G, et al. Device-related pressure ulcers: SECURE prevention. J Wound Care. 2020;29(Sup2a):S1-S52. doi:10.12968/jowc.2020.29.Sup2a.S13​, Visscher MO, White CC, Jones JM, Cahill T, Jones DC, Pan BS. Face Masks for Noninvasive Ventilation: Fit, Excess Skin Hydration, and Pressure Ulcers. Respir Care. 2015;60(11):1536-1547. doi:10.4187/respcare.040364​, Alqahtani JS, AlAhmari MD. Evidence based synthesis for prevention of noninvasive ventilation related facial pressure ulcers. Saudi Med J. 2018;39(5):443-452. doi:10.15537/smj.2018.5.220585​, Black J, Kalowes P. Medical device-related pressure ulcers. Chronic Wound Care Management and Research 2016:3 91–99.6​, Ashcroft H, Moore M. Preventing Pressure Sores whilst using NIV masks. Aintree University Hospital NHS Foundation Trust January 20167​)

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Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System.

Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System. J Wound Ostomy Continence Nurs. 2016;43(6):585-597. doi:10.1097/WON.0000000000000281

Our understanding of pressure injury etiology and development has grown in recent years through research, clinical expertise, and global interdisciplinary expert collaboration. Therefore, the National Pressure Ulcer Advisory Panel (NPUAP) has revised the definition and stages of pressure injury. The revision was undertaken to incorporate the current understanding of the etiology of pressure injuries, as well as to clarify the anatomical features present or absent in each stage of injury. An NPUAP-appointed Task Force reviewed the literature and created drafts of definitions, which were then reviewed by stakeholders and the public, including clinicians, educators, and researchers around the world. Using a consensus-building methodology, these revised definitions were the focus of a multidisciplinary consensus conference held in April 2016. As a result of stakeholder and public input, along with the consensus conference, important changes were made and incorporated into the new staging definitions. The revised staging system uses the term injury instead of ulcer and denotes stages using Arabic numerals rather than Roman numerals. The revised definition of a pressure injury now describes the injuries as usually occurring over a bony prominence or under a medical or other device. The revised definition of a Stage 2 pressure injury seeks to clarify the difference between moisture-associated skin damage and injury caused by pressure and/or shear. The term suspected has been removed from the Deep Tissue Pressure Injury diagnostic label. Each definition now describes the extent of tissue loss present and the anatomical features that may or may not be present in the stage of injury. These important revisions reflect the methodical and collaborative approach used to examine the available evidence and incorporate current interdisciplinary clinical expertise into better defining the important phenomenon of pressure injury etiology and development.

N95 respirator associated pressure ulcer amongst COVID-19 health care workers.

Lam UN, Md Mydin Siddik NSF, Mohd Yussof SJ, Ibrahim S. N95 respirator associated pressure ulcer amongst COVID-19 health care workers. Int Wound J. 2020;17(5):1525-1527. doi:10.1111/iwj.13398

Device-related pressure ulcers: SECURE prevention.

Gefen A, Alves P, Ciprandi G, et al. Device-related pressure ulcers: SECURE prevention. J Wound Care. 2020;29(Sup2a):S1-S52. doi:10.12968/jowc.2020.29.Sup2a.S1

Face Masks for Noninvasive Ventilation: Fit, Excess Skin Hydration, and Pressure Ulcers.

Visscher MO, White CC, Jones JM, Cahill T, Jones DC, Pan BS. Face Masks for Noninvasive Ventilation: Fit, Excess Skin Hydration, and Pressure Ulcers. Respir Care. 2015;60(11):1536-1547. doi:10.4187/respcare.04036



BACKGROUND

Pressure ulcers (stages III and IV) are serious safety events (ie, never events). Healthcare institutions are no longer reimbursed for costs to care for affected patients. Medical devices are the leading cause of pediatric pressure ulcers. Face masks for noninvasive ventilation were associated with a high percentage of pressure ulcers at our institution.

METHODS

A prospective cohort study investigated factors contributing to pressure ulcer development in 50 subjects using face masks for noninvasive ventilation. Color imaging, 3-dimensional surface imaging, and skin hydration measurements were used to identify early skin compromise and evaluate 3 interventions to reduce trauma: (1) a silicone foam dressing, (2) a water/polyethylene oxide hydrogel dressing, and (3) a flexible cloth mask. A novel mask fit technique was used to examine the impact of fit on the potential for skin compromise.

RESULTS

Fifty subjects age 10.4 ± 9.1 y participated with color images for 22, hydration for 34, and mask fit analysis for 16. Of these, 69% had diagnoses associated with craniofacial anomalies. Stage I pressure ulcers were the most common injury. Skin hydration difference was 317 ± 29 for sites with erythema versus 75 ± 28 for sites without erythema (P < .05) and smallest for the cloth mask (P < .05). Fit distance metrics differed for the nasal, oronasal, and face shield interfaces, with threshold distances being higher for the oronasal mask than the others (P < .05). Areas of high contact were associated with skin erythema and pressure ulcers.

CONCLUSIONS

This fit method is currently being utilized to select best-fit masks from available options, to identify the potential areas of increased tissue pressure, and to prevent skin injuries and their complications. Improvement of mask fit is an important priority for improving respiratory outcomes. Strategies to maintain normal skin hydration are important for protecting tissue integrity.

Evidence based synthesis for prevention of noninvasive ventilation related facial pressure ulcers.

Alqahtani JS, AlAhmari MD. Evidence based synthesis for prevention of noninvasive ventilation related facial pressure ulcers. Saudi Med J. 2018;39(5):443-452. doi:10.15537/smj.2018.5.22058

The last 2 decades have seen a growing trend towards the use of noninvasive ventilation (NIV) therapy in the management of many conditions that cause acute respiratory failure. However, there is a serious side effect that results in using these devices; the development of facial skin pressure damage, specifically pressure ulcers. This skin damage has a considerable effect on patients' quality of life, treatment adherence and patients' comfort in addition to the therapy challenges of wound care. The aim of this clinical review is to discuss the different characteristics of NIV interfaces and to provide evidence based recommendations to facilitate the selection and application of such interfaces to reduce NIV interfaces related pressure ulcers.

Black J, Kalowes P. Medical device-related pressure ulcers. Chronic Wound Care Management and Research 2016:3 91–99

Pressure ulcers from medical devices are common and can cause significant morbidity in patients of all ages. These pressure ulcers appear in the shape of the device and are most often found from the use of oxygen delivery devices. A hospital program designed to reduce the number of pressure ulcers from medical devices was successful. The program involved the development of a team that focused on skin, the results were then published for the staff to track their performance, and it was found that using foam dressings helped reduce the pressure from the device. The incidence of ulcers from medical devices has remained at zero at this hospital since this program was implemented.

Ashcroft H, Moore M. Preventing Pressure Sores whilst using NIV masks. Aintree University Hospital NHS Foundation Trust January 2016