Randomized crossover trial of a pressure sensing visual feedback system to improve mask fitting in noninvasive ventilation

Health System Factors Affecting the Experience of Non-Invasive Ventilation Provision of People with Neuromuscular Disorders in New Zealand

Non-invasive ventilation (NIV) is a critical therapy for many patients with neuromuscular disorders (NMD), supporting those with respiratory failure to achieve adequate respiration and improve their quality of life. The aim of this study was to explore the experiences of access to, consent, uptake, maintenance and safe use of non-invasive ventilation by people with NMD. Semi-structured individual interviews were conducted with 11 people with NMD, each using NIV for more than 12 months. A critical realism ontological paradigm with contextualism epistemology guided the Reflexive Thematic Analysis. An Equity of Health Care Framework underpinned the analysis. Three themes were interpreted: Uptake and informed consent for NIV therapy; Practicalities of NIV; and Patient-clinician relationships. We identified issues at the system, organization and health professional levels. Conclusions: We recommend the development of national service specifications with clear standards and dedicated funding for patients with NMD and call on the New Zealand Ministry of Health to proactively investigate and monitor the variations in service delivery identified. The specific areas of concern for patients with NMD suggest the need for NMD-related NIV research and service provision responsive to the distinct needs of this population.

Effects of a feedback intervention on antibiotic prescription control in primary care institutions based on a Health Information System: a cluster randomized cross-over controlled trial

OBJECTIVES

Overuse and misuse of antibiotics are major factors in the development of antibiotic resistance in primary care institutions of rural China. In this study, the effectiveness of a Health Information System-based, automatic, and confidential antibiotic feedback intervention was evaluated.

METHODS

A randomized, cross-over, cluster-controlled trial was conducted in primary care institutions. All institutions were randomly divided into two groups and given either a three-month intervention followed by a three-month period without any intervention or vice versa. The intervention consisted of three feedback measures: a real-time pop-up warning message of inappropriate antibiotic prescriptions on the prescribing physician's computer screen, a 10-day antibiotic prescription summary, and distribution of educational manuals. The primary outcome was the 10-day inappropriate antibiotic prescription rate.

RESULTS

There were no significant differences in inappropriate antibiotic prescription rates (69.1% vs. 72.0%) between two groups at baseline (P = 0.072). After three months (cross-over point), inappropriate antibiotic prescription rates decreased significantly faster in group A (12.3%, P < 0.001) compared to group B (4.4%, P < 0.001). At the end point, the inappropriate antibiotic prescription rates decreased in group B (15.1%, P < 0.001) while the rates increased in group A (7.2%, P < 0.001). The characteristics of physicians did not significantly affect the rate of antibiotic or inappropriate antibiotic prescription rates.

CONCLUSION

A Health Information System-based, real-time pop-up warnings, a 10-day prescription summary, and the distribution of educational manuals, can effectively reduce the rates of antibiotic and inappropriate antibiotic prescriptions.

The Effectiveness of NIV and CPAP Training on the Job in COVID-19 Acute Care Wards: A Nurses' Self-Assessment of Skills

Background: Noninvasive ventilation (NIV) in COVID-19 patients outside of intensive care unit (ICU) settings was a feasible support during the pandemic outbreak. The aim of this study was to assess the effectiveness of an “on the job” NIV training program provided to 66 nurses working in 3 COVID-19 wards in an Italian university hospital. Methods: A quasi-experimental longitudinal before−after study was designed. The NIV Team education program, provided by expert ICU nurses, included: 3 h sessions of training on the job during work-shifts about the management of helmet-continuous positive airway pressure (CPAP) Venturi systems, and NIV with oronasal and full-face masks. An eleven-item “brief skills self-report tool” was administered before and after the program to explore the perception of NIV education program attendees about their level of skills. Results: In total, 59 nurses responded to the questionnaire. There was an improvement in the skill levels of the management of Helmet-CPAP (median before training 2, inter-quartile range (IQR) 0−6; median after training 8, IQR 3−9; p < 0.0001), and mask-NIV (median before training 2, IQR 0−6; median after training 8, IQR 3−9; p < 0.0001). Conclusions: Training on the job performed by expert ICU nurses can be a valuable and fast means to implement new Helmet-CPAP and mask-NIV skills outside of ICUs.

The right interface for the right patient in noninvasive ventilation: a systematic review

INTRODUCTION

Research in the field of noninvasive ventilation (NIV) has contributed to the development of new NIV interfaces. However, interface tolerance plays a crucial role in determining the beneficial effects of NIV therapy.

AREAS COVERED

This systematic review explores the most significant scientific research on NIV interfaces, with a focus on the potential impact that their design might have on treatment adherence and clinical outcomes. The rationale on the choice of the right interface among the wide variety of devices that are currently available is discussed here.

EXPERT OPINION

The paradigm "The right mask for the right patient" seems to be difficult to achieve in real life. Ranging from acute to chronic settings, the gold standard should include the tailoring of NIV interfaces to patients' needs and preferences. However, such customization may be hampered by issues of economic nature. High production costs and the increasing demand represent consistent burdens and have to be considered when dealing with patient-tailored NIV interfaces. New research focusing on developing advanced and tailored NIV masks should be prioritized; indeed, interfaces should be designed according to the specific patient and clinical setting where they need to be used.

Validation of a numerical model for the mechanical behavior of a continuous positive airway pressure mask

Finite Element models (FEM) are developed for the analysis of the contact pressures exerted by a Continuous Positive Airway Pressure (CPAP) mask applied to a dummy head. This is seen as a preliminary step in the analysis of the mechanical effects of CPAP masks applied to human faces, such as recently employed for the care of COVID-19 patients, or other purposes. These mechanical effects can range from negligible, in the case of correct positioning, sufficiently light tension in the headgear, correct mask design, etc., to the possible development of device-related pressure ulcers and/or dentofacial deformations, especially in children. The results of Finite Element analyses are compared, for their validation, with experimental ones. The numerical analysis tool appears able to predict, at an acceptable cost, both the intensity and the area distribution of the contact pressures, as well as the force-displacement relationship occurring in the headgear. This might help the design and the production of more effective and tolerable CPAP masks.

A numerical analysis of skin-PPE interaction to prevent facial tissue injury

The use of close-fitting PPE is essential to prevent exposure to dispersed airborne matter, including the COVID-19 virus. The current pandemic has increased pressure on healthcare systems around the world, leading to medical professionals using high-grade PPE for prolonged durations, resulting in device-induced skin injuries. This study focuses on computationally improving the interaction between skin and PPE to reduce the likelihood of discomfort and tissue damage. A finite element model is developed to simulate the movement of PPE against the face during day-to-day tasks. Due to limited available data on skin characteristics and how these vary interpersonally between sexes, races and ages, the main objective of this study was to establish the effects and trends that mask modifications have on the resulting subsurface strain energy density distribution in the skin. These modifications include the material, geometric and interfacial properties. Overall, the results show that skin injury can be reduced by using softer mask materials, whilst friction against the skin should be minimised, e.g. through use of micro-textures, humidity control and topical creams. Furthermore, the contact area between the mask and skin should be maximised, whilst the use of soft materials with incompressible behaviour (e.g. many elastomers) should be avoided.

Wax-oil lubricants to reduce the shear between skin and PPE

Prolonged use of tight-fitting PPE, e.g., by COVID-19 healthcare workers leads to skin injuries. An important contributor is the shear exerted on the skin due to static friction at the skin-PPE interface. This study aims to develop an optimised wax-oil lubricant that reduces the friction, or shear, in the skin-PPE contact for up to four hours. Lubricants with different wax-oil combinations were prepared using beeswax, paraffin wax, olive oil, and mineral oil. In-vivo friction measurements involving seven participants were conducted by sliding a polydimethylsiloxane ball against the volar forearms to simulate the skin-PPE interface. The maximum static coefficient of friction was measured immediately and four hours after lubricant application. It was found that the coefficient of friction of wax-oil lubricants is mainly governed by the ratio of wax to oil and the thermal stability and morphology of the wax. To maintain long-term lubricity, it is crucial to consider the absorption of oil into the PPE material. The best performing lubricant is a mixture of 20 wt% beeswax, 40 wt% olive oil, and 40 wt% mineral oil, which compared to unlubricated skin, provides 87% (P = 0.0006) and 59% (P = 0.0015) reduction in instantaneous and 4-h coefficient of friction, respectively.

In Vitro Evaluation of Facial Pressure and Air Leak with a Newly Designed Cushion for Non-Invasive Ventilation Masks

Background: The aim of this study was to evaluate the effect of a newly designed foam cushion on the air leakage and pressure when applied to the face. Methods: A teaching manikin connected to a bilevel positive airway pressure ventilator attached to four different brands of oronasal masks (Amara, Mirage, Forma, and Wizard) was used. The foam cushions of 5-mm and 10-mm-thickness were attached to the masks, and each mask was tested without a cushion. Six pressure sensors were placed on the manikin’s face, and data were recorded. Inspiratory volume and air leak flow from the ventilator were observed. Results: Air leakage was influenced by both the mask brand and the presence of a cushion. The presence of a cushion did not affect the Wizard mask in terms of leakage (p = 0.317) or inspiratory volume (p = 0.726). The Wizard and Amara masks generated the lowest contact pressure on the frontal forehead (p < 0.001) compared to the other five points. Conclusions: Utilisation of a cushion reduces air leakage and maintains greater inspiratory volume regardless of its thickness. The contact pressure varies depending on the brand of the mask, which would require a difference in the thickness of the cushion for pressure reduction.

A 3D registration methodology to evaluate the goodness of fit at the individual-respiratory mask interface

Respiratory masks are used to deliver non-invasive ventilation for cardiorespiratory pathologies. Masks must minimize skin tissue compression while maintaining a seal at the interface. Ill-fitting masks or those applied too tightly are implicated in pressure ulcer formation. This study aimed to analyse respiratory mask goodness of fit in a cohort of face shapes. A number of parameters were identified and analysed with a novel registration protocol. In the majority of cases, mask indentation exceeded the thickness of the interface material and significant gapping was observed. The size range was most appropriate for males, with only one size suitable for females.

Evaluating lubricant performance to reduce COVID-19 PPE-related skin injury

BACKGROUND

Healthcare workers around the world are experiencing skin injury due to the extended use of personal protective equipment (PPE) during the COVID-19 pandemic. These injuries are the result of high shear stresses acting on the skin, caused by friction with the PPE. This study aims to provide a practical lubricating solution for frontline medical staff working a 4+ hours shift wearing PPE.

METHODS

A literature review into skin friction and skin lubrication was conducted to identify products and substances that can reduce friction. We evaluated the lubricating performance of commercially available products in vivo using a custom-built tribometer.

FINDINGS

Most lubricants provide a strong initial friction reduction, but only few products provide lubrication that lasts for four hours. The response of skin to friction is a complex interplay between the lubricating properties and durability of the film deposited on the surface and the response of skin to the lubricating substance, which include epidermal absorption, occlusion, and water retention.

INTERPRETATION

Talcum powder, a petrolatum-lanolin mixture, and a coconut oil-cocoa butter-beeswax mixture showed excellent long-lasting low friction. Moisturising the skin results in excessive friction, and the use of products that are aimed at 'moisturising without leaving a non-greasy feel' should be prevented. Most investigated dressings also demonstrate excellent performance.

Preventing medical device-related skin damage

While medical technology is continuing to improve healthcare outcomes and quality of life for patients, the number of people affected by medical device-related skin damage is increasing. In many cases, life-preserving medical devices used in interventions such as nasal continuous positive airway pressure or oxygen therapy can cause significant skin damage, with negative consequences including pain, infection and delayed hospital discharge. This article outlines methods that nurses can use to minimise the risk of skin damage, focusing primarily on the prevention of pressure ulcers. It also examines how nurses can work collaboratively with patients, manufacturers and regulatory bodies to reduce the risk of medical device-related skin damage in the future.

Mask pressure effects on the nasal bridge during short-term noninvasive ventilation

The aim of this study was to assess the influence of different masks, ventilator settings and body positions on the pressure exerted on the nasal bridge by the mask and subjective comfort during noninvasive ventilation (NIV). We measured the pressure over the nasal bridge in 20 healthy participants receiving NIV via four different NIV masks (three oronasal masks, one nasal mask) at three different ventilator settings and in the seated or supine position. Objective pressure measurements were obtained with an I-Scan pressure-mapping system. Subjective comfort of the mask fit was assessed with a visual analogue scale. The masks exerted mean pressures between 47.6±29 mmHg and 91.9±42.4 mmHg on the nasal bridge. In the supine position, the pressure was lower in all masks (57.1±31.9 mmHg supine, 63.9±37.3 mmHg seated; p<0.001). With oronasal masks, a change of inspiratory positive airway pressure (IPAP) did not influence the objective pressure over the nasal bridge. Subjective discomfort was associated with higher IPAP and positively correlated with the pressure on the skin. Objective measurement of pressure on the skin during mask fitting might be helpful for mask selection. Mask fitting in the supine position should be considered in the clinical routine.