Prevention of nasal injuries secondary to NCPAP application in the ELBW infant

Satisfaction of Health Professionals Regarding the Short Binasal Prong Used as a Non-Invasive Ventilation Interface in Neonatology

Purpose

To evaluate the health professionals' satisfaction regarding the short binasal prong used in Neonatal Intensive Care Units (NICU), evaluate the difficulties related to its use, and present possible improvements in the design of this device.

Patients and Methods

Observational, cross-sectional study with prospective data collection carried out in the NICU of a public hospital in southern Brazil. This research was presented into two stages. In the first stage, the Quebec User Evaluation of Satisfaction with Assistive Technology was applied with 90 health professionals to evaluate the satisfaction regarding the short binasal prong. In the second stage, the health professional's experiences and difficulties in using the binasal prongs in 14 newborns (NBs) that required non-invasive ventilation was collected. The short binasal prongs used was the Fanem® brand and the CPAP circuit was Gabisa Medical International (GMI®). Finally, improvements and recommendations were presented to optimize the device's design.

Results

The mean score of the health professionals' satisfaction with short binasal prongs was 3.8 ± 0.6. Ease of adjustment (3.27) and dimensions (3.62) variables had the worst scores. The main difficulties pointed out by health professionals were: circuit disconnection (57.1%), the size of the prong did not correspond to NBs' anatomical characteristics (35.7%), air leakage (21.4%), and difficulty in fixing and positioning the prong in the NB (14.28%). The improvements suggested were: appropriate prong sizes based on the anatomical characteristics of the NBs; adjustable distance between insertion and base catheters; manufactured with malleable material, however not easily foldable; curved and adjustable insertion catheters and functional system of tracheas' connection.

Conclusion

The dissatisfaction of health professionals with the dimensions and prongs adjustments and the difficulties faced in clinical practice indicate the need for improvements in these interfaces. The recommendations presented in this study may contribute to optimizing the design of the binasal prong in the future.

Systematic rotation versus continuous application of 'nasal prongs' or 'nasal mask' in preterm infants on nCPAP: a randomized controlled trial

To compare whether alternate rotation of nasal mask with nasal prongs every 8 h as compared to continuous use of either interface alone decreases the incidence of nasal injury in preterm infants receiving nasal Continuous Positive Airway Pressure (nCPAP). This was an open-label, three-arm, stratified randomized controlled trial where infants < 35 weeks receiving nCPAP were randomized into three groups using two different nasal interfaces (continuous prongs group, continuous mask group, and rotation group). All infants were assessed for nasal injury six hours post-removal of nCPAP using grading suggested by Fischer et al. The nursing care was uniform across all three groups. Intention-to-treat analysis was done. Fifty-seven infants were enrolled, with nineteen in each group. The incidence of nasal injury was 42.1% vs. 47.4% vs. 68.4% in the rotation group, continuous mask, and continuous prongs groups, respectively (P = 0.228). On adjusted analysis (gestational age, birth weight, and duration of nCPAP therapy), the incidence of nasal injury was significantly less in the rotation group as compared to continuous prongs group (Adjusted Odds Ratio [AOR], 95% confidence interval [CI]; 0.10 [0.01-0.69], P = 0.02) and a trend towards lesser nasal injury as compared to continuous mask group (AOR, 95% CI; 0.15 [0.02-1.08], P = 0.06). However, there was no significant difference in incidence of nasal injuries between continuous prongs versus continuous mask group (P = 0.60). The need for surfactant, nCPAP failure rate, duration of nCPAP, and common neonatal co-morbidities were similar across all three groups.   Conclusion: Systematic rotation of nasal mask with nasal prongs significantly reduced nasal injury among preterm infants on nCPAP as compared to continuous use of nasal prongs alone without affecting nCPAP failure rate.   Trial registration: CTRI/2019/01/017320, registered on 31/01/2019. What is Known: • Use of nasal mask as an interface for nasal Continuous Positive Airway Pressure decreases nasal injury as compared to nasal prongs. What is New: • Rotation of nasal prongs and nasal mask interfaces alternately every 8 h may reduce the nasal injury even further as compared to either interface alone.

Reducing Mask-Related Pressure Injuries in Pediatric Patients During Noninvasive Ventilation by Targeting Patient Mask Leak: A Quality Improvement Initiative

PURPOSE

To compare outcomes following implementation of patient mask leak range of 25 to 55 liters per minute (lpm) to guide strap tension of sleep masks during noninvasive ventilation against baseline data with no patient mask leak range on number of noninvasive mask-related pressure injuries (PIs).

PARTICIPANTS AND SETTING

All noninvasively ventilated pediatric acute care patients admitted to general wards and intensive care units between February 1, 2018, and February 1, 2019, in a quaternary hospital in the southwest United States.

APPROACH

Using the Plan Do Study Act model, we employed an intervention to examine the rate of PIs per noninvasive positive pressure ventilation (NIPPV) days and patient-days before and after implementation of patient mask leak parameters between 25 and 55 lpm to guide mask strap tension. Since patients are at an increased risk of sleep mask-related PIs only when on NIPPV, we sought to describe that as number or PIs per number of days at risk, described as NIPPV days, and patient days which is the traditional denominator for wounds and hospital-acquired conditions.

OUTCOMES

Preintervention, 6 out of 115 subjects (5.2 %) incurred PI at a rate of 0.51 per 100 NIPPV days or 0.26 per 1000 patient-days. Of the 1932 NIPPV days since education was completed, only 1 subject out of 87 (1.1%) incurred a high-stage PI (0.05/100 NIPPV days-a 96.79% reduction or 0.05/1000 patient-days-a 92.86% reduction). Upon reaching more than 90% compliance with patient mask leak range in December 2018, 1221 NIPPV days resulted in 0 noninvasive mask-related PIs. Greater than 90% compliance with a patient mask leak of 25 to 55 lpm allowed us to successfully achieve our hospital's operating plan goal of 0.15 of 1000 patient-days within this group.

IMPLICATIONS FOR PRACTICE

Maintaining a patient mask leak range between 25 and 55 lpm should be considered as part of proper fit for pediatric patients using NIPPV with a mask. Additional work is needed to assess this leak range in more children and in studies conducted at multiple sites.

Workflow to develop 3D designed personalized neonatal CPAP masks using iPhone structured light facial scanning

Background

Continuous positive airway pressure (CPAP) is a common mode of respiratory support used in neonatal intensive care units. In preterm infants, nasal CPAP (nCPAP) therapy is often delivered via soft, biocompatible nasal mask suitable for long-term direct skin contact and held firmly against the face. Limited sizes of nCPAP mask contribute to mal-fitting related complications and adverse outcomes in this fragile population. We hypothesized that custom-fit nCPAP masks will improve the fit with less skin pressure and strap tension improving efficacy and reducing complications associated with nCPAP therapy in neonates.

Methods

After IRB approval and informed consent, we evaluated several methods to develop 3D facial models to test custom 3D nCPAP masks. These methods included camera-based photogrammetry, laser scanning and structured light scanning using a Bellus3D Face Camera Pro and iPhone X running either Bellus3D FaceApp for iPhone, or Heges application. This data was used to provide accurate 3D neonatal facial models. Using CAD software nCPAP inserts were designed to be placed between proprietary nCPAP mask and the model infant’s face. The resulted 3D designed nCPAP mask was form fitted to the model face. Subsequently, nCPAP masks were connected to a ventilator to provide CPAP and calibrated pressure sensors and co-linear tension sensors were placed to measures skin pressure and nCPAP mask strap tension.

Results

Photogrammetry and laser scanning were not suited to the neonatal face. However, structured light scanning techniques produced accurate 3D neonatal facial models. Individualized nCPAP mask inserts manufactured using 3D printed molds and silicon injection were effective at decreasing surface pressure and mask strap pressure in some cases by more than 50% compared to CPAP masks without inserts.

Conclusions

We found that readily available structured light scanning devices such as the iPhone X are a low cost, safe, rapid, and accurate tool to develop accurate models of preterm infant facial topography. Structured light scanning developed 3D nCPAP inserts applied to commercially available CPAP masks significantly reduced skin pressure and strap tension at clinically relevant CPAP pressures when utilized on model neonatal faces. This workflow maybe useful at producing individualized nCPAP masks for neonates reducing complications due to misfit.

Medical Device-Related Pressure Injuries in Infants and Children

PURPOSE

The purpose of this study was to describe medical device-related pressure injuries (MDRPIs) in hospitalized pediatric patients.

DESIGN

A prospective, descriptive study.

SAMPLE/SUBJECTS AND SETTING

The sample comprised 625 patients cared for in 8 US pediatric hospitals. Participants were aged preterm to 21 years, on bed rest for at least 24 hours, and had a medical device in place.

METHODS

Two nursing teams, blinded to the other's assessments, worked in tandem to assess pressure injury risk, type of medical devices in use, and preventive interventions for each medical device. They also identified the presence, location, and stage of MDRPI. Subjects were observed up to 8 times over 4 weeks, or until discharge, whichever occurred first.

RESULTS

Of 625 enrolled patients, 42 (7%) developed 1 or more MDRPIs. Two-thirds of patients with MDRPIs were younger than 8 years. Patients experiencing MDRPIs had higher acuity scores on hospital admission, were more frequently cognitively and/or functionally impaired, or were extreme in body mass index. Respiratory devices caused the most injuries (6.19/1000 device-days), followed by immobilizers (2.40/1000 device-days), gastric tubes (2.24/1000 device-days), and external monitoring devices (1.77/1000 device-days). Of the 6336 devices in place, 36% did not have an MDRPI preventive intervention in place. Clinical variables contributing to MDRPI development included intensive care unit care (odds ratio [OR] 8.9, 95% confidence interval [CI] 1.9-43.6), use of neuromuscular blockade (OR 3.7, 95% CI 1.7-7.8), and inotropic/vasopressor medications (OR 2.7, 95% CI 1.7-4.3). Multivariable analysis indicated that Braden QD scores alone predicted MDRPI development.

CONCLUSION

Medical devices are common in hospitalized infants and children and these medical devices place patients at risk for MDRPI.

Incidence and Severity of Nasal Injuries in Preterm Infants Associated to Non-Invasive Ventilation Using Short Binasal Prong

Short binasal prongs can cause skin and mucosal damage in the nostrils of preterm infants. The objective of this study was to investigate the incidence and severity of nasal injuries in preterm infants during the use of short binasal prongs as non-invasive ventilation (NIV) interfaces. A prospective observational study was carried out in the public hospital in a Southern Brazil. The incidence and severity of internal and external nasal injuries were evaluated in 28 preterm infants who required NIV using short binasal prongs for more than 24 hours. In order to identify possible causes of those nasal injuries, the expertise researcher physiotherapist has been carried empirical observations, analyzed the collected data, and correlated them to the literature data. A cause and effect diagram was prepared to present the main causes of the nasal injury occurred in the preterm infants assessed. The incidence of external nasal injuries was 67.86%, and internal ones 71.43%. The external nasal injuries were classified as Stage I (68.42%) and Stage II (31.58%). All the internal injuries had Stage II. The cause and effect diagram was organized into 5 categories containing 17 secondary causes of nasal injuries. There was a high incidence of Stage II-internal nasal injury and Stage I-external nasal injury in preterm infants submitted to NIV using prongs. The injuries genesis can be related to intrinsic characteristics of materials, health care, neonatal conditions, professional competence, and equipment issues.

Sustained Reduction of Nasal Pressure Injuries in the Neonatal Intensive Care Unit With the Use of Bubble Continuous Positive Airway Pressure: A Quality Improvement Project

PURPOSE

The purpose of this interprofessional team-driven quality improvement project was to implement a Bubble continuous positive airway pressure (CPAP) Skincare Protocol proactively to prevent potential device-related pressure injuries.

PARTICIPANTS AND SETTING

The setting was a level 3, 60-bed single patient room neonatal intensive care unit (NICU) located within a Midwest urban academic medical center with more than 200 healthcare providers. Prior to the beginning of this project, the NICU had been using the CPAP apparatus that had documented 6 nasal pressure injuries over a 6-month period. Because of ease of use, the NICU moved to using Bubble CPAP (BCPAP), which is known to place patients at a higher risk of nasal pressure injuries due to the way the apparatus sits inside the nares.

APPROACH

An evidence-based practice model provided the guiding framework for the development of our BCPAP Skincare Protocol. Knowing that the unit had already documented nasal pressure injuries, the interprofessional-devised protocol was developed to decrease the risk of nasal injuries with the use of BCPAP in premature infants. The protocol was disseminated via an all-healthcare provider educational program.

OUTCOMES

During the first 3 months postprotocol implementation period, one stage 2 nasal injury was noted and immediately treated and healed without incident. During the next 24-month, postimplementation period, there were zero nasal pressure injuries reported.

IMPLICATIONS FOR PRACTICE

The healthcare providers found that using an interprofessional team approach in developing and implementing an evidence-based BCPAP Skincare Protocol reduced the incidence of nasal pressure injuries associated with the use of BCPAP in the NICU.

Neonatal skin assessments and injuries: Nomenclature, workplace culture and clinical opinions-Method triangulation a qualitative study

AIM AND OBJECTIVE

To explore and establish the language, clinical opinions and workplace culture around neonatal skin injury nomenclature. Specifically, what nomenclature is used to describe, define, identity and communicate neonatal skin injuries including (a) terms, (b) locations, (c) associated risks and (d) mechanical forces.

BACKGROUND

Skin injuries are affirmed or denied based on visual assessment with findings reported by language rather than measurements. However, if language or nomenclature is ambiguous, assessments could be misinterpreted effecting healthcare delivery.

DESIGN

Qualitative enquiry including applied discourse analysis and between-method triangulation, within a larger exploratory mixed-methods study.

METHODS

Data were collected over two years from four sources: literature, documents, interviews/focus groups and free text injury assessments. Data analysis included content analysis, selective coding and thematic analysis. The collective data were further explored using discourse analysis and triangulation to achieve collective conclusions about opinions, emotions, feelings, perceptions and workplace cultures. The COREQ checklist provided structure for the reporting of study methods, analysis and findings.

RESULTS

A total of 427 data points were collected from literature, documentation and two clinical data sources. Data convergence revealed that neonatal skin injuries are described by numerous terms with preferences for "injury," "trauma" or "redness." Injuries occur in over 20 anatomical locations and risks for injuries included hospitalisation, specific treatments and prematurity. Essential medical devices, clinical condition, lack of clinician experience and overactive neonates were uniquely associated risks. There was incongruency between sources. The literature and documents empathise pressure as the primary force related to skin injury, while varied forces were identified within interviews, focus groups and free text injury assessments.

CONCLUSIONS

The variety of unique terms, locations and risks for injury indicate the need for updated neonatal skin injury frameworks. If frameworks and policies continue to be created without the empirical knowledge of neonatal clinicians, misrepresentation of neonatal skin injury locations and risk will continue to dominate the literature.

RELEVANCE TO CLINICAL PRACTICE

The recognition and management of neonatal skin injuries are related to language used to describe assessments in the absence of diagnostic confirmation, which has implications for both the neonate and the healthcare team.

Hydrocolloid versus silicone gel for the prevention of nasal injury in newborns submitted to noninvasive ventilation: A randomized clinical trial

Purpose

To compare the effectiveness of the hydrocolloid and the silicone gel on the nasal protection of the newborns (NBs) during the use of noninvasive ventilation (NIV).

Materials and methods

Thirty-three NBs were selected. They were randomly divided into three groups of 11 NBs, according to the type of nasal protection used: hydrocolloid, thick silicone gel, and thin silicone gel. The stage of the nasal injury and need for exchanging nasal protection were assessed before the connection to the NIV and every 24 h until the physician's authorization for NIV's suspension.

Results

The mean gestational age was 32.03 ± 3.93 weeks, and the median birth weight was 1760 g (750–3535 g). The incidence of nasal injury using hydrocolloid, thick silicone gel, and a thin silicone gel group was 36.36%, 81.81%, and 72.72%, respectively (p = 0.06). Regarding the injury stage, there was no statistical significance between the three study groups. The hydrocolloid protection type had the best adhesion (p = 0.03) on the NBs' skin.

Conclusions

Although this study was conducted by local practice patterns, the results showed that the hydrocolloid could be the best choice to prevent the nasal septum base injury in the NB submitted to NIV.

Nasal Prongs: Risks, Injuries Incidence and Preventive Approaches Associated with Their Use in Newborns

Purpose

To assess the incidence of nasal injury in newborns submitted to non-invasive ventilation (NIV) via binasal prongs, to identify risks that come with using this interface, and to present actions for nasal injury prevention.

Patients and Methods

Observational and descriptive study performed in neonatal intensive care unit (NICU) of a public hospital in the south of Brazil. This research was divided into three stages. In the first one, nasal injury incidence was assessed in 148 newborns, using data collection from medical records. In the second stage, injury incidence, severity and a preliminary analysis of risks associated with the prescription of binasal prongs were analyzed in 33 newborns who required NIV. In the third stage. recommendations were presented to prevent nasal injury during NIV with short binasal prong.

Results

The incidence of nasal injury in the first stage was 37.16%, and 63.64% in the second one. As for severity, 68.42% of the injuries showed Stage I severity, and 31.58% Stage II. The main risks associated with the use of binasal prongs were inappropriate prong size, inappropriate prong model, interface reuse, prolonged NIV use exclusively with binasal prongs, incorrect prong position and NIV circuit pulled. A total of 17 preventive approaches were recommended: 13 related to newborns care and not dependent on prior investment. Among them: to choose appropriate prong size; to keep the prong and the NIV circuit well positioned and periodically massages with circular movements in the nasal septum and columella.

Conclusion

The inappropriate prong size, interface reuse, prong model, prolonged NIV use with binasal prong and incorrect prong and NIV circuit position may be associated with the high occurrence of injury in the NICU studied. Simple approaches concerning clinical staff care actions towards the newborn in NIV, which do not require a financial investment, can prevent nasal injury.

Impact of Systematic Training and CPAP Checklist in the Prevention of NCPAP Related Nasal Injuries in Neonates- A Quality Improvement Study

OBJECTIVE

Nasal continuous positive airway pressure (NCPAP) related nasal injury in neonates is a type of device-related pressure injury and is a common event with the varying incidence in different hospitals. Understanding and adhering to the recommendation of the manufacturer in fixing the NCPAP interface is vital for the prevention of nasal injuries. A quality improvement initiative was undertaken to decrease the incidence of NCPAP related nasal injuries in a Level 3 neonatal unit by using a customized NCPAP checklist and application of the checklist using Plan-Do-Study-Act (PDSA) cycles.

METHODS

A baseline audit was conducted for two months. An evidence-based checklist was formed by a quality improvement team and was exercised by a designated CPAP nurse using videos, small seminars, handouts, and hands-on training. Modifications in the checklist were done during the study using three PDSA cycles.

RESULTS

A total of 129 babies with a median gestational age of 31 wk (IQR: 28-34 wk), median birth weight of 1320 g (IQR: 1030-1842 g) were studied. The mean duration of NCPAP was 5.4 d. The incidence of CPAP injuries decreased from 91 per 1000 CPAP days to 8 per 1000 CPAP days over 8 mo. The compliance with fixing NCPAP as per recommendation improved from 35% to 95% during the study with p values <0.05.

CONCLUSIONS

Nurses training based on a structured checklist and highlighting important features of standardized NCPAP care helps in preventing NCPAP related nasal injury.

Evidence Regarding the Use of Bubble Continuous Positive Airway Pressure in the Extremely Low Birth-Weight Infant: Benefits, Challenges, and Implications for Nursing Practice

BACKGROUND

Gentle ventilation with optimal oxygenation is integral to prevention of chronic lung disease in the extremely low birth-weight (ELBW) infant. Various types of noninvasive ventilation are used in neonatal intensive care units worldwide. Bubble continuous positive airway pressure (BCPAP) has been in use in newborn intensive care since 1975.

PURPOSE

To synthesize the current evidence on the use of BCPAP in the ELBW infant and its relationship to outcomes, particularly morbidity and mortality.

METHODS/SEARCH STRATEGIES

A literature review was completed using PubMed, EMBASE, CINAHL, and Cochrane with a focus on BCPAP use in the ELBW population.

FINDINGS/RESULTS

No study found was exclusive to the ELBW population. All studies ranged from ELBW to full-term neonates. Studies supported the use of BCPAP in the ELBW, demonstrating decreased incidence of chronic lung disease and barotrauma through the use of oscillation and permissive hypercapnia.

IMPLICATIONS FOR PRACTICE

Literature supports the use of nasal bubble CPAP in the ELBW population. Barriers such as septal erosion, pneumothorax, inconsistent pressures, and air in the abdomen were identified and management recommendations were provided.

IMPLICATIONS FOR RESEARCH

Studies are needed comparing outcomes of nasal bubble CPAP use with other forms of CPAP in the ELBW infant, comparison of prongs to mask for nasal bubble CPAP, and comparing interventions to recommend optimal care bundles to prevent nasal septum injuries.

Nasal injury in preterm infants receiving non-invasive respiratory support: a systematic review

OBJECTIVE

Binasal prongs are the most commonly used interface for the delivery of nasal positive airway pressure (CPAP) to preterm infants. However, they are associated with pressure-related nasal injury, which causes pain and discomfort. Nasal injury may necessitate a change in interface and occasionally damage is severe enough to require surgical repair. We aim to determine the incidence and risk factors for nasal injury in preterm infants, and to provide clinicians with strategies to effectively prevent and treat it.

DESIGN

We conducted a systematic search of databases including MEDLINE (PubMed including the Cochrane Library), EMBASE, CINAHL and Scopus. Included studies enrolled human preterm infants and were published prior to 20 February 2017.

RESULTS

Forty-five studies were identified, including 14 ra ndomised controlled trials, 10 observational studies, two cohort studies, eight case reports and 11 reviews. The incidence of nasal injury in preterm infants ranged from 20-100%. Infants born <30 weeks' gestation are at highest risk. Strategies shown to reduce nasal injury included: nasal barrier dressings (2 studies, n=244, risk ratio (RD) -0.12, 95%, CI - 0.20 to -0.04), nasal high flow therapy as an alternative to binasal prong CPAP (7 studies, n=1570, risk difference (RD) -0.14, 95% CI -0.17 to -0.10), and nasal masks rather than binasal prongs (5 studies, n=544, RR 0.80, 95% CI 0.64 to 1.00).

CONCLUSIONS AND RELEVANCE

Nasal injury is common in preterm infants born <30 weeks' gestational age receiving CPAP via binasal prongs. Larger randomised trials are required to fully evaluate strategies to reduce nasal injury.

NeoSeal to Prevent Nasal Injury in Preterm Infants Receiving Oxygen Therapy

PURPOSE

To determine if a foam septum protector prevents nasal injury in preterm infants receiving nasal heated humidified oxygen.

DESIGN

A retrospective before and after comparative design was used.

SAMPLE

Medical records of 101 preterm infants receiving either nasal continuous positive airway pressure (NCPAP) or nasal intermittent positive pressure ventilation (NIPPV) were reviewed; 50 were in the control group and 51 were in the intervention group that had the NeoSeal septum protector applied. The groups were not different in terms of gender, birth weight, gestational age, days intubated, or on days on NCPAP/NIPPV. Skin condition of nares was scored daily using the Neonatal Skin Risk Assessment Scale (NSRAS).

RESULTS

Infants who had the NeoSeal applied had significantly less nasal injuries, OR = 4.08; 95% confidence interval (CI), 1.22-9.59; p = .01. The best predictors of nasal injury were gestational age and whether the NeoSeal was applied or not.

Airways and Injuries: Protecting Our Pediatric Patients from Respiratory Device-Related Pressure Injuries

Pressure injury prevention is required in all health care environments. Respiratory technology includes invasive and noninvasive positive pressure ventilation methods of support and life-saving equipment. Pressure injury can occur from tracheostomy tubes and their securement devices, or use of noninvasive positive pressure ventilation interfaces or the head gear. Methods instituted to decrease hospital-acquired pressure injury related to noninvasive positive pressure ventilation and tracheostomy securement devices are discussed.

Quality Improvement of Nasal Continuous Positive Airway Pressure Therapy in Neonatal Intensive Care Unit

BACKGROUND

Nasal continuous positive airway pressure (NCPAP) therapy is widely used in neonates, but the clinical practice varies. However, nursing practice differs among individuals, and an inappropriate application method may delay the respiratory therapy, influence the beneficial effect of NCPAP, and increase complications. We introduced a quality improvement project to expedite the application of NCPAP therapy and decrease the incidence of nasal trauma.

METHODS

A new strategy of mobile NCPAP cart with prepacked fixation kits and a written protocol was implemented from April 2006. All medical staff answered a questionnaire to assess their basic knowledge before and after intensive training. The records of the patients who were treated with NCPAP from October 2005 to November 2006 were reviewed.

RESULTS

Fifty-nine medical staff were involved in the project, and their mean score for the questionnaire improved from 69.2 points to 98.3 points after training. From October 2005 to November 2006, 113 infants were recruited in total and 82 of them were admitted after the protocol was implemented. The NCPAP cart dramatically shortened the preparation time (from 520 seconds to 72 seconds) and the application time (from 468 seconds to 200 seconds). The use of the nursing protocol significantly decreased the incidence of nasal trauma in the study population (45.2% vs. 19.6%, p = 0.006), but not in infants with a birth weight of < 1000 g. Risk factors for nasal skin trauma included lower gestational age and birth weight, longer duration of NCPAP use, and lack of standardized nursing care.

CONCLUSION

The mobile NCPAP cart with prepacked fixation kits is a practical way of expediting the initiation of NCPAP therapy. The written nursing protocol decreased the incidence of nasal trauma in infants, except for those with an extremely low birth weight.

Neonatal Pressure Ulcer Prevention

The incidence of pressure ulcers in acutely ill infants and children ranges up to 27 percent in intensive care units, with a range of 16-19 percent in NICUs. Anatomic, physiologic, and developmental factors place ill and preterm newborns at risk for skin breakdown. Two case studies illustrate these factors, and best practices for pressure ulcer prevention are described.

Nasal septum injury in preterm infants using nasal prongs

OBJECTIVE:

to assess the incidence and risk factors associated with nasal septum injury in premature infants using reused and new nasal prongs.

METHOD:

the study was a cohort from an open therapeutic intervention. The sample included 70 infants with a gestational age inferior to 37 weeks, who used nasal prongs and were hospitalized at the neonatal service of a hospital in Recife-PE, in the Northeast of Brazil. The data were collected in patient files through the assessment of the application of the device and of the nasal septum. Multinomial Logistic Regression and Survival analyses were applied.

RESULTS:

the incidence of nasal injury corresponded to 62.9%. In the multiple analysis, only the length of the infant's treatment was a determinant factor for the occurrence and severity of the injuries.

CONCLUSION:

the type of nasal prong does not serve as a risk factor for the nasal injury. The high incidence of nasal injury indicates the need to adapt the nursing care with emphasis on prevention.

The Pressure Is On!: Neonatal Skin and Nasal Continuous Positive Airway Pressure

BACKGROUND

Premature infants have an increased risk for developing skin breakdown. Perceivably noninvasive interventions may have detrimental effects on the infant's skin.

PURPOSE

This case presentation describes an extreme case of nasal breakdown associated with nasal continuous positive airway pressure (nCPAP).

METHODS

Highlighted is the vital importance of proper placement, along with appropriate apparatus size, in the efforts to prevent skin breakdown. Ensuring that pressure points are avoided is imperative to prevent nCPAP-related injuries, along with treating the area in the event of skin denudation. A literature search was conducted to determine best practice options to prevent these injuries.

FINDINGS

There is little information in the literature to guide treatment and prevention of this type of breakdown.

IMPLICATIONS FOR PRACTICE

Avoidance of pressure in a localized area is the most commonly found recommendation.

IMPLICATIONS FOR RESEARCH

There are extensive opportunities for adding to our current knowledge in terms of prevention and treatment of skin breakdown associated with device utilization in the neonatal intensive care unit, especially with the increasing use of nCPAP.

Early Bubble Continuous Positive Airway Pressure: Investigating Interprofessional Best Practices for the NICU Team

Premature neonates delivered <32 completed weeks gestation are unprepared to handle the physiologic demands of extrauterine life. Within the respiratory system, alveolar instability and collapse can cause decreased functional residual capacity, impaired oxygenation, and hypoxemia leading to respiratory distress syndrome. Supportive measures are indicated immediately after birth to establish physiologic stability including bubble continuous positive airway pressure (CPAP) or endotracheal intubation and mechanical ventilation. CPAP is a noninvasive, gentle mode of ventilation that can mitigate the effects of lung immaturity, but prolonged use can increase the risk for nasal breakdown. Strategies to mitigate this risk must be infused as best practices in the NICU environment. The purpose of this article is to propose an evidence-based best practice care bundle for the early initiation of CPAP in the delivery room and associated skin barrier protection strategies for premature neonates <32 weeks gestation and weighing <1,500 g.

Significance of antenatal glucocorticoid exposure for pressure injury prevalence in neonates

AIMS

Studies have highlighted that antenatal steroids could have an effect on neonatal skin maturation. This study examined if there was a relationship between the administration of antenatal glucocorticoids for mothers and the skin injuries in their neonates. Data from skin injury audit were extracted from the neonatal database and analyzed to determine differences in the prevalence of neonates with pressure injuries [cases] whose mothers had received antenatal steroids, compared to those without pressure injuries [control].

RESULTS

Of 247 neonates audited, 77 [31%], had documented pressure injuries, 170 [69%] had no documented injury. The median birth weight and gestation were 1400 g [IQR 893-2268 g] and 30.3 weeks [IQR 26.3-40.0 weeks] respectively. Of the neonates born less than 34 weeks, 80% were exposed to antenatal steroids and were equally distributed across patient genders. Within the 77 cases, 53 [66%] were exposed to antenatal steroids compared to controls in which 88 [53%] had not. The effect between cases and controls was not statistically significant [χ2 = 2.81, P = 0.09]. However a difference was noted between genders, as female neonates benefited from the exposure to steroids [OR = 0.317, 95% [CI 0.105-0.956], p value -0.041].

CONCLUSION

Antenatal glucocorticoids appear to be beneficial in reducing pressure injury prevalence in female neonates.

High flow nasal cannula (HFNC) with Heliox decreases diaphragmatic injury in a newborn porcine lung injury model

BACKGROUND

High flow nasal cannula (HFNC) improves ventilation by washing out nasopharyngeal dead space while delivering oxygen. Heliox (helium-oxygen gas mixture), a low-density gas mixture, decreases resistance to airflow, reduces the work of breathing, and facilitates distribution of inspired gas. Excessive lung work and potential injury increases the workload on the immature diaphragm predisposing the muscle to fatigue, and can lead to inflammatory and oxidative stress, thereby contributing to impaired diaphragmatic function. We tested the hypothesis that HFNC with Heliox will decrease the work of breathing thereby unloading the neonatal diaphragm, and potentially reducing diaphragmatic injury.

METHODS

Spontaneously breathing neonatal pigs were randomized to Nitrox (nitrogen-oxygen gas mixture) or Heliox, and studied over 4 hr following oleic acid injury. Gas exchange, pulmonary mechanics indices, and systemic markers of inflammation were measured serially. Diaphragm inflammation biomarkers and histology for muscle injury were assessed at termination.

RESULTS

Heliox breathing animals demonstrated decreased respiratory load and work of breathing with lower pressure-rate product, lower labored breathing index, and lower levels of diaphragmatic inflammatory markers, and muscle injury score as compared to Nitrox.

CONCLUSION

These results suggest that HFNC with Heliox is a useful adjunct to attenuate diaphragmatic fatigue in the presence of lung injury by unloading the diaphragm, resulting in a more efficient breathing pattern, and decreased diaphragm injury.

Hydrocolloid dressing in preventing nasal trauma secondary to nasal continuous positive airway pressure in preterm infants

BACKGROUND

Continuous positive airway pressure (CPAP) with nasal devices (nCPAP) is widely used in the respiratory management of newborns. The present study aimed to compare the incidence of nasal trauma secondary to nasal continuous positive airway pressure (nCPAP) protected with or without hydrocolloid dressing in preterm infants.

METHODS

This prospective controlled study was performed in the neonatal intensive care unit (NICU) of the Children's Hospital of Hunan Province from March 1, 2010 to June 31, 2010. A total of 65 infants, 46 males and 19 females, were recruited in this study. Their average gestational age was 32.6 weeks (range 28-37 weeks). The infants were randomly divided into clinical trial group (group A, n=33) and control group (group B, n=32). Paraffin oil was smeared around the nostrils before inserting prongs in group B; the infants in group A were covered on the infant's nostrils surface with hydrocolloid dressing (hydrocolloid dressing, 1.8 mm thick, 90029T, 3M Company, Minnesota, USA) with a size of 2-3 cm cutting two holes adapted to the nose and nostrils. The nostrils of those infants were inspected daily during nCPAP support until they were weaned off nCPAP.

RESULTS

Nine infants (2 in group A and 7 in group B) developed nasal injury during nCPAP support. The Chi-square test revealed that there was a statistically significant difference (P=0.01) in the incidence of nasal injury between groups A and B.

CONCLUSION

The study demonstrated that hydrocolloid dressing significantly decreased the incidence and the severity of nasal injury.

[Prevalence of nasal septum injury in premature infants using nasal prongs]

The aim of this study was to investigate the prevalence and factors associated with nasal septum injury in preterm infants in the use of noninvasive ventilation. A cross-sectional study with data collection between March and July 2012 and with search for records, interviews with mothers and nasal evaluation of 47 premature in the neonatal unit of a teaching hospital in Recife, Pernambuco, northeastern Brazil. A descriptive bivariate statistical analysis was performed through the chi-square test or Fisher exact test using the SPSS software. The prevalence of nasal lesions was 68.1%, associated with low birth weight and duration of treatment. The prevalence of nasal injury in this population is high and associated with low birth weight and length of stay in noninvasive ventilation. Due to these facts the necessity for preventive actions was noticed, such as continuous care in nursing, suitability of devices and permanent education in service.

A comparative effectiveness study of continuous positive airway pressure-related skin breakdown when using different nasal interfaces in the extremely low birth weight neonate

A three group prospective randomized experimental design was conducted to identify differences in frequency and severity of nasal injuries when comparing various interfaces used during continuous positive airway pressure (CPAP) and identified risk factors associated with injury. Seventy-eight neonates <1500 g were randomized into three groups: continuous nasal prongs; continuous nasal mask; or alternating mask/prongs. Repeated measures ANOVA with Bonferroni correction demonstrated that significantly less skin injury was detected in the rotation interface group when compared to both mask and prong groups. In the final stepwise regression model (F = 11.51; R(2) = 0.221; p = 0.006) significant predictors of skin injury included number of days on nasal CPAP (p < 0.001) and current mean post menstrual age (p = 0. 006). Reduced nasal injury was demonstrated using rotating mask/prong nasal interfaces. Future best practices must include precise selection of device size, developmental and CPAP device positioning with focused skin assessment including rapid intervention for skin injury.

Noninvasive respiratory support for neonates

PURPOSE OF THE REVIEW

Noninvasive respiratory support for neonates is growing in popularity as clinicians increasingly recognize the dangers of prolonged invasive ventilation. The purpose of this review is to critically evaluate the existing evidence for safety and efficacy of these modes of respiratory support in neonates.

RECENT FINDINGS

In recent years, multiple randomized controlled trials (RCTs) have evaluated several modes of noninvasive support, most importantly nasal intermittent positive pressure ventilation and high flow nasal cannulae, in comparison to the standard therapy of continuous positive airway pressure (CPAP). The three largest RCTs were recently published in 2013. One demonstrated no difference in death or survival with bronchopulmonary dysplasia between nasal intermittent positive pressure ventilation and CPAP, both when used as primary support and as postextubation support. Two others demonstrated that high flow nasal cannulae are noninferior to or no better than CPAP when used to support preterm infants after extubation. These trials showed no serious safety concerns with current modalities.

SUMMARY

The optimal forms of noninvasive respiratory support for neonates remain to be determined. Continued evaluation of these technologies with large, well-designed RCTs is warranted.

An integrative review of skin breakdown in the preterm infant associated with nasal continuous positive airway pressure

OBJECTIVE

To identify factors associated with skin injury during nasal continuous positive airway pressure (NCPAP) and describe differences in frequency, severity, and type of skin injuries when comparing nasal interfaces used during NCPAP in the preterm infant.

DATA SOURCES

Scientific databases were searched using provided key terms and yielded 113 articles.

STUDY SELECTION

Forty-six articles were included in this integrative review: six case studies, 22 with identified aim of examining skin and nasal injury during NCPAP; 18 included skin care considerations during NCPAP.

DATA EXTRACTION

Studies were categorized into four themes: types of nasal injuries; associated risk factors that increase incidence of injury; differences between NCPAP devices and/or nasal interface and corresponding rate and severity of nasal injury; and recommended prevention strategies to reduce iatrogenic cutaneous injury.

DATA SYNTHESIS

Skin injury was a common theme during neonatal NCPAP with skin breakdown rates of 20% to 60%. Increased skin injury risk was associated with smaller infant size, gestational age, and duration of therapy. Nursing care strategies to improve skin integrity during NCPAP had little supportive evidence. Nursing practice is varied with reportedly little standardized care during NCPAP therapy. Recommendations for specific care strategies to reduce skin injury during NCPAP were supported by limited experimental studies.

CONCLUSIONS

Risk factors during NCPAP include nasal injury and trauma secondary to tight-fitting nasal interfaces necessary to provide continuous distending pressure for respiratory stability. Identifying strategies to reduce skin breakdown will support noninvasive treatment success, reduce reintubation rates, reduce sepsis, reduce patient discomfort, and improve developmental outcomes during NCPAP use.

Forehead pressure necrosis in neonates following continuous positive airway pressure

After treatment with continuous positive airway pressure (CPAP) via nasal masks and a face mask, three neonates developed pressure necrosis involving their central forehead and left eyebrow. The pressure necrosis resulted in permanent scarring in all three infants. We describe a case series of a new cutaneous iatrogenic complication of CPAP.