Minimizing HAPIs from NIPPV

By Jeanne Pettinichi, MSN, RN, CPN, CPEN
Vapotherm Clinical Nurse Educator

The views and ideas presented in this blog article are solely those of the author, and the content is not intended to serve as medical advice. Vapotherm does not practice medicine or provide medical services. Practitioners should refer to the full indications for use and operating instructions of any products referenced herein before prescribing them.

The National Pressure Ulcer Agency Advisory Panel (NPUAP) considers all patients with a medical device to be at risk for medical device related pressure injuries (MDRPIs).¹1. National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance (PPPIA). Prevention and treatment of pressure ulcers: Quick reference guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Australia; 2014. Retrieved from http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdfRead Full Text Interventions and successful minimization of hospital acquired pressure injuries (HAPIs) from non-invasive positive pressure ventilation (NIPPV) require specific assessment and prevention strategies and begin with a comprehensive multi-disciplinary approach and education program. The Agency for Healthcare Quality and Research (AHQR) promotes “enhanced knowledge of evidence based practices” related to pressure injury prevention and treatment for the front line clinical staff to ensure a shared ownership of outcomes and achievement of desired results.²2. Agency for Healthcare Quality and Research (AHRQ), Preventing pressure injuries in hospitals, a toolkit for improving quality of care. 2017;Retrieved from www.ahrq.govRead Full Text The National Database for Nursing Quality Indicators (NDNQI) pressure ulcer training module emphasizes the need for the RN and other clinical caregivers to be properly trained to assess for risk factors in addition to the ability to “modify any modifiable risk factors”. NDNQI further emphasizes that prevention efforts should be implemented accordingly.³3. National Database of Nursing Quality Indicators (NDNQI). Medical Device Related (MDR) Pressure Injuries. Retrieved from https://members.nursingquality.org/NDNQIPressure
UlcerTraining/Default.aspxRead Full Text Initial and ongoing education on pressure injury prevention and management should exist for both nursing and non-nursing staff.¹⁰10. Agency for Healthcare Quality and Research (AHRQ).Pressure ulcer toolkit. 2014.https://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/putool7b.htmlRead Full Text

Frequent assessments of the skin condition under the interface device and pressure injury identification are critical elements for early recognition of pressure injury. NDNQI recommends training for clinical staff to demonstrate inter-rater reliability of pressure injury identification and staging in order to promptly initiate treatment measures. Education for comprehensive skin assessment of pressure injuries must include pressure injury risk assessment, knowledge of the NPUAP pressure injury staging system, knowledge of other wound types and skin injuries for differentiation from pressure injuries and determination of whether the pressure injury is related to a medical device.

Another important component of NIPPV interface pressure injury education includes instruction on the proper documentation of skin assessment including the type of device, the location, how it is secured, the condition of the skin under the device and the prevention strategies being implemented.³3. National Database of Nursing Quality Indicators (NDNQI). Medical Device Related (MDR) Pressure Injuries. Retrieved from https://members.nursingquality.org/NDNQIPressure
UlcerTraining/Default.aspxRead Full Text

A lack of standardization in skin-care practice and documentation has shown to contribute to inconsistencies in care of patients.⁸8. Kiss E, Heiler, M. Pediatric skin integrity practice guideline for institutional use: A quality improvement project. Journal of Pediatric Nursing 2014; 29(4): 362-367Read Full Text Pressure injury prevention bundles have shown to reinforce strategies to reduce pressure injury and patient harm. Best practices for the prevention of pressure injuries related to NIPPV mask interface is supported by the NPUAP recommendations and include choosing the correct type and size of the interface to fit the individual “based on the devices’ ability to induce the least degree of damage from the forces of pressure and/or shear”.¹1. National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance (PPPIA). Prevention and treatment of pressure ulcers: Quick reference guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Australia; 2014. Retrieved from http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdfRead Full Text Application of cushioning and protective measures to the skin with prophylactic dressings in high risk areas such as the nasal bridge is also strongly recommended.⁴4. Haesler, E. Pressure injuries: Preventing medical device related pressure injuries. Wound Practice & Research. 2017; 25(4): 214-216 Clinical staff must, however, be careful to avoid excessive dressings beneath tight devices which may create additional pressure to skin tissue. Removal of the interface to conduct skin assessments for evidence of pressure injury at least twice daily is a crucial and a fundamental practice recommendation. Moisture underneath a medical device creates an environment that increases the risk for alterations in skin integrity.¹1. National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance (PPPIA). Prevention and treatment of pressure ulcers: Quick reference guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Australia; 2014. Retrieved from http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdfRead Full Text Skin with excess moisture is more likely to breakdown when exposed to pressure and shear of a mask interface. Best practice therefore recommends moisture management of skin and utilization of prophylactic dressings to protect from excessive moisture.⁴4. Haesler, E. Pressure injuries: Preventing medical device related pressure injuries. Wound Practice & Research. 2017; 25(4): 214-216 Avoiding placement of the mask interface over sites with a prior or existing injury is also important in averting additional skin damage. Rotating interface type and placement is also recommended when possible.^2,42. Agency for Healthcare Quality and Research (AHRQ), Preventing pressure injuries in hospitals, a toolkit for improving quality of care. 2017;Retrieved from www.ahrq.govRead Full Text
4. Haesler, E. Pressure injuries: Preventing medical device related pressure injuries. Wound Practice & Research. 2017; 25(4): 214-216 Removal of the device as soon as medically feasible is critical to minimizing the skin damage.¹1. National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance (PPPIA). Prevention and treatment of pressure ulcers: Quick reference guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Australia; 2014. Retrieved from http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdfRead Full Text

As highlighted by the NDNQI in the below list, practice strategies should link risk factors and interventions to prevent the occurrence of pressure injury rather than protocols based on total risk scores:³3. National Database of Nursing Quality Indicators (NDNQI). Medical Device Related (MDR) Pressure Injuries. Retrieved from https://members.nursingquality.org/NDNQIPressure
UlcerTraining/Default.aspxRead Full Text

 

1. Follow proper mask or interface selection and fit techniques—assess for skin risk factors
2. Apply facility approved cushioning to points of mask-skin contact: forehead, nasal bridge, below nares or nasal septum.
3. Skin assessment under and around interface device at least two times a day—document skin assessment
4. Moisture management practices—keep skin clean and dry
5. Rotate interface type and placement
6. Remove mask when medically feasible. Proceed to step #1.

Risk factors for the development of a pressure injury with the use of NIPPV involve multiple components requiring consideration and assessment of patient age, trauma from friction and shearing forces, nutrition, perfusion, duration of use, interface type, ventilatory mode, inspiratory positive airway pressure, expiratory positive airway pressure, and pressure support.^1,61. National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance (PPPIA). Prevention and treatment of pressure ulcers: Quick reference guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Australia; 2014. Retrieved from http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdfRead Full Text
6. Yamaguti W, Moderno E, Yamashita S, Gomes T, Maida A, Kondo C, de Salles I, de Brito C. Treatment-related risk factors for development of skin breakdown in patients with acute respiratory failure undergoing noninvasive ventilation or CPAP. Respiratory Care 2014; 59(10): 1-7Read Full Text To identify patient risk for skin breakdown, it is recommended to use a risk assessment tool that is appropriate to the population, is valid and reliable.¹1. National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance (PPPIA). Prevention and treatment of pressure ulcers: Quick reference guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Australia; 2014. Retrieved from http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdfRead Full Text The Braden Scale is widely used for the adult patient population and the Braden Q Scale for the pediatric patient population. The scale consists of six subscales and the total scores range from 6-23. A lower Braden score indicates higher levels of risk for pressure ulcer development. Generally, a score of 18 or less indicates at-risk status.¹¹11. Braden B & Bergstrom N. The Braden Scale for predicating pressure sore risk. 1998; http://www.bradenscale.com/images/bradenscale.pdfRead Full Text The risk assessment tool is used in conjunction with clinical assessment to determine patients at risk for pressure injury and provide for early intervention and care planning. Abnormal scores in the individual subscales should be addressed accordingly.

Appropriate mask interface selection and fit is a major determinant of NIPPV success or failure and correct mask fit has been found to significantly reduce skin injury. Incorrectly fitting facemasks have been reported to be responsible for up to 50% of NIPPV failures and contribute to pressure areas and mask leaks^5,75. Visscher MO,White CC, Jones JM, Cahill T, Jones DC, Pan BS. Face masks for noninvasive ventilation: Fit, excess skin hydration, and pressure ulcers. Respiratory Care 2015; 60(11): 1536-1547.Read Full Text
7. Nava S, Navalesi P, & Gregoretti, C. Interfaces and humidification for noninvasive mechanical ventilation. Respiratory Care 2009; 54(1)Read Full Text Many options exist for mask selection requiring skilled decision making and careful attention to individual patient needs. According to Visscher et al, few interface options are available to offset pressure. The mask fit method, however, is used to select masks from available options, to identify the potential areas of increased tissue pressure, and to prevent skin injury.⁵5. Visscher MO,White CC, Jones JM, Cahill T, Jones DC, Pan BS. Face masks for noninvasive ventilation: Fit, excess skin hydration, and pressure ulcers. Respiratory Care 2015; 60(11): 1536-1547.Read Full Text Avoiding an excessively tight fitting interface was found to be the most important strategy to prevent pressure injury.⁷7. Nava S, Navalesi P, & Gregoretti, C. Interfaces and humidification for noninvasive mechanical ventilation. Respiratory Care 2009; 54(1)Read Full Text To ensure enough space exists between the mask and the skin, it is recommended that 2 fingers can pass beneath the headgear.⁷7. Nava S, Navalesi P, & Gregoretti, C. Interfaces and humidification for noninvasive mechanical ventilation. Respiratory Care 2009; 54(1)Read Full Text The small amount of air leak that may occur is acceptable and should not affect the interaction between the patient and ventilation mode.⁷7. Nava S, Navalesi P, & Gregoretti, C. Interfaces and humidification for noninvasive mechanical ventilation. Respiratory Care 2009; 54(1)Read Full Text

Proper selection of the interface size is essential in achieving best clinical results as patient facial anatomy differs dramatically.⁷7. Nava S, Navalesi P, & Gregoretti, C. Interfaces and humidification for noninvasive mechanical ventilation. Respiratory Care 2009; 54(1)Read Full Text Overall, individualization of fit is a key component and critical in providing the correct fit for successful delivery of effective ventilation.⁷7. Nava S, Navalesi P, & Gregoretti, C. Interfaces and humidification for noninvasive mechanical ventilation. Respiratory Care 2009; 54(1)Read Full Text

Use of prophylactic dressing materials in areas of mask -skin contact is recommended for managing moisture and microclimate, and preventing pressure injuries from NIPPV. Considerations for prophylactic dressing use include ease of application and removal; ability to regularly assess skin condition; thickness of the dressing under tightly fitting devices and the location of the interface to be applied for NIPPV. As previously noted, excessive layering of prophylactic dressings that may increase pressure at the skin device interface should be avoided. Selection of a dressing is made based upon appropriateness to the individual and the clinical use.¹1. National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance (PPPIA). Prevention and treatment of pressure ulcers: Quick reference guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Australia; 2014. Retrieved from http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdfRead Full Text It is been recommended to institute the use of a thin hydrophilic silicone foam dressing and no sting skin prep prior to placement of the mask interface device. For patients with abnormal facial structure or history of previous pressure injury, it is recommended to apply a thick hydrophilic silicone foam dressing to ensure additional cushion from device related pressure. For nasal prong devices, institute a hydrocolloid dressing under devices and secure the device to hydrocolloid dressing with retention tape that is a non-irritating, water resistant adhesive. To protect the nasal septum in the neonate population, place a thin hydrocolloid under the nasal septum, and apply a foam or hydroconductive dressing that is cut in a “T” shape pattern to septum.¹²12. Children’s National Medical Center (CNMC). Nursing practice guideline for skin care 2017. Replacement of the prophylactic dressing should occur if it becomes damaged, displaced, loosened or excessively moist.¹1. National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance (PPPIA). Prevention and treatment of pressure ulcers: Quick reference guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Australia; 2014. Retrieved from http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdfRead Full Text

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Figure 1: Examples of hydrophilic soft silicone foam to mask-skin contact areas (adapted from CNMC)

It is important for the clinician to be attentive during patient assessments and mindful of potential skin related complications with an NIPPV interface for early detection of skin injury. A risk assessment using the Braden Scale should be completed before application of the mask and initiation of NIPPV. An admission skin assessment should be performed and documented to evaluate skin integrity in the location of the mask interface identifying erythema, blanching response, localized heat, edema or induration.¹1. National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance (PPPIA). Prevention and treatment of pressure ulcers: Quick reference guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Australia; 2014. Retrieved from http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdfRead Full Text At least twice a day inspections of skin under and around the interface area exposed to device pressure and shear forces, provides an opportunity to reposition the mask.^1,41. National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance (PPPIA). Prevention and treatment of pressure ulcers: Quick reference guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Australia; 2014. Retrieved from http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdfRead Full Text
4. Haesler, E. Pressure injuries: Preventing medical device related pressure injuries. Wound Practice & Research. 2017; 25(4): 214-216 Many options exist for mask selection requiring skilled decision making and careful attention to individual patient needs. According to Visscher et al, few interface options are available to offset pressure. The mask fit method, however, is used to select masks from available options, to identify the potential areas of increased tissue pressure, and to prevent skin injury.⁵5. Visscher MO,White CC, Jones JM, Cahill T, Jones DC, Pan BS. Face masks for noninvasive ventilation: Fit, excess skin hydration, and pressure ulcers. Respiratory Care 2015; 60(11): 1536-1547.Read Full Text Avoiding an excessively tight fitting interface was found to be the most important strategy to prevent pressure injury.⁷7. Nava S, Navalesi P, & Gregoretti, C. Interfaces and humidification for noninvasive mechanical ventilation. Respiratory Care 2009; 54(1)Read Full Text Individuals with evidence of localized edema should be assessed more often than twice a day to detect first signs of injury.⁴4. Haesler, E. Pressure injuries: Preventing medical device related pressure injuries. Wound Practice & Research. 2017; 25(4): 214-216 It is important to note that monitoring frequency is based upon patient relative risk and should be performed accordingly using clinical judgment and institutional guidelines for optimal prevention strategy implementation.

The composition of prophylactic dressings allow for easy lift for routine skin checks without creating other skin injuries and do not negate the need for thorough and regular skin assessment. The assessment of a pressure injury related to the NIPPV interface should be classified according to level of tissue loss using the International NPUAP classification system.¹1. National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance (PPPIA). Prevention and treatment of pressure ulcers: Quick reference guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Australia; 2014. Retrieved from http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdfRead Full Text Recommended treatment includes mask adjustment or change of the interface to overcome the pressure injury pain experience and ensure successful delivery of ventilatory support.⁶6. Yamaguti W, Moderno E, Yamashita S, Gomes T, Maida A, Kondo C, de Salles I, de Brito C. Treatment-related risk factors for development of skin breakdown in patients with acute respiratory failure undergoing noninvasive ventilation or CPAP. Respiratory Care 2014; 59(10): 1-7Read Full Text Interface rotation between mask and nasal prong interfaces has demonstrated a decrease in skin breakdown in low birth weight neonates requiring CPAP.⁹9. Newnam KM, McGrath JM, Salyer J, Estes T Jallo , Bass WT. A comparative effectiveness study of continuous positive airway pressure-related skin breakdown when using different nasal interfaces in the extremely low birth weight neonate. Applied Nursing Research 2015. 28; 36-41Read Full Text

Pain assessments should be included in the skin assessment and skin integrity must be assessed at the first report of pain under the interface device. It is important to closely monitor skin integrity as tissue damage can increase patient discomfort and reduce tolerance of the interface and success of NIPPV.⁶6. Yamaguti W, Moderno E, Yamashita S, Gomes T, Maida A, Kondo C, de Salles I, de Brito C. Treatment-related risk factors for development of skin breakdown in patients with acute respiratory failure undergoing noninvasive ventilation or CPAP. Respiratory Care 2014; 59(10): 1-7Read Full Text

Skin injury is described as an aggravating factor for patient tolerance of NIPPV.⁶6. Yamaguti W, Moderno E, Yamashita S, Gomes T, Maida A, Kondo C, de Salles I, de Brito C. Treatment-related risk factors for development of skin breakdown in patients with acute respiratory failure undergoing noninvasive ventilation or CPAP. Respiratory Care 2014; 59(10): 1-7Read Full Text Minimization of skin injury is critical to successful implementation of NIPPV respiratory management of the patient. Successful use of NIPPV may be maximized by the ability to provide better patient comfort while reducing skin injury.⁶6. Yamaguti W, Moderno E, Yamashita S, Gomes T, Maida A, Kondo C, de Salles I, de Brito C. Treatment-related risk factors for development of skin breakdown in patients with acute respiratory failure undergoing noninvasive ventilation or CPAP. Respiratory Care 2014; 59(10): 1-7Read Full Text Optimum mask interface fit and the use of materials that normalize skin hydration during wear have shown to significantly reduce skin injury from face masks.⁵5. Visscher MO,White CC, Jones JM, Cahill T, Jones DC, Pan BS. Face masks for noninvasive ventilation: Fit, excess skin hydration, and pressure ulcers. Respiratory Care 2015; 60(11): 1536-1547.Read Full Text Effective clinical application requires complete skin assessment to monitor associated treatment-related risk factors of mask interfaces and implementation of best skin care guidelines for a safer use of this NIPPV modality.⁶6. Yamaguti W, Moderno E, Yamashita S, Gomes T, Maida A, Kondo C, de Salles I, de Brito C. Treatment-related risk factors for development of skin breakdown in patients with acute respiratory failure undergoing noninvasive ventilation or CPAP. Respiratory Care 2014; 59(10): 1-7Read Full Text

References

1. National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance (PPPIA). Prevention and treatment of pressure ulcers: Quick reference guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Australia; 2014. Retrieved from http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdf
2. Agency for Healthcare Quality and Research (AHRQ), Preventing pressure injuries in hospitals, a toolkit for improving quality of care. 2017;Retrieved from www.ahrq.gov
3. National Database of Nursing Quality Indicators (NDNQI). Medical Device Related (MDR) Pressure Injuries. Retrieved from https://members.nursingquality.org/NDNQIPressureUlcerTraining/Default.aspx
4. Haesler, E. Pressure injuries: Preventing medical device related pressure injuries. Wound Practice & Research. 2017; 25(4): 214-216
5. Visscher MO,White CC, Jones JM, Cahill T, Jones DC, Pan BS. Face masks for noninvasive ventilation: Fit, excess skin hydration, and pressure ulcers. Respiratory Care 2015; 60(11): 1536-1547.
6. Yamaguti W, Moderno E, Yamashita S, Gomes T, Maida A, Kondo C, de Salles I, de Brito C. Treatment-related risk factors for development of skin breakdown in patients with acute respiratory failure undergoing noninvasive ventilation or CPAP. Respiratory Care 2014; 59(10): 1-7
7. Nava S, Navalesi P, & Gregoretti, C. Interfaces and humidification for noninvasive mechanical ventilation. Respiratory Care 2009; 54(1)
8. Kiss E, Heiler, M. Pediatric skin integrity practice guideline for institutional use: A quality improvement project. Journal of Pediatric Nursing 2014; 29(4): 362-367
9. Newnam KM, McGrath JM, Salyer J, Estes T Jallo , Bass WT. A comparative effectiveness study of continuous positive airway pressure-related skin breakdown when using different nasal interfaces in the extremely low birth weight neonate. Applied Nursing Research 2015. 28; 36-41
10. Agency for Healthcare Quality and Research (AHRQ).Pressure ulcer toolkit. 2014.https://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/putool7b.html
11. Braden B & Bergstrom N. The Braden Scale for predicating pressure sore risk. 1998; http://www.bradenscale.com/images/bradenscale.pdf
12. Children’s National Medical Center (CNMC). Nursing practice guideline for skin care 2017.

 

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