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.

Staff education

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).^[1] 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.^[2] 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.^[3] Initial and ongoing education on pressure injury prevention and management should exist for both nursing and non-nursing staff.^[10]

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.^[3]

Standardized Practice

A lack of standardization in skin-care practice and documentation has shown to contribute to inconsistencies in care of patients.^[8] 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”.^[1] 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.^[4] 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.^[1] 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.^[4] 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.^[2,4]
Removal of the device as soon as medically feasible is critical to minimizing the skin damage.^[1]

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:^[3]

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.

Patient Risk Assessment

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.^[1,6]
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.^[1] 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.^[11] 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.

Proper mask sizing and fitting

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^[5,7] 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.^[5] Avoiding an excessively tight fitting interface was found to be the most important strategy to prevent pressure injury.^[7] To ensure enough space exists between the mask and the skin, it is recommended that 2 fingers can pass beneath the headgear.^[7] The small amount of air leak that may occur is acceptable and should not affect the interaction between the patient and ventilation mode.^[7]

Proper selection of the interface size is essential in achieving best clinical results as patient facial anatomy differs dramatically.^[7] Overall, individualization of fit is a key component and critical in providing the correct fit for successful delivery of effective ventilation.^[7]

Skin care product

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.^[1] 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.^[12] Replacement of the prophylactic dressing should occur if it becomes damaged, displaced, loosened or excessively moist.^[1]

Patient Monitoring

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.^[1] 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.^[1,4]
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.^[5] Avoiding an excessively tight fitting interface was found to be the most important strategy to prevent pressure injury.^[7] Individuals with evidence of localized edema should be assessed more often than twice a day to detect first signs of injury.^[4] 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.

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.^[1] 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.^[1,4]
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.^[5] Avoiding an excessively tight fitting interface was found to be the most important strategy to prevent pressure injury.^[7] Individuals with evidence of localized edema should be assessed more often than twice a day to detect first signs of injury.^[4] 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.^[1] Recommended treatment includes mask adjustment or change of the interface to overcome the pressure injury pain experience and ensure successful delivery of ventilatory support.^[6] Interface rotation between mask and nasal prong interfaces has demonstrated a decrease in skin breakdown in low birth weight neonates requiring CPAP.^[9]

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.^[6]

Skin injury is described as an aggravating factor for patient tolerance of NIPPV.^[6] 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.^[6] 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.^[5] 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.^[6]

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