Nasal Injury with Continuous Positive Airway Pressure: Need for “Privileging” Nursing Staff

Abstract

Objectives Use of continuous positive airway pressure (CPAP) in neonates is associated with nasal injury (NI) for which various risk factors related to the neonatal characteristics and properties of interfaces used have been reported. BPrivileging^of nursing staff may influence safety and incidence of adverse events. In this prospective cohort study, authors studied the incidence of NI and risk factors for NI in babies requiring CPAP after privileging staff for CPAP care bundles. Methods All neonates on CPAP over a 6-mo period were included. Standard operating procedures were formulated and staff of NICU (nurses and doctors) were educated at the start of the study and periodically in 6 comprehensive areas of careencompassing position of head, prongs and cap; nasal suctioning and interruptions in pressure on the nose. The staff who completed the training and evaluation were declared as Bprivileged^. NI (measured by a standard staging) and risk factors were predefined and studied. Results Of the 51 babies who required respiratory supports, 35 required CPAP care. Nine babies (25%) out of 35 who required CPAP had NI (2, 4, 3 babies had stages 1, II and III of NI respectively). Seventy seven percent of babies were cared for by privileged nurses. NI was significantly higher when cared for by non-privileged staff (66% vs. 11%, unadjusted RR = 6.75, 95%CI 2.16-21.09). All other risk factors were not significant. Conclusions NI was noted in 25% neonates on CPAP, and those cared for by non-privileged staff had higher chances of NI. Quality processes and emphasis on continued monitoring and evaluation of nursing skills may help prevent these untoward complications.

Noninvasive Respiratory Support in Neonates: A Review of Current Evidence and Practices

“…The maintenance of noninvasive respiratory support equipment and appropriate cleaning has to be done on a regular basis. The training of nurses for managing neonates on noninvasive support decreases the incidence of nasal trauma [ 37 ]. Quality improvement measures like using a nCPAP cart, prepacked fixation kits, a written nursing protocol, ensuring adherence to manufacturers recommendations and evidence-based checklists are effective measures to expedite nCPAP initiation and decrease nasal trauma [ 38 , 39 ].…”

Evaluating the Effectiveness of Brief Training for Neonatal Intensive Care Nurses on the Prevention of Medical Device-Related Nasal Pressure Injury

“…18,22 However, several studies have evaluated changes in the frequency of nasal injuries after nurses receive NIV-related nasal injury prevention training. 8,12,21 Naha et al 8 reported that the frequency of nasal injuries was 11% among infants in the care of nurses who received training and 66% among those cared for by nurses who did not receive training. Mariam and Buddhavarapu 21 developed a nasal continuous positive-airway pressure (nCPAP) checklist and a quality improvement initiative related to the implementation of the checklist.…”

“…The researchers developed this form based on the literature to evaluate nurses' level of knowledge about evidence-based interventions to protect preterm infants from nasal MDRPI. 8,21,[28][29][30] The form consists of 40 questions in five sections: neonatal skin structure, medical device injury, skin assessment tools, NIV injury, and NIV injury prevention interventions. The nurses were asked to agree or disagree with the statement given in each item.…”

“…4,8,9 Because preterm infants' skin is thin, permeable, and sensitive, their skin integrity is easily disrupted by shear. 8,10,11 Underdevelopment of the nasal tissue further increases the risk of developing medical device-related pressure injuries (MDRPIs) even with short-term NIV. 9,[11][12][13][14][15] It has been reported that 20% to 60% of nasal pressure injuries (PIs) in preterm infants treated in neonatal ICUs (NICUs) are a result of shear from medical devices and equipment.…”

“…Although NIV has many benefits for the infant, it can also cause complications 7 . Nasal injury is the most common preventable complication of NIV 4,8,9 . Because preterm infants’ skin is thin, permeable, and sensitive, their skin integrity is easily disrupted by shear 8,10,11 .…”