Avoiding pressure injuries from NIV masks

A pressure injury is defined as "localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer . . . [and] occurs as a result of intense and/or prolonged pressure or pressure in combination with shear" (Edsberg et al., 2016).

In order to protect your patient’s skin, you can reduce the risk of pressure injuries (also known as pressure ulcers) during noninvasive ventilation by carefully selecting a suitable NIV mask and by taking precautionary steps.
 

These injuries can occur as a result of pressure on the skin over a bony prominence. Patients receiving respiratory support using a mask may develop pressure ulcers on different parts of the face, including the forehead, cheeks, chin, and bridge of the nose, where they are most common.

There are various reasons why a patient may develop pressure injuries: 

• Incorrect positioning or size of the mask 
• Skin inspections not thorough or frequent enough
• Incorrect placement or removal of the mask
• Insufficient mask seal
• Over-tightening of the mask straps
• Increased inspiratory pressure or air volume in the mask
• Poor patient compliance with the interface
• The patient’s inability to sense the device and associated pressure on their skin due to sedation, encephalopathy or neurologic disease
• The patient’s inability to reposition themselves
• The duration of device use
• The patient’s latex allergy (occasionally results in florid skin reactions; some patients seem especially prone to mask-related rash even in the absence of allergy)

Severe patient discomfort can be prevented by spotting a pressure injury early in its development. 

Firstly, the patient’s facial anatomy should be assessed. Does the patient have any facial anomalies? Which mask configuration is better suited to the treatment and will promote greater breathing comfort? It is important to select the most suitable size and type of mask for the individual patient. This not only helps prevent leakage, it can also guard against possible pressure injuries. 

During the treatment, the patient’s skin should be kept clean and dry to help reduce friction from the mask. It is crucial to examine the placement of patient’s mask regularly for early signs of pressure points. If there is skin irritation, hydration and moistening of the affected area can speed up the recovery. If the patient can tolerate a break from the oxygen, stop the therapy for 10 minutes. It is also advisable to either reposition the mask or change to a different mask configuration at regular intervals. A different mask configuration  will relieve the pressure from the previous mask and let the wounds heal. It is important to check regularly for the signs: 

• Assess the facial anatomy
• Determine the most suitable mask size and configuration for breathing comfort and treatment type
• Regularly inspect the skin for early signs of pressure points
• Routinely reposition the mask 
• Rotate different mask types throughout the treatment

Commonly used types of masks are nasal, full face, or helmet masks. Hamilton Medical offers a wide range of interfaces in different configurations and sizes. 

Full citations below: (Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System. J Wound Ostomy Continence Nurs. 2016;43(6):585-597. doi:10.1097/WON.00000000000002811​, Lam UN, Md Mydin Siddik NSF, Mohd Yussof SJ, Ibrahim S. N95 respirator associated pressure ulcer amongst COVID-19 health care workers. Int Wound J. 2020;17(5):1525-1527. doi:10.1111/iwj.133982​, Gefen A, Alves P, Ciprandi G, et al. Device-related pressure ulcers: SECURE prevention. J Wound Care. 2020;29(Sup2a):S1-S52. doi:10.12968/jowc.2020.29.Sup2a.S13​, Visscher MO, White CC, Jones JM, Cahill T, Jones DC, Pan BS. Face Masks for Noninvasive Ventilation: Fit, Excess Skin Hydration, and Pressure Ulcers. Respir Care. 2015;60(11):1536-1547. doi:10.4187/respcare.040364​, Alqahtani JS, AlAhmari MD. Evidence based synthesis for prevention of noninvasive ventilation related facial pressure ulcers. Saudi Med J. 2018;39(5):443-452. doi:10.15537/smj.2018.5.220585​, Black J, Kalowes P. Medical device-related pressure ulcers. Chronic Wound Care Management and Research 2016:3 91–99.6​, Ashcroft H, Moore M. Preventing Pressure Sores whilst using NIV masks. Aintree University Hospital NHS Foundation Trust January 20167​)