The use of noninvasive ventilation masks is known to cause damage to facial skin tissue, which affects both the efficacy of the intervention and the patient's quality of life. The use of humidification with noninvasive ventilation is a common practice, but its relative role in the development of facial pressure ulcers has not been fully studied.
METHODS:
A crossover cohort design was used in this study, with 15 healthy volunteers. Each volunteer randomly received both 10 cm H2O of CPAP with and without humidification through an oronasal mask. Skin integrity was evaluated by measuring transepidermal water loss, skin hydration, and skin pH at the bridge of the nose. Device-skin interface conditions (pressure and microclimate) were recorded at the bridge of the nose and both cheeks. The pro-inflammatory cytokine interleukin-1α was collected from the nose bridge before and after CPAP application by using a skin analysis tape. Nasal symptoms were collected by using a validated 6-point score.
RESULTS:
Humidified CPAP significantly increased transepidermal water loss (P < .001) and skin humidity (P = .02) compared with non-humidified CPAP. There were no significant differences in skin hydration, skin pH, skin temperature, and cytokine expression between both conditions. However, there was a trend of increased median ratios of interleukin-1α concentrations in the humidified CPAP. There was a significant increase in the interface pressure at the bridge of the nose after CPAP application (P = .02), with higher interface pressure values at the nose bridge compared with both left (P = .002) and right (P = .003) cheeks. The participants reported elevated nasal discomfort during non-humidified CPAP.
CONCLUSIONS:
These findings indicated that noninvasive ventilation with humidification had a potential disrupting effect on the barrier function of facial skin, associated with changes in skin microclimate and function. Further research is required to establish the cause of mask-related skin damage and to evaluate the effects of mask design, application techniques, and air flow and humidity settings.
CabriniL, EsquinasA, PasinL, NardelliP, FratiE, PintaudiM, et al. An international survey on noninvasive ventilation use for acute respiratory failure in general non-monitored wards. Resp Care, 2015; 60(4):586–592.
PlaisanceP, PirracchioR, BertonC, VicautE, PayenD. A randomized study of out-of-hospital continuous positive airway pressure for acute cardiogenic pulmonary oedema: physiological and clinical effects. Eur Heart J, 2007; 28(23):2895–2901.
4.
PlantPK, OwenJL, ElliottMW. Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomised controlled trial. Lancet, 2000; 355(9219):1931–1935.
HessDR. Noninvasive positive-pressure ventilation and ventilator-associated pneumonia. Respir Care, 2005; 50(7):924–929, discussion 929–931.
7.
TomiiK, SeoR, TachikawaR, HaradaY, MuraseK, KajiR, et al. Impact of noninvasive ventilation (NIV) trial for various types of acute respiratory failure in the emergency department; decreased mortality and use of the ICU. Respir Med, 2009; 103(1):67–73.
8.
VitaccaM, AmbrosinoN, CliniE, PortaR, RampullaC, LaniniB, NavaS. Physiological response to pressure support ventilation delivered before and after extubation in patients not capable of totally spontaneous autonomous breathing. Am J Respir Crit Care, 2001; 164(4):638–641.
9.
AhmadZ, VenusM, KiskuW, RayattSS. A case series of skin necrosis following use of non invasive ventilation pressure masks. Int Wound J, 2013; 10(1):87–90.
10.
RaccaF, AppendiniL, BertaG, BarberisL, VittoneF, GregorettiC, et al. Helmet Ventilation for Acute Respiratory Failure and Nasal Skin Breakdown in Neuromuscular Disorders. Anesth Analg, 2009; 109(1):164–167.
11.
SleilatiFH, StephanHA, NasrMW, RiachyMA. An unusual pressure sore of the nasal bridge. Br J Oral Maxillofac Surg, 2008; 46(5):411–412.
12.
CarronM, FreoU, BaHammamAS, DellwegD, GuarracinoF, CosentiniR, et al. Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials. Brit J Anaesth, 2013; 110(6):896–914.
13.
National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. In: HaeslerE. editor. Prevention and treatment of pressure ulcers: quick reference guide. Perth, Australia: Cambridge Media; 2014.
14.
ColemanS, NixonJ, KeenJ, WilsonL, McGinnisE, DealeyC, et al. A new pressure ulcer conceptual framework. J Adv Nurs, 2014; 70(10):2222–2234.
15.
GoreckiC, BrownJM, NelsonEA, BriggsM, SchoonhovenL, DealeyC, et al. European Quality of Life Pressure Ulcer Project group. Impact of pressure ulcers on quality of life in older patients: a systematic review. J Am Geriatr Soc, 2009; 57(7):1175–1183.
16.
BlackJM, CuddiganJE, WalkoMA, DidierLA, LanderMJ, KelpeMR. Medical device related pressure ulcers in hospitalized patients. Int Wound J, 2010; 7(5):358–365.
17.
DellwegD, HochrainerD, KlaukeM, KerlJ, EigerG, KohlerD. Determinants of skin contact pressure formation during non-invasive ventilation. J Biomech, 2010; 43(4):652–657.
18.
MuncktonK, HoKM, DobbGJ, Das-GuptaM, WebbSA. The pressure effects of facemasks during noninvasive ventilation: a volunteer study. Anaesthesia, 2007; 62(11):1126–1131.
19.
SchettinoGP, TucciMR, SousaR, Valente BarbasCS, Passos AmatoMB, CarvalhoCR. Mask mechanics and leak dynamics during noninvasive pressure support ventilation: a bench study. Intensive Care Med, 2001; 27(12):1887–1891.
20.
WorsleyPR, PruddenG, GowerG, BaderDL. Investigating the effects of strap tension during non-invasive ventilation mask application: a combined biomechanical and biomarker approach. Med Devices (Auckl), 2016; 9:409–417.
21.
Esquinas RodriguezAM, ScalaR, SorokskyA, BaHammamA, de KlerkA, ValipourA, et al. Clinical review: humidifiers during non-invasive ventilation–key topics and practical implications. Crit Care, 2012; 16(1):203.
22.
GefenA. How do microclimate factors affect the risk for superficial pressure ulcers: A mathematical modeling study. J Tissue Viability, 2011; 20(3):81–88.
23.
RegerSI, RanganathanVK, SahgalV. Support surface interface pressure, microenvironment, and the prevalence of pressure ulcers: an analysis of the literature. Ostomy Wound Manage, 2007; 53(10):50–58.
24.
Royal College of Physicians, British Thoracic Society, Intensive Care Society. Chronic obstructive pulmonary disease: non-invasive ventilation with bi-phasic positive airways pressure in the management of patients with actute type 2 respiratory failure. Concise Guidance to Good Practice series, No 11. London: RCP, 2008.
25.
CrimiC, NotoA, PrinciP, EsquinasA, NavaS. A European survey of noninvasive ventilation practices. Eur Respir J, 2010; 36(2):362–369.
26.
FluhrJW, FeingoldKR, EliasPM. Transepidermal water loss reflects permeability barrier status: validation in human and rodent in vivo and ex vivo models. Exp Dermatol, 2006; 15(7):483–492.
AitkenRC. Measurement of feelings using visual analogue scales. Proc R Soc Med, 1969; 62(10):989–993.
30.
HurstJR, WilkinsonTM, PereraWR, DonaldsonGC, WedzichaJA. Relationships among bacteria, upper airway, lower airway, and systemic inflammation in COPD. Chest, 2005; 127(4):1219–1226.
31.
PerkinsMA, OsterhuesMA, FarageMA, RobinsonMK. A noninvasive method to assess skin irritation and compromised skin conditions using simple tape adsorption of molecular markers of inflammation. Skin Res Technol, 2001; 7(4):227–237.
32.
MeduriGU, Abou-ShalaN, FoxRC, JonesCB, LeeperKV, WunderinkRG. Noninvasive face mask mechanical ventilation in patients with acute hypercapnic respiratory failure. Chest, 1991; 100(2):445–454.
33.
CornelissenLH, BronnebergD, BaderDL, BaaijensFP, OomensCW. The transport profile of cytokines in epidermal equivalents subjected to mechanical loading. Ann Biomed Eng, 2009; 37(5):1007–1018.
34.
Angelova-FischerI, WutheD, ZillikensD, KahleB. Noninvasive bioengineering assessment of the skin barrier function in patients with chronic venous insufficiency. Br J Dermatol, 2010; 162(5):1071–1075.
35.
PedersenL, JemecGB. Mechanical properties and barrier function of healthy human skin. Acta Derm Venereol, 2006; 86(4):308–311.
36.
MarksR, BlackD. Methodologies to produce and assess standardized trauma to the skin. Am J Ind Med, 1985; 8(4–5):491–498.
37.
FartaschM, TaegerD, BrodingHC, SchöneweisS, GellertB, PohrtU, BrüningT. Evidence of increased skin irritation after wet work: impact of water exposure and occlusion. Contact Dermatitis, 2012; 67(4):217–228.
38.
VisscherMO, WhiteCC, JonesJM, CahillT, JonesDC, PanBS. Face Masks for Noninvasive Ventilation: Fit, Excess Skin Hydration, and Pressure Ulcers Respir Care. 2015; 60(11):1536–1547.
39.
YusufS, OkuwaM, ShigetaY, DaiM, IuchiT, RahmanS, et al. Microclimate and development of pressure ulcers and superficial skin changes. Int Wound J, 2015; 12(1):40–46.
40.
GerhardtLC, SträssleV, LenzA, SpencerND, DerlerS. Influence of epidermal hydration on the friction of human skin against textiles. J R Soc Interface, 2008; 5(28):1317–1328.
41.
BrienzaDM, GeyerMJ. Using support surfaces to manage tissue integrity. Adv Skin Wound Care, 2005; 18(3):151–157.
42.
International review. Pressure ulcer prevention: pressure, shear, friction and microclimate in context. A consensus document. London: Wounds International, Wounds International Pressure Ulcer Prevention, 2010. http://www.woundsinternational.com/media/issues/300/files/content_8925.pdf. Accessed November 19, 2016.
43.
KokateJY, LelandKJ, HeldAM, HansenGL, KveenGL, JohnsonBA, et al. Temperature-modulated pressure ulcers: a porcine model. Arch Phys Med Rehabil, 1995; 76(7):666–673.
44.
BronnebergD, SpiekstraSW, CornelissenLH, OomensCW, GibbsS, BaaijensFP, BoutenCV. Cytokine and chemokine release upon prolonged mechanical loading of the epidermis. Exp Dermatol, 2007; 16(7):567–573.
45.
AlahmariMD, SapsfordRJ, WedzichaJA, HurstJR. Dose response of continuous positive airway pressure on nasal symptoms, obstruction and inflammation in vivo and in vitro. Eur Respir J, 2012; 40(5):1180–1190.
46.
WengMH. The effect of protective treatment in reducing pressure ulcers for non-invasive ventilation patients. Intensive Crit Care Nurs, 2008; 24(5):295–299.
