To the Editor:
We read with interest the paper by Fisher et al1 regarding the methods for securing endotracheal tubes. The authors should be congratulated for a carefully performed experiment in a model of the head and upper airway. We noted the increase in pressure exerted by the commercially available devices, which the authors reported as not clinically important. Although the authors used an elaborate model for simulating the patient and patient movements, the impact of the pressure on skin integrity could not be truly appreciated.
In recent months, with the increase in the use of prone positioning following publication of the PROSEVA study,2 we have noted that the use of these commercially available devices can be associated with significant facial ulceration. Skin breakdown and pressure ulcers on the forehead, chin, abdomen, and extremities have been reported to occur more frequently in patients placed in the prone position.3,4 This is largely due to body areas with little subcutaneous tissue and pressure: bone and skin versus the bed surface. The tops of the feet, knees, and elbows also seem to be commonly involved.
The authors did not test devices in the prone position, and the model likely could not approximate the changes in facial edema associated with this position. Facial edema is a common experience with the prone position and often leads to a return to the supine position, secondary to concern of the family and staff. Similarly, it is likely that manufacturers have not considered the use of these devices in the prone position and how, with time, facial edema probably significantly changes the pressure profile.
We observed significant facial ulcers in 3 patients using the Hollister device in the prone position. In all 3 cases, the ulcers required treatment. The first patient was an obese pregnant woman with severe ARDS and suspected H1N1 influenza. She was transferred from another hospital, where she had been managed for 6 d. She developed skin ulcers on both cheekbones after 3 d of prone positioning (Fig. 1). The second patient developed ARDS following intra-abdominal sepsis and aspiration pneumonia. He had a normal body habitus and developed ulcers after 4 d of prone positioning. In this case, the skin ulcers were similar to the first case (Fig. 2). The third patient was an 84-y-old man with esophageal cancer who underwent an esophagectomy. He aspirated on day 4 postoperatively and developed severe ARDS (PaO2/FIO2 < 80 mm Hg). After < 36 h of prone positioning, he developed an ulcer on the left side of his face that mimicked the outline of the Hollister endotracheal tube holder. This patient had poor nutritional status and cancer cachexia, predisposing him to skin integrity issues (Fig. 3).
Pressure ulcer at the edge of the endotracheal tube holder in patient 1.
Pressure ulcer at the edge of the endotracheal tube holder in patient 2.
Pressure ulcer appearing to reflect the shape of the endotracheal tube holder in patient 3.
Others have noted similar issues, and Jackson et al5 proposed specific padding of the head and face to reduce ulcers during prone positioning. Therapists should be cognizant of the potential for these types of facial ulcers (usually associated with mask ventilation), which have been identified by Medicare as avoidable complications.6
Facial edema associated with the prone position clearly increases the risk of airway complications regardless of the method of tube fixation. Clinicians should be vigilant to maintain airway position and prevent skin breakdown. The data obtained by Fisher et al1 and our observations urge extreme caution during use of commercially available tube-fixation devices for patients placed in the prone position.
Footnotes
The authors have disclosed no conflicts of interest.
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