Elsevier

Applied Nursing Research

Volume 28, Issue 1, February 2015, Pages 36-41
Applied Nursing Research

Original Article
A comparative effectiveness study of continuous positive airway pressure-related skin breakdown when using different nasal interfaces in the extremely low birth weight neonate

https://doi.org/10.1016/j.apnr.2014.05.005Get rights and content

Abstract

A three group prospective randomized experimental design was conducted to identify differences in frequency and severity of nasal injuries when comparing various interfaces used during continuous positive airway pressure (CPAP) and identified risk factors associated with injury. Seventy-eight neonates < 1500 g were randomized into three groups: continuous nasal prongs; continuous nasal mask; or alternating mask/prongs. Repeated measures ANOVA with Bonferroni correction demonstrated that significantly less skin injury was detected in the rotation interface group when compared to both mask and prong groups. In the final stepwise regression model (F = 11.51; R2 = 0.221; p = 0.006) significant predictors of skin injury included number of days on nasal CPAP (p < 0.001) and current mean post menstrual age (p = 0. 006). Reduced nasal injury was demonstrated using rotating mask/prong nasal interfaces. Future best practices must include precise selection of device size, developmental and CPAP device positioning with focused skin assessment including rapid intervention for skin injury.

Introduction

The use of nasal continuous positive airway pressure (CPAP) is the standard for care of preterm infants with respiratory distress syndrome (RDS) (Davis et al., 2009, Verder, 2007, Verder et al., 2009). Various nasal interfaces are currently available to provide neonatal CPAP yet few studies have compared the effectiveness of these devices to determine efficacy, tolerance and measure differences in the incidence and/or the severity of nasal skin breakdown—a well described side effect of this useful treatment (Ramanathan, 2010, Rego and Martinez, 2002, Yong et al., 2005).

Section snippets

Background

Following an integrative review of 113 articles related to the use of nasal CPAP for preterm infants, only two randomized controlled trials (RCTs) included comparisons of nasal interfaces to determine the frequency of skin breakdown or nasal trauma (Rego and Martinez, 2002, Yong et al., 2005). Rego and Martinez evaluated the performance of two types of nasal prongs—Argyle™ and Hudson™—used to deliver nasal CPAP to preterm infants. Although both were found to be equally effective in the delivery

Research design and methodology

A three group prospective randomized experimental study design was conducted in a 70 bed level III neonatal intensive care unit (NICU) in the southeastern United States. The study was approved by the Institutional Review Board (IRB), and parents provided informed consent for infant participation. A flow diagram describes the process of screening through completion of data collection following Consolidated Standards of Reporting Trials (CONSORT) guidelines (see Fig. 1). Each infant admitted to

Results

A total of 377 admissions to the NICU were screened for eligibility during the study period. Of these, 140 patients met BW criteria of 500–1500 g. Two patients were diagnosed with airway deformities that compromised their ability to successfully extubate to nasal CPAP and were eliminated. Parental consent was obtained on 90 infants (65%). Two parents refused study participation for their infant (1%). Fourteen (10%) expired prior to obtaining study consent and 32 (23%) were missed. Typically

Discussion

This study was conducted to determine differences in nasal injuries when comparing different nasal CPAP interfaces (prongs/mask/rotation) used to treat RDS in the preterm neonate < 1500 g. Additionally, we wanted to identify risk factors associated with skin breakdown during nasal CPAP administration. The incidence of skin breakdown reported in the literature associated with nasal CPAP in the neonate was 20 to 60% (Fischer et al., 2010). This study demonstrated an overall skin breakdown rate of

Conclusions and recommendations

Early use of nasal CPAP at the time of delivery or as respiratory support following early extubation has shown merit in improving neonatal outcomes and preventing chronic lung disease. Overall, CPAP use has increased dramatically throughout NICUs across both the United States and developed nations (Jatana et al., 2010, Verder, 2007). This study examined differences in the frequency, severity and specific types of nasal injuries described when comparing different CPAP interfaces

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      A limitation to this study was the NSCS tool that was used; other criteria for observing the skin which are more specific to the use of nCPAP were observed but were not measurable with the use of NSCS, such as, indentations and pressure on the skin (Newman et al., 2014). Another limitation to this study which could have potentially impacted the results, were the sample sizes and unequal grouping; power analysis confirmed the need for at least 24 infants in each group, which was not achieved in the nasal prong group, or rotational group (Newman et al., 2014). Power analysis is a planning tool which is used to determine outcomes such as the number of participants that need to be included in the study (Murphy et al., 2014).

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    The authors have no conflict of interest to report.

    All authors have seen and approved the manuscript.

    There are no funding sources or non-author contributions to be acknowledged.

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