Nasal trauma due to NCPAP

Fischer C, Bertelle V, Hohlfeld J et al. Nasal trauma due to continuous positive airway pressure in neonates. Arch Dis Child Fetal and Neonatal Ed 2010 June 28. [Epub ahead of print]. Abstract, PDF

Objective To evaluate the incidence and severity of nasal trauma secondary to nasal continuous positive airway pressure (nCPAP) in neonates.

Results 989 neonates were enrolled. Mean gestational age was 34 weeks (SD 4), mean birth weight 2142 g (SD 840). Nasal trauma was reported in 420 (42.5%) patients and it was of stage I, II and III in 371 (88.3%), 46 (11%) and 3 (0.7%) patients, respectively. Incidence and severity of trauma were inversely correlated with gestational age and birth weight. The risk of nasal trauma was greater in neonates <32 weeks of gestational age (OR 2.48, 95% CI 1.59 to 3.86), weighing <1500 g at birth (OR 2.28, 95% CI 1.43 to 3.64), treated >5 days by nCPAP (OR 5.36, 95% CI 3.82 to 7.52), or staying >14 days in the NICU (OR 1.67, 95% CI 1.22 to 2.28). Most cases of nasal trauma (90%) appeared during the first 6 days of nCPAP. Persistent visible scars were present in two cases.

Conclusions Nasal trauma is a frequent complication of nCPAP, especially in preterm neonates, but long-term cosmetic sequelae are very rare. This study provides a description of nasal trauma and proposes a simple staging system. This could serve as a basis to develop strategies of prevention and treatment of this iatrogenic event.

Nasal CPAP has become a mainstay in the management of preterm infants in our NICUs. Encouraged by the results of several recent large RCTs examining approaches to the initial respiratory management of preterm infants, more and more infants are being started on NCPAP shortly after birth and being maintained on it for long periods. This report from Switzerland describes a classification system for nasal trauma from NCPAP, the incidence of the various types in their centre and risk factors for occurence. Some degree of trauma/irritation was detected in almost 50% of infants on CPAP with ulceration in 11% but permanent damage in only 0.7%. Not surprisingly, the main risk factors were low GA, small size and long CPAP duration.

Should the incidence of nasal trauma become one of our NICU Quality Indicators? The authors of this paper propose a standarized system to classify nasal trauma that could be used to track performance over time and/or benchmark with other NICUs. Reporting #lesions/1000 CPAP days would be a great way to report the data in a meaningful way. This is not a trivial problem - the occurence of a significant erosion in a baby causes considerable angst amongst parents and health care providers as well as sometimes necessitates a switch to a less effective or more invasive system for respiratory support. Permanent scarring with the need for plastic surgery can occur.

As part of the training package for the recently completed VON Delivery Room Management Trial, Rose de Klerk put together a short presentation on how to manage babies on bubble NCPAP that includes a section on avoiding nasal septal injury (link here). There is a good recent review article written by our own Amanda Squires (NNP) and Marilyn Hyndman (RRT) about the the subject (link to PDF). I also uploaded to NICQPedia a powerpoint presentation created by Maureen Luther (PT) and the aforementioned Marilyn Hyndman called "Spare the Nares" (link here). Many strategies have been applied to reduce the incidence of this complication including meticulous securing and positioning, regular inspection of the septum and nose, use of hydrocolloid dressings and alternating between nasal prongs and mask for the CPAP interface. Prevention should be possible but cases continue to occur.

Several questions may be posed regarding this complication. I would be interested to hear from you.

Good commentary and reference links on this post Mike. The related NICQpedia article pages should have information about this hazard and the controls necessary to reduce the risks. I wonder if this has been discussed among the centers in the Respiratory Topic Group?

Jim Handyside
jim@improvisionhealthcare.com

Mike, thanks for bring up this great topic for discussion.

In response to your question #5 (should nasal erosion from CPAP be considered a medical error): At least, we need to think of this condition as a preventable hospital acquired condition. This is the same category as bed sores in the adult population. It is no more a complication of CPAP use than bed sores are a complication of using beds. In the US, the Center for Medicare and Medicaid Services considers these conditions "Never Events" and is no longer paying the hospital for the care associated with their treatment. Don't be surprised if nasal erosion from CPAP shows up on a future CMS "never event" list.

Andy Kairalla
ABKair@aol.com

Fri, Jul 2 2010 8:37 PM

Further on Question 5... Perhaps it should be recognized as a hazard rather than either of the two choices. This places the emphasis on management of the risk with hazard control measures. Might use of the term "just a complication" imply that it is not manageable or preventable? One team has approached this issue using the hazard management framework - see Hackensack's hazard management worksheet on "Skin breakdown / nasal septum erosion due to pressure from CPAP prongs in chapter 2 of the NICQ 2007 ebook here: www.vtoxford.org/.../ebook.aspx. In their work they reduced the probability of injury using revised control measures cited on the worksheet.

Jim Handyside
jim@improvisionhealthcare.com