Prevention of skin injuries associated with non-invasive mechanical ventilation

Dear Editor,

In volume 28 of Enfermería Intensiva (January–March 2017) recommendations by experts were published on the “Prevention and treatment of skin injuries associated with non-invasive mechanical ventilation”.¹ The guide that it contains to improve the quality and utility of care in intensive and coronary units as well as in other department is highly interesting. There can be no doubt that non-invasive mechanical ventilation (NIMV) is a procedure that is used increasingly and which has been shown to be effective in the initial treatment of acute respiratory failure.¹ Achieving a correct adaptation of the procedure increases the tolerability of the treatment together with adherence to it, thereby reducing morbimortality; it is here that the work of the nurse is of key importance.²

To concentrate on the skin, the pressures exerted by the interface as well as the flow and constant leaks intrinsic to NIMV create a high risk of deterioration of skin integrity. The correct management of the interface to ensure patient comfort is therefore associated with the success of NIMV.^1,2

Within the context of the doctoral thesis “Nursing care in critical patients with non-invasive mechanical ventilation”² a clinical trial was undertaken in Spain³ that was published in March 2017. This 4-arm study analyses the prevention of facial ulcers in patients with NIMV—under acute treatment—in a high dependency unit belonging to the Emergency and Critical Care Department of the Hospital General Universitario Gregorio Marañón, Madrid, Spain. Always using an oronasal interface, this randomised clinical trial analyses the deterioration of facial skin. It compares direct application to the application of an ultrafine adhesive polyurethane foam dressing (ATD), an adhesive multiple layer hydrocellular foam dressing (AFD) and the application of hyperoxygenated fatty acids (HOFA). The results obtained (No. = 152), with the application of an average of 14.48 h of NIMV and a score on the NORTON scale of 10.69, show that the HOFA achieve the best prevention of skin deterioration and the appearance of sores.³

The paper published in your journal¹ concludes that the zones exposed to pressure and friction must be protected by polyurethane foam dressings and silicon adhesive, or hydrocoloid dressings when the only risk is friction. Nevertheless, the results of the randomised clinical trial show that the application of HOFA every 4–6 h reduces the incidence of facial sores. In fact it would only be necessary to treat 5 patients to see the effect of HOFA (NNT = 4.76) in the 4 arms analysed.

Considering that this update may be highly interesting for intensive care and coronary unit nurses; and acknowledging the quality of the published study (although subject to the principle of causality,⁴ as the review took place up to August 2016), we would be grateful if this contribution is considered with the aim of adding to knowledge, being of use in improving care and also generating new lines of research that increase the degree of evidence for our procedures.