Internal trauma to the lungs is not the only morbidity threat to critical care patients; these patients also face the potential of external injuries due to respiratory device-related pressure injury and pressure ulcers. 

By Bill Pruitt, MBA, RRT, CPFT, FAARC

Internal trauma to the lungs is not the only morbidity threat to critical care patients; these patients also face the potential of external injuries due to device-related pressure injury and pressure ulcers. The need to maintain tight securements for artificial airways like endotracheal tubes, noninvasive ventilation interfaces, and even oxygen masks can lead to pressure injuries from the securement device, including lip and facial ulcers. 

This article will discuss best practices for reducing and preventing respiratory device-related pressure injury (RDRPI) and how advancements in securement technology have improved outcomes for patients.

Pressure injury/ulcers (also referred to as decubitus ulcers) are the result of prolonged pressure on the skin or mucosal tissues that reduces or stops blood flow in the capillary bed leading to tissue damage (ischemia or infarction). Friction and shear caused by movement of the patient, device or interface can also contribute to skin or mucosal damage. (Friction and shear are more related to the formation of bedsores but can also be a consideration in dealing with respiratory devices).

Devices such as endotracheal and tracheostomy tubes, masks used for noninvasive ventilation (CPAP or BiPAP), high-flow nasal cannulas (and regular cannulas), or oxygen masks need to be held in place and secured to effectively provide the needed therapy (ventilation, positive pressure support, and/or oxygen therapy). 

As the level of support increases, the need for continuous application increases, as well as an increase in pressure or flow to be effective. These factors carry an increased risk of pressure injury/ulcers. The mouth, lips, face, forehead, bridge of the nose, nares, and the skin fold where the ears meet the side of the head are areas that can be harmed by improperly secured (or inadequately monitored/maintained) devices and interfaces.

RDRPIs develop due to several issues.1 These include:

  • Devices secured too tightly that causes poor circulation, friction, or shear
  • Prolonged exposure to pressure
  • Perspiration, secretions, or moisture under the device or device holder which makes the skin softer and reduces skin integrity
  • Lack of awareness by the staff of preventive measures and protocols to reduce RDRPI
  • Failure to perform routine assessment of the skin and devices to check for signs of ischemia/infarction

Added to these risk factors, ICU patients have additional risk factors that can contribute to a RDRPI: they have decreased awareness of their environment and their condition, have less mobility, often have malnutrition, are generally older patients, are receiving sedatives, paralytics, or muscle relaxers, have hypotension being treated with inotropes/vasopressors, have poor oxygenation, and tend to have tissue edema.2

The assessment of risk for pressure injury is often performed using the Braden scale, which provides a score from 1-to-4 in six areas. A score of 1 is linked to the highest risk, and a score of 4 is linked to the lowest risk.

At the conclusion of the assessment, scores are totaled and labeled as:

  • Mild risk (15-18 score)
  • Moderate risk (13-14 score)
  • High risk (10-12 score), or
  • Severe risk (score less than 9).3

The six scored areas are: 

  1. Sensory perception (able to respond meaningfully to pressure-related discomfort)
  2. Moisture (the degree that skin is exposed to moisture)
  3. Activity (how much physical activity is the patient undertaking)
  4. Mobility (how able or limited is the patient to change and control their body position)
  5. Nutrition (how much nutrition is being consumed and how is it being given – either in terms of actual meals or use of IV or total parenteral nutrition)
  6. Friction and shear (assessing factors that might contribute to issues with friction/shear forces)*
    • *This area relates mostly to the issue of bedsores

Reducing and Preventing RDRPI

There are several strategies to consider that can reduce and prevent RDRPI. These include the use of care bundles, guidelines, and protocols, use of protective dressings or cushions, use of specially designed equipment, appropriately sized devices, increased knowledge, training, and awareness for staff, and assessment of the compliance with strategies being used.4 A multidisciplinary approach should be used in reducing and preventing RDRPI, including nursing, respiratory therapy staff, ostomy and wound nursing specialists, and physicians.

Education is needed to provide background information (ie, assessment of risk, stages of injury), the steps/protocols to use, how/when tissue assessment should be performed, explanation and training in use of special devices or dressings, what documentation is needed, and how compliance with the strategies will be performed and reported. Often, respiratory therapists help train the nursing staff on how to release and reattach the straps on CPAP/BiPAP interfaces and how to release and reattach the endotracheal tube holders. It is helpful for skin assessment to be performed by one (or a few) trained staff member(s) to help ensure consistency in assessment and reduce variations.4 

Injury Staging System

The National Pressure Injury Advisory Panel (NPIAP) has produced an Injury Staging System to help categorize the extent of pressure injury to the tissues. These include:5

  • Stage 1 Pressure Injury: Non-blanchable erythema of intact skin;
  • Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis;
  • Stage 3 Pressure Injury: Full-thickness skin loss;
  • Stage 4 Pressure Injury: Full-thickness skin and tissue loss;
  • Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss;
  • Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon, or purple discoloration.5

Recommendations for Reducing RDRPI

The Joint Commission5 has designated pressure injuries to be a preventable issue and recommends four areas to be addressed in preventing and reducing pressure injuries. All four are applicable in addressing RDRPI. 

1) Skin

The skin should be inspected upon admission and then daily to look for signs of pressure injury. Pressure points, temperature, and the skin beneath the medical device should be assessed. Skin should be kept clean and dry. Positioning should include consideration of increasing the risk of a pressure injury (ie positioning the head and ventilator tubing to avoid pulling on an endotracheal tube).5

2) Nutrition

Patients should be assessed for malnutrition. Patients who are at risk should be referred to a registered dietitian or nutritionist. The patient’s weight and intake should be assessed regularly and supplemental nutrition should be provided as indicated.5

3) Positioning and Mobilization

At-risk patients should be turned and repositioned on a scheduled frequency. Regarding RDRPI, this includes repositioning the endotracheal tube from one side of the mouth to the other—this often occurs every two to four hours and the frequency should be covered by a policy.5

CPAP/BiPAP straps and nasal cannulas should be regularly repositioned (if possible) to change or rotate possible pressure points. Repositioning allows for an opportunity to assess the skin beneath the straps and at points where the device may be pressing on the skin or mucosa. Ventilator or CPAP/BiPAP tubing support arms should also be included in this area. The support arms should be checked and adjusted to reduce any chance of pulling on the interface or causing pressure against the skin or mucosa. Positioning of the flange on tracheostomy tubes should also be checked and steps taken to reduce pressure on the skin around the stoma. 

4) Monitoring, Training, and Leadership Support

Success in implementing a process improvement plan or initiative needs to have proper monitoring, staff training, and leadership support. Pressure injuries should be monitored for prevalence and incidence. All members of the multidisciplinary team should receive education and training so all are aware of the plans and that proper documentation is carried out. Lastly, leadership should provide support and oversight and ensure that adequate resources are provided.5 

Securing Airways and Masks

Once established, it is often imperative that an airway such as an endotracheal tube or tracheostomy tube be secured to prevent accidental extubation of the airway and to provide a dependable means to provide ventilation/oxygenation. 

Traditionally adhesive cloth tape has been used to secure endotracheal (ET) tubes and cloth or cotton ties or hook-and-loop (Velcro-type) fasteners for tracheostomy tubes. Using tape on endotracheal tubes can be very secure but there is a risk of secretions causing a loosening of the tape. There is a risk of accidentally extubating the airway when removing/replacing the tape to change the position of the tube or refresh old tape. Additionally, tape can get stuck in a beard or in the hair, or adhere to the face, causing damage to the skin when being removed. In applying tape to an ET tube, the skin at the side of the mouth can be accidentally pinched against the tube, causing a pressure injury. Finally, taping/retaping an ET tube takes practice, skill, and time. 

Newer devices have been developed to try and alleviate these problems and help make moving an ET to a new position quicker, less demanding and less risky. The Hollister AnchorFast Guard Select oral endotracheal tube fastener is one of the newer devices available. This device uses a security clamp to grasp the tube and can accommodate standard ET tubes and ET with a subglottic suction lumen. The clamp is attached to a gliding shuttle to allow for repositioning from side to side. Cheek pads provide the main points for securing the tube along with a hook-and-loop neck strap around the back of the head. The device also has a foam pad across the upper lip to provide stability. Hollister also has the Anchorfast device in a small size to fit smaller patients. Securisyn Medical has a similar product (the SolidAIRity Flex) to secure ET tubes. B&B Medical Technologies also offers several items to secure ET tubes without having to use adhesive cotton tape (including StabilTube, ET Tape II, LockTite, and BabyTape Plus). Neotech Products offers a range of securement devices and tapes designed specifically for neonates, including NeoBar and NeoSnug tubing holder. 

Tracheostomy tube kits come with cloth ties that loop around the neck, attach to the flange of the tube, and are tied in place. Companies such as Dale, Neotech, and TIDI Posey offer foam neck straps with hook-and-loop connections to take the place of the cloth ties. CPAP and BiPAP masks are secured with head straps and hook-and-loop closures. Adding cotton padding or hydrocolloid foam dressings at pressure points can help reduce RDRPI for these devices, including high-flow nasal cannulas and regular cannulas. 

Conclusion

RDRPI is a problem that needs to be addressed through many strategies. The Joint Commission has made prevention of pressure injury a priority. Reducing the incidence of pressure injury and RDRPI provides better patient comfort, reduced cost, reduced risk of infection, reduced liability for healthcare staff, and overall improved care. For a successful program in prevention/reduction of RDRPI, education, training, development and implementation of protocols, access to new technology, monitoring/reporting, and leadership support needs to be present. New devices and changes in strategies are being introduced to help in addressing pressure injury. Respiratory therapists should be at the forefront of the team by staying up-to-date with these developments, researching the impact on patient care, and incorporating the best practices as they provide therapy and care for the patient.

RT

Bill Pruitt, MBA, RRT, CPFT, FAARC, is a writer, lecturer, and consultant. Bill has over 40 years of experience in respiratory care in a wide variety of settings and has over 20 years teaching at the University of South Alabama in Cardiorespiratory Care. Now retired from teaching, Bill continues to provide guest lectures, participates in podcasts, and writes professionally. For more info, contact [email protected].


References

  1. Camacho-Del Rio G. Evidence-based practice: Medical device–related pressure injury prevention. American Nurse. Published October 2018. https://www.myamericannurse.com/medical-device-pressure-injury-prevent/.
  2. Dallı ÖE, Girgin NK. Medical Device-Related Pressure Injury Care and Prevention Training Program (DevICeU): Effects on intensive care nurses’ knowledge, prevention performance and point prevalence. Intensive and Critical Care Nursing. 2024 Jun 1;82:103622.
  3. From Open Washington Pressbooks: 10.5 Braden Scale – Nursing Fundamentals. https://openwa.pressbooks.pub/nursingfundamentals/chapter/10-5-braden-scale/.
  4. Lee H, Choi S. Protocols and their effects for medical device-related pressure injury prevention among critically ill patients: a systematic review. BMC nursing. 2024 Jun 17;23(1):403.
  5. Joint Commission. Quick safety 25: Preventing pressure injuries. Updated March 2022. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-25-preventing-pressure-injuries/preventing-pressure-injuries/.