Impact of a Nursing Intervention Bundle of Care on Nasal-CPAP-Related Nasal Injuries in Preterm Infants: A Quality Improvement Initiative

Mohab  Mohamed; Ahmed Noaman; Islam Nour; Hesham Abdel-Hady

doi:10.3889/oamjms.2023.11685

Authors

Mohab Mohamed Departement of Pediatrics, Faculty of Medicine, University of Mansoura, Mansoura, Egypt
Ahmed Noaman Departement of Pediatrics, Faculty of Medicine, University of Mansoura, Mansoura, Egypt https://orcid.org/0000-0002-3694-5773
Islam Nour Departement of Pediatrics, Faculty of Medicine, University of Mansoura, Mansoura, Egypt; Neonatal Intensive Care Unit, Mansoura University Children’s Hospital, Mansoura, Egypt https://orcid.org/0000-0002-9033-6290
Hesham Abdel-Hady Departement of Pediatrics, Faculty of Medicine, University of Mansoura, Mansoura, Egypt; Neonatal Intensive Care Unit, Mansoura University Children’s Hospital, Mansoura, Egypt https://orcid.org/0000-0003-1908-9423

DOI:

https://doi.org/10.3889/oamjms.2023.11685

Keywords:

CPAP, Preterm, Nasal injury, Quality improvement

Abstract

AIM: The objective is to assess the effect of the application of a nasal injury prevention bundle on the incidence and severity of nasal-continuous positive airway pressure (nCPAP)-related nasal injuries in preterm infants.

METHODS: We conducted a prospective controlled before-after study in a preterm neonate, <37 weeks gestation, who required nCPAP in the neonatal intensive care unit, at Mansoura University Children’s Hospital, between September 2018 through October 2019. After 2 months of nursing staff training, a nasal trauma prevention bundle was implemented. The nursing intervention bundle comprised nasal barrier dressing, regular focused checking for evolving nasal skin injury, and proper application of the CPAP device. nCPAP-related nasal injuries per 1000 days and grading of nasal injury severity were the primary outcomes. Time to onset of nasal injury after initiation of CPAP; duration of nCPAP use, duration of oxygen dependency; incidence of pneumothorax, broncho-pulmonary dysplasia; intraventricular hemorrhage; periventricular leukomalacia; late-onset sepsis; length of hospital stay; and in-hospital mortality were the secondary outcomes.

RESULTS: Data from 62 preterm neonates were analyzed (31 in each group). The nasal trauma prevention bundle of care was associated with reduced nasal injury incidence per 1000 nCPAP-days (140 vs. 148.94, p = 0.03) with improved nasal injury severity staging (p = 0.003) compared to the pre-bundle era. Nasal injury developed earlier in the control group (1 [1–1] vs. 2 [1–3] days, p = 0.002) compared to the intervention group. No statistically significant differences were reported between groups regarding any of the other secondary outcomes. Longer duration of CPAP use (p = 0.009) and lack of bundle application (0.03) were the independent risk factors associated with nCPAP-related nasal injuries in preterm neonates.

CONCLUSION: The implementation of a bundle of nursing interventions is associated with a substantially improved incidence and severity of nasal injuries in preterm infants receiving nCPAP.

Downloads

Download data is not yet available.

Metrics

Metrics Loading ...

Plum Analytics Artifact Widget Block

References

Schmölzer GM, Kumar M, Pichler G, Aziz K, O’Reilly M, Cheung PY. Non-invasive versus invasive respiratory support in preterm infants at birth: Systematic review and meta-analysis. BMJ. 2013;347:f5980. https://doi.org/10.1136/bmj.f5980 PMid:24136633 DOI: https://doi.org/10.1136/bmj.f5980

Falk M, Gunnarsdottir K, Baldursdottir S, Donaldsson S, Jonsson B, Drevhammar T. Interface leakage during neonatal CPAP treatment: A randomised, cross-over trial. Arch Dis Child Fetal Neonatal Ed 2021;106(6):663-7. https://doi.org/10.1136/archdischild-2021-321579 PMid:33963004 DOI: https://doi.org/10.1136/archdischild-2021-321579

McCoskey L. Nursing care guidelines for prevention of nasal breakdown in neonates receiving nasal CPAP. Adv Neonatal Care. 2008;8(2):116-24. https://doi.org/10.1097/01.ANC.0000317260.99072.ae PMid:18418209 DOI: https://doi.org/10.1097/01.ANC.0000317260.99072.ae

Fischer C, Bertelle V, Hohlfeld J, Forcada-Guex M, Stadelmann- Diaw C, Tolsa JF. Nasal trauma due to continuous positive airway pressure in neonates. Arch Dis Child Fetal Neonatal Ed. 2010;95(6):F447-51. https://doi.org/10.1136/adc.2009.179416 PMid:20584802 DOI: https://doi.org/10.1136/adc.2009.179416

Li Y, Sepulveda A, Buchanan EP. Late presenting nasal deformities after nasal continuous positive airway pressure injury: 33-year experience. J Plast Reconstr Aesthetic Surg. 2015;68(3):339-43. https://doi.org/10.1016/j.bjps.2014.10.036 DOI: https://doi.org/10.1016/j.bjps.2014.10.036

DeRowe A, Landsberg R, Fishman G, Halperin D, Fliss D. Neonatal iatrogenic nasal obstruction. Int J Pediatr Otorhinolaryngol. 2004;68(5):613-7. https://doi.org/10.1016/j.ijporl.2003.12.012 DOI: https://doi.org/10.1016/j.ijporl.2003.12.012

Aly H, Hammad T, Ozen M, Sandhu I, Taylor C, Olaode A, et al. Nasal colonization among premature infants treated with nasal continuous positive airway pressure. Am J Perinatol. 2011;28(4):315-20. https://doi.org/10.1055/s-0030-1268711 PMid:21117015 DOI: https://doi.org/10.1055/s-0030-1268711

Günlemez A, Isken T, Gökalp AS, Türker G, Arisoy EA. Effect of silicon gel sheeting in nasal injury associated with nasal CPAP in preterm infants. Indian Pediatr. 2010;47(3):265-7. https://doi.org/10.1007/s13312-010-0047-9 PMid:19430064 DOI: https://doi.org/10.1007/s13312-010-0047-9

Do Nascimento RM, Ferreira AL, Coutinho AC, Veríssimo RC. The frequency of nasal injury in newborns due to the use of continuous positive airway pressure with prongs. Rev Lat Am Enfermagem. 2009;17(4):489-94. https://doi.org/10.1590/s0104-11692009000400009 PMid:19820855 DOI: https://doi.org/10.1590/S0104-11692009000400009

Chen CY, Chou AK, Chen YL, Chou HC, Tsao PN, Hsieh WS. Quality improvement of nasal continuous positive airway pressure therapy in neonatal intensive care unit. Pediatr Neonatol. 2017;58(3):229-35. https://doi.org/10.1016/j.pedneo.2016.04.005 PMid:27666491 DOI: https://doi.org/10.1016/j.pedneo.2016.04.005

Naha N, Pournami F, Prabhakar J, Jain N. Nasal injury with continuous positive airway pressure: Need for “Privileging” nursing staff. Indian J Pediatr. 2019;86(7):595-8. https://doi.org/10.1007/s12098-019-02960-1 PMid:31020593 DOI: https://doi.org/10.1007/s12098-019-02960-1

Yong SC, Chen SJ, Boo NY. Incidence of nasal trauma associated with nasal prong versus nasal mask during continuous positive airway pressure treatment in very low birthweight infants: A randomised control study. Arch Dis Child Fetal Neonatal Ed. 2005;90(6):F480-3. https://doi.org/10.1136/adc.2004.069351 PMid:15941825 DOI: https://doi.org/10.1136/adc.2004.069351

Shanmugananda K, Rawal J. Nasal trauma due to nasal continuous positive airway pressure in newborns. Arch Dis Child Fetal Neonatal Ed. 2007;92(1):F18. https://doi.org/10.1136/adc.2006.095034 PMid:17185425 DOI: https://doi.org/10.1136/adc.2006.095034

Bonner KM, Mainous RO. The nursing care of the infant receiving bubble CPAP therapy. Adv Neonatal Care. 2008;8(2):78-95; quiz 96-7. https://doi.org/10.1097/01.ANC.0000317256.76201.7 PMid:18418205 DOI: https://doi.org/10.1097/01.ANC.0000317256.76201.72

Rezaei P, Jafari-Mianaei S, Sadeghnia A, Heidari Z. Protective dressings,injury,anddevicefailureinpreterminfantsreceivingnasal continuous positive airway pressure: A randomized controlled trial. Adv Skin Wound Care. 2021;34(9):1-6. https://doi.org/10.1097/01.ASW.0000767344.37591.b6 PMid:34415257 DOI: https://doi.org/10.1097/01.ASW.0000767344.37591.b6

Imbulana DI, Manley BJ, Dawson JA, Davis PG, Owen LS. Nasal injury in preterm infants receiving non-invasive respiratory support: A systematic review. Arch Dis Child Fetal Neonatal Ed. 2018;103(1):F29-35. https://doi.org/10.1136/archdischild-2017-313418 PMid:28970314 DOI: https://doi.org/10.1136/archdischild-2017-313418

Jobe AH, Bancalari E. Bronchopulmonary dysplasia. Am J Respir Crit Care Med. 2001;163(7):1723-9. https://doi.org/10.1164/ajrccm.163.7.2011060 PMid:11401896 DOI: https://doi.org/10.1164/ajrccm.163.7.2011060

Milligan PS, Goldstein MR. Implementation of an evidence- based non-invasive respiratory support (NIRS) bundle in the NICU to decrease nasal injury complications. J Neonatal Nurs. 2017;23(2):89-98. https://doi.org/10.1016/j.jnn.2016.05.003 DOI: https://doi.org/10.1016/j.jnn.2016.05.003

Bonfim SF, de Vasconcelos MG, de Sousa NF, da Silva DV, Leal LP. Nasal septum injury in preterm infants using nasal prongs. Rev Lat Am Enfermagem. 2014;22(5):826-33. http://doi.org/10.1590/0104-1169.3451.2486 PMid:25493679 DOI: https://doi.org/10.1590/0104-1169.3451.2486

Xie L. Hydrocolloid dressing in preventing nasal trauma secondary to nasal continuous positive airway pressure in preterm infants. World J Emerg Med. 2014;5(3):218-22. https://doi.org/10.5847/wjem.j.issn.1920-8642.2014.03.011 PMid:25225588 DOI: https://doi.org/10.5847/wjem.j.issn.1920-8642.2014.03.011

Imbulana DI, Owen LS, Dawson JA, Bailey JL, Davis PG, Manley BJ. A randomized controlled trial of a barrier dressing to reduce nasal injury in preterm infants receiving binasal noninvasive respiratory support. J Pediatr. 2018;201:34-9.e3. https://doi.org/10.1016/j.jpeds.2018.05.026 PMid:30251638 DOI: https://doi.org/10.1016/j.jpeds.2018.05.026

Mariam S, Buddhavarapu S. Impact of systematic training and CPAP checklist in the prevention of NCPAP related nasal injuries in neonates- a quality improvement study. Indian J Pediat. 2020;87(4):256-61. https://doi.org/10.1007/s12098-019-03146-5 PMid:31942677 DOI: https://doi.org/10.1007/s12098-019-03146-5