To investigate the efficacy of hydrocolloid dressing in reducing the occurrence rate and severity of nasotracheal tube related pressure injury.
Patients:
Pediatric patients received invasive mechanical ventila tion via nasotracheal tubes.
Interventions:
The hydrocolloid dressing was cut into an optimal square size, which should cover the area from the nasal columella to the ala.
Introduction：
As an artificial airway, the nasotracheal tube (NTT) is preferable for a critically ill child who requires medium-term mechanical ventilation (MV) in the PICU, because it ensures the stability of the nasal tube, reduces the risk of unplanned extubation and makes oral care practical . On the other hand, the NTT can cause harm to the nasal skin. From the literature review, the NTT led to 24.5% to 100% nasal pressure injuries (PIs) among adults undergoing oral maxillofacial surgery . In contrast, only five nasal PIs were found in critically ill children in two reports . It seems that NTT would not be a problem for a critically ill child.
However, critically ill children have distinctive, anatomic, physiologic, and pathophysiologic features. Limited mobility, unstable hemodynamics, poor perfusion, and vasopressor infusion are considered to be crucial factors that have association with PIs among critically ill patients. Infants and children under sedation and children at young ages cannot communicate and express discomfort related to medical devices with healthcare practitioners. The limitation of communication impedes the healthcare practitioner’s ability to recognize nasotracheal tube-related pressure injuries (NTR PIs) as early as possible . Furthermore, intubation for 8 hours was long enough to induce nasal PI . Studies showed that the median length of MV lasts for 2 to 4 days in the PICU . Consequently, we assumed that with NTT constantly pressing on nasal skin for days, a critically ill child could be at high risk of NTR PI. The harmfulness of an NTT to the nasal skin might be underestimated in the PICU.
PI is a global concern for healthcare practitioners owing to the negative impacts such as pain, infection, increasing the intensity of nursing care, and the associated economic cost. Although different materials and methods have been studied for understanding their effectiveness in preventing NTR PI among surgical adults , whether the recommendations from the adult studies are suitable for critically ill children remains unknown. This study was designed to fill the gaps, including the occurrence rate of NTR PI and the efficacy of hydrocolloid dressing (HD) as a protective barrier in the PICU. We hypothesized that critically ill children had a high occurrence rate of NTR PI, and the HD could reduce the number of NTR PI.
Figure 1：Steps of changing the securing tape and hydrocolloid dressing (HD). 1) Clean the nose secretion. Remove the securing tape and HD, then use alcohol pad to clean the glue that left in the tube and skin. 2) Cut an optimal size of HD, making two small cuts to separate it. The uncut portion of the HD is applied to the anterior and lateral portions of the outer skin of the nostril, the inner tab is folded into the nostril, and the lateral tabs are passed on either side of the nasotracheal tube (NTT) and adhered to the skin. 3) Secure the NTT.
Results and Discussion:
This study first reports the HD as a protective barrier to the nasal skin of a critically ill child with long-term nasotracheal intubation and the efficacy of the HD to retain the nasal skin integrity. Some studies have indicated that the respiratory devices, such as the facial mask or nasal prongs for the continuous positive airway pressure (CPAP) device, tracheostomy tube and its tie, and endotracheal tube (ETT), are the common factors leading to medical device-related PIs. Some authors emphasized the high occurrence rate of PIs resulting from respiratory devices and the importance of implementing interventions . Surprisingly, few authors have given any suggestion on the prevention of PI caused by ETT in children.
Both Zhou and our study used only HD as a protective barrier, and both our study results are consistent. Our study also demonstrated HD can improve the endurance of the nasal skin to the chemical irritation or mechanical insult that nasotracheal intubation brought about in the experimental group. On the other hand, it is noteworthy that the occurrence rate of NTR PIs is much lower in the study by Zhou and Zhou , in which the occurrence rate was 36.7% versus 6.7%. Several reasons could possibly explain the difference between the two studies. First, the target population of this study was critically ill children with comorbidities. Their hemodynamics fluctuated and their microcirculation was disturbed. Second, the severe condition determined the duration of nasotracheal intubation. In this study, the average duration of intubation was 156 hours, which was over ten times longer than that of the study by Zhou and Zhou. The longer duration of nasotracheal intubation the patients have, the higher the risk the patients will have NTR PI. Third, the skin of the child is susceptible to chemical irritation or mechanical insult due to immature skin development. Thus, the fragile skin also makes the child vulnerable to NTR PI. Since multiple risk factors put the critically ill child at high risk of nasal PI, we applied special attention to the child with long-term nasotracheal intubation. Of the NTR PIs identified, nearly half of them were stage 1, which were mild skin injuries. The other half was stage 2 or 3 PIs, which would leave scars when the skin injuries recovered. The sensitivity analysis showed no statistical significance of the occurrence rate of NTR PIs between the two groups when the events of stage 1 were excluded. The comparison of the severity of the NTR PIs also did not show statistical difference between two groups. As the sample size of this study was calculated on the basis of the occurrence rate of all stages of PIs, it was not big enough to neither reflect the efficacy of HD in preventing stage 2 and more severe PI, nor detect which stage of PI can benefit most from the protection of HD. Further studies with bigger sample sizes are required to determine whether the HD can help relieve the severity of NTR PIs.
Conclusions：
Critically ill children who need long-term IMV are at high risk of developing NTR PIs. Based on our study, we recommend HD as a protective barrier owing to its characteristics of adhesion, thinness, reduction of pressure and shear force, and absorption of exudate. HD shows sufficient efficacy of protecting the nasal skin. However, even with the protection of HD, NTR PI still occurred with high occurrence rate. Future study is needed to find an integrated approach which can protect the nasal skin more effectively.
Reference：
Chen, Jie, et al. "Investigating the efficacy of hydrocolloid dressing for preventing nasotracheal tube-related pressure injury in the PICU." Pediatric Critical Care Medicine 21.9 (2020): e752-e758.
