Cath Lab Digest

In the quest to maintain skin integrity, reduce pain, and improve outcomes for preterm infants (babies born before 37 weeks gestation¹), neonatal intensive care clinicians must balance technology with tissue protection. Protecting the nasal septum and perinasal tissue during the course of continuous positive air pressure (CPAP) therapy provided via nasal prongs or mask has been identified by the neonatal skin care team at Duke University Medical Center as an area of particular concern. Infants cared for by this team may be very low birth weight (VLBW) — less than 1,500 g or 3.3 lb — or extremely low birth weight (ELBW) — less than 1,000 g or 2.2 lb.¹

Continuous positive air pressure therapy was reported by Gregory² in 1971 to be an efficacious method of treatment for respiratory distress syndrome and is used today to wean infants from mechanical ventilators and to address apnea concerns. Early ventilator weaning can reduce the incidence of subglottic stenosis, tracheal stenosis, secondary infections, aspiration, and bronchopulmonary dysplasia (BPD).² In BPD, the delicate lung tissues may become injured when the alveoli are overstretched by mechanical ventilation or by high oxygen levels. After several years and the lung tissue heals, these children are at risk for developing asthma and viral pneumonia, such as that caused by respiratory syncytial virus (RSV).³

Protecting the skin of the preterm infant is a challenge. In a review of the literature, Quinn et al⁴ reported that although the skin of the newborn infant is similar in function to an adult, the skin of the premature infant has poor barrier function. This can result in greater risk of injury and infection due to the thinness of the stratum corneum and the poorly developed dermoepidermal junction.

Assessing and managing pain for hospitalized infants is an ongoing clinical challenge. According to a position statement issued by the National Association of Neonatal Nurses (NANN),⁵ clinical assessment of pain in the newborn is imprecise and a high index of suspicion is required to identify an infant in pain. Additional contributing factors to this challenge are related to the infant’s developmental maturity, behavioral state, clinical status, and environment. The Association encourages ongoing education regarding the assessment and management of pain in hospitalized infants for all healthcare professionals.⁵

The Problem

Staff at the Duke University Medical Center Neonatal Intensive Care Nursery constantly strive to initiate nasal CPAP on low birth weight babies in the hopes of decreasing BPD and managing them off of mechanical ventilation. As soon as ventilator settings are low enough, the infant will be challenged to CPAP. Once CPAP is initiated for the ELBW/VLBW infant, the fragile tissue of the nares must be protected from pressure injuries and stripping that can occur at the base of the nasal septum (see Figure 1), on either side of the nares, and across the bridge of the nose. In addition to equipment placement around the nose, Duke clinicians have found increased infant activity, therapeutic handling, and frequency of and inconsistency with skin assessment to be factors in tissue damage.