Noninvasive positive pressure ventilators (NIPPV) require the use of nasal or facial masks. Due to the need for these masks to tightly adhere to prevent air leaks, they can cause facial pressure ulcers. The author developed an innovative method to reduce the incidence of ulcers by replacing the hydrocolloid dressings that were used as a barrier between the tube and facial skin, with a modified silicone soft foam dressing.

INTRODUCTION
Noninvasive positive pressure ventilators (NIPPVs) provide improved gaseous exchange without the need for artificial airways such as intratracheal intubation or tracheotomy. NIPPVs reduce the risk of respiratory tract infection and the production of excessive secretions. Nevertheless, long-term use can affect patient comfort and even lead to complications such as gastric distention, pressure necrosis of the facial skin and accidental removal of and leakage from nasal or facial masks.


PRESSURE DAMAGE
Pressure ulcers are caused by excessive long-term pressure on the skin and resultant tissue ischaemia, necrosis and ulceration. The European Pressure Ulcer Advisory Panel [EPUAP][1] defines pressure ulcers as damage to the integument or underlying structures due to pressure, friction or shear. Besides occurring over bony prominences, pressure ulcers can develop at any skin sites that are being directly oppressed by auxiliary tubes.
 
Pressure is the main cause of these ulcers and is associated with a number of complex interrelated extrinsic factors such as shear, friction and moisture[2].


PATIENT INJURY DUE TO TUBE OPPRESSION
Patients with NIPPVs wear a nasal or facial mask to replace the artificial airway. During ventilation, these masks must fit the face tightly in order to prevent leaks and poor supply. However, prolonged use of these masks can lead to discomfort and even the development of pressure damage on the patient's face.
 
According to an unpublished 2006 care quality study into acute facial pressure ulcers performed in the authors' medical centre, these ulcers were caused primarily by pressure exerted via fixation devices (53%) and occur mostly in patients undergoing NIPPV using face masks (22%). Further analysis indicated that 47 out of 797 patients (who had NIPPV devices applied via masks) had a facial pressure ulcer (an incidence rate of 5.90%) (Table 1). The cheeks were the most common site of pressure (59%) followed by the bridge of the nose (22%). Most of the wounds were classified as stage 1 ulcers (59%), with two wounds being classified as stage 3 ulcers (Table 2) (according to the National Pressure Ulcer Advisory Panel's [NPUAP] pressure ulcer staging system)[3].

Table 1 – Incidence rates of pressure ulcers in patients on NIPPV using facial masks between January and October, 2006.

Table 2 – Sites and degrees of facial pressure ulcers in patients on NIPPV using face masks before use of the modified dressings.