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LETTERS TO EDITOR
Year : 2021  |  Volume : 22  |  Issue : 1  |  Page : 114-115
 

Pressure sore with high-flow nasal canula: Another challenge in the COVID-19 pandemic


Department of Anaesthesiology and Critical Care, AIIMS, Jodhpur, Rajasthan, India

Date of Submission07-Jan-2021
Date of Acceptance13-Jan-2021
Date of Web Publication22-Feb-2021

Correspondence Address:
Dr. Sadik Mohammed
Department of Anaesthesiology and Critical Care, AIIMS, Phase II, Basani Industrial Area, Jodhpur - 342 005, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_3_21

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How to cite this article:
Mohammed S, Chhabra S, Bhatia P, Paliwal B, Sharma L. Pressure sore with high-flow nasal canula: Another challenge in the COVID-19 pandemic. Indian Anaesth Forum 2021;22:114-5

How to cite this URL:
Mohammed S, Chhabra S, Bhatia P, Paliwal B, Sharma L. Pressure sore with high-flow nasal canula: Another challenge in the COVID-19 pandemic. Indian Anaesth Forum [serial online] 2021 [cited 2021 May 9];22:114-5. Available from: http://www.theiaforum.org/text.asp?2021/22/1/114/309833




Sir,

High-flow nasal cannula (HFNC) oxygen therapy has revolutionized the treatment of patients with acute hypoxemic respiratory failure. Its use has been extended to critically ill patients with COVID-19 disease as the surviving sepsis campaign has recommended its use over conventional oxygen therapy and noninvasive positive-pressure ventilation (NIPPV).[1] A common problem associated with the NIPPV mask is pressure sore. The nasal cannulas of HFNC have soft nasal prongs and a pad to improve patient comfort. We report a case wherein prolonged continuous use of nasal cannula resulted in the formation of pressure ulcer at the cannula application site.

A 65-year-old male with laboratory-confirmed COVID-19 severe illness was admitted to COVID critical care unit. In view of increasing oxygen requirement, he was put on HFNC (Airvo™ 2, Fisher and Paykel Healthcare Limited, Auckland, NZ) oxygen therapy in addition to the COVID-19 disease-specific treatment as per institutional protocol. The patient responded to the therapy as there was a gradually decreasing flow and FiO2 requirement. On day 9 of continued HFNC oxygen therapy, the patient complaint of irritation at the entry of both nares and at the base of the columella. The nasal cannula was removed and the area was inspected which revealed ulcer at the cannula application site [Figure 1]a. On close inspection, it was a grade II pressure ulcer showing skin excoriation over the skin areas in close contact with the nasal cannula. The ulcer took shape of the base on which the nasal prong rests. As the patients had gradually decreasing oxygen requirement, the HFNC was removed and he was put on nonrebreather mask with 10 L/min O2 flow along with the application of mupirocin ointment over the ulcer. Over the next 7 days, the ulcer showed healing [Figure 1]b and the oxygen requirement further decreases to 3–4 L/min by simple face mask. The patient was shifted to step down and further to the stable ward in the next 7 days.
Figure 1: (a) Presence of active pressure sore at the skin area in contact with the nasal cannula, (b) pressure sore after healing

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The HFNC was first developed for use in neonates with the intention of maintaining the benefit of high oxygen flows (and thus the increased end-expiratory pulmonary pressures) without compromising blood flow to skin areas susceptible to pressure sores.[2] Therefore, they were designed to match the internal diameter of the neonatal nasal orifice and were also constructed from materials that are softer than their predecessors.[2] Moreover, the prongs are contoured (softer and streamlined fit) and they rest on concave base designed to alleviate pressure on the septum.[3] However, we found that compared to the prongs (made up of soft thermo-elastomeric polymer) the base is made up of hard material that might cause pressure ulcer in the susceptible individual when used for a prolonged period. When used for a prolonged period, hyper oxygenated fatty acid could be applied on the facial skin in contact with the cannula to prevent the formation of facial pressure ulcer.[4]

We suggest that the skin area in contact with the cannula must be regularly inspected for early detection of skin changes.

Financial support and sponsorship

This work was supported by the Department of Anaesthesiology and Critical Care, AIIMS Hospital, Jodhpur, India.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, et al. Surviving sepsis campaign: Guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). Crit Care Med 2020;46:854-87.  Back to cited text no. 1
    
2.
Ward JJ. High-flow oxygen administration by nasal cannula for adult and perinatal patients. Respir Care 2013;58:98-122.  Back to cited text no. 2
    
3.
Available from: https://resources.fphcare.com/content/optiflow-nasal-cannula-brochure-pm-185048452.pdf. [Last assessed on 2020 Nov 10].  Back to cited text no. 3
    
4.
Otero DP, Domínguez DV, Fernández LH, Magariño AS, González VJ, Klepzing JV, et al. Preventing facial pressure ulcers in patients under non-invasive mechanical ventilation: A randomised control trial. J Wound Care 2017;26:128-36.  Back to cited text no. 4
    


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