The current novel coronavirus-19 disease (COVID-19) outbreak in Italy has caused a massive increase in the use of personal protective equipment by health-care workers, including tight-fitting NP95 respirator.
An otherwise healthy 35-year-old male intensivist seeked ENT attention following a 6-hour shift in the isolated COVID-19 unit. He had been wearing a NP95 face respirator nonstop for several hours over the previous 7 days. He noticed a painful swollen red area around the point of contact between the mask and the nose. Physical examination (Figure 1) confirmed he was suffering from red skin with initial abrasion, stage II nasal pressure injuries (NPIs). Many other colleagues followed (Figure 2).
Figure 1
Nasal pressure injuries (NPIs) with dermal involvement (stage II). Patient develops partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed without slough. Stage II NPI may also present as an intact or open/ruptured serum-filled blister.
Figure 2
Less serious nasal pressure injuries: Skin appears intact with nonblanchable redness localized area, usually over the nasal bony prominence (stage I).
According to National Pressure Ulcer Staging System, these NPIs appeared at stage II in the reported case and at stage I in other collected cases (Figure 2).
The discomfort developed after the first hour, but at the end of the shift, the skin of the back of the nose appears red, painful, and accompanied by pain on palpation and sometimes requires treatment with antidecubitus ointments.
The injury can be painful and occurs as a result of the intense and prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear, similarly to already known decubitus, are also affected by microclimate, nutrition, perfusion, comorbidities, and condition of the soft tissue.
NP95 respirators require complete adherence, causing continuous pressure with/without shear on the nasal back that slightly increases during inspiration. Nasal skin, thin and delicate, is at risk of NPI especially in case of a prominent nasal bone.
Worsening of NPI can create discomfort in using such device, discourage its use, or even decrease its performance, affecting the operator’s safety, occurring in a severe situation that is already causing stress, anxiety, and fear.
Prevention (frequent skin check, hydrogel foam application) and treatment are mandatory. Applying silicone or hydrogel foam cover between the mask and the skin or protecting the skin under the mask with padded bandage made with gauze, containing sodium chloride and hyaluronic acid, may be useful, but prospective study or IPD test must confirm fitness guarantee. Associated with the use of this protection, it is essential to systematically control the contact points between the skin and the rigid parts of the mask, with rigorous follow-up (skin check every 3-4 hours).
Acknowledgments
Thanks to all health-care workers involved in the management of this emergency situation.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
Valeria Dell’Era
https://orcid.org/0000-0002-2171-4120
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