Investigating the effects of strap tension during non-invasive ventilation mask application: a combined biomechanical and biomarker approach

Non-invasive ventilation is commonly used for respiratory support. However, in some cases, mask application can cause pressure ulcers to specific features of the face, resulting in pain and reduced quality of life for the individual. This study investigated the effects of mask strap tension on the biomechanical and biomarker responses at the skin interface. Healthy participants (n = 13) were recruited and assigned two different masks in a random order, which were fitted with three strap conditions representing increments of 5 mm to increase tension. Masks were worn for 10 minutes at each tension followed by a 10-minute refractory period. Assessment at the device–skin interface included measurements of pressures at the nose and cheeks, temperature and humidity, a selection of inflammatory cytokine concentrations collected from sebum and scores of comfort. The results indicated significantly higher interface pressures at the bridge of the nose compared to the cheeks for both masks (p < 0.05), with nasal interface pressures significantly increasing with elevated strap tension (p < 0.05). One inflammatory cytokine, IL-1α, increased following mask application at the highest tension, with median increases from baselines ranging from 21 to 33%. The other cytokines revealed a less consistent trend with strap tension. The participants reported statistically greater discomfort during elevated strap tension. Temperature and humidity values under the mask were elevated from ambient conditions, although no differences were observed between mask type or strap tension. The bony prominence on the bridge of the nose represented a vulnerable area of skin during respiratory mask application. This study has shown that mask strap tension has a significant effect on the pressure exerted on the nose. This can result in discomfort and an inflammatory response at the skin surface. Further studies are required to investigate respiratory mask application for appropriate individuals with comorbidities.

[1]  Dieter Hochrainer,et al.  Determinants of skin contact pressure formation during non-invasive ventilation. , 2010, Journal of biomechanics.

[2]  M. Cowie.  National Institute for Health and Care Excellence. , 2015, European heart journal.

[3]  M. Weng.  The effect of protective treatment in reducing pressure ulcers for non-invasive ventilation patients. , 2008, Intensive & critical care nursing.

[4]  V Allen,et al.  Accuracy of interface pressure measurement systems. , 1993, Journal of biomedical engineering.

[5]  C. Carvalho,et al.  Mask mechanics and leak dynamics during noninvasive pressure support ventilation: a bench study , 2001, Intensive Care Medicine.

[6]  Anne-Kathrin Brill,et al.  How to avoid interface problems in acute noninvasive ventilation , 2014, Breathe.

[7]  C. Oomens,et al.  The Transport Profile of Cytokines in Epidermal Equivalents Subjected to Mechanical Loading , 2009, Annals of Biomedical Engineering.

[8]  David J Atherton,et al.  A review of the pathophysiology, prevention and treatment of irritant diaper dermatitis , 2004, Current medical research and opinion.

[9]  G. Ogg,et al.  Cytokine regulation of the epidermal barrier , 2012, Clinical and experimental allergy : journal of the British Society for Allergy and Clinical Immunology.

[10]  B. De Wever,et al.  Analysis of interleukin-1alpha (IL-1alpha) and interleukin-8 (IL-8) expression and release in in vitro reconstructed human epidermis for the prediction of in vivo skin irritation and/or sensitization. , 2003, Toxicology in vitro : an international journal published in association with BIBRA.

[11]  Jasper Reenalda,et al.  Clinical Use of Interface Pressure to Predict Pressure Ulcer Development: A Systematic Review , 2009, Assistive technology : the official journal of RESNA.

[12]  W. P. Yamaguti,et al.  Treatment-Related Risk Factors for Development of Skin Breakdown in Subjects With Acute Respiratory Failure Undergoing Noninvasive Ventilation or CPAP , 2014, Respiratory Care.

[13]  S. A. Webb,et al.  The pressure effects of facemasks during noninvasive ventilation: a volunteer study , 2007, Anaesthesia.

[14]  S. Jaber,et al.  Comparative evaluation of three interfaces for non-invasive ventilation: a randomized cross-over design physiologic study on healthy volunteers , 2014, Critical Care.

[15]  J P Rood,et al.  Measurement of facial skin temperature. , 1990, Journal of dentistry.

[16]  Louise Toner,et al.  European Pressure Ulcer Advisory Panel , 2007 .

[17]  P. Barnes,et al.  Chronic obstructive pulmonary disease. , 2000, The New England journal of medicine.

[18]  Joyce M Black,et al.  Medical device related pressure ulcers in hospitalized patients , 2010, International wound journal.

[19]  Karin Gardner Johnson,et al.  Treatment of sleep-disordered breathing with positive airway pressure devices: technology update , 2015, Medical devices.

[20]  A. Bahammam,et al.  Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials. , 2013, British journal of anaesthesia.

[21]  Rana Chreyh,et al.  A proposed framework to improve the safety of medical devices in a Canadian hospital context , 2014, Medical devices.

[22]  Brian S. Pan,et al.  Face Masks for Noninvasive Ventilation: Fit, Excess Skin Hydration, and Pressure Ulcers , 2015, Respiratory Care.

[23]  R. Aitken.  Measurement of feelings using visual analogue scales. , 1969, Proceedings of the Royal Society of Medicine.

[24]  P. Gay.  Complications of noninvasive ventilation in acute care. , 2009, Respiratory care.

[25]  S Derler,et al.  Influence of epidermal hydration on the friction of human skin against textiles , 2008, Journal of The Royal Society Interface.

[26]  C. Gregoretti,et al.  Helmet ventilation for acute respiratory failure and nasal skin breakdown in neuromuscular disorders. , 2009, Anesthesia and analgesia.

[27]  S. White,et al.  Nosocomial Pressure Ulcer Rates in Critical Care: Performance Improvement Project , 2005, Journal of nursing care quality.

[28]  Cees W J Oomens,et al.  A new method to evaluate the effects of shear on the skin , 2015, Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society.

[29]  B. Lüscher,et al.  Cytokines and the Skin Barrier , 2013, International journal of molecular sciences.

[30]  Lisette Schoonhoven,et al.  The physiological response of soft tissue to periodic repositioning as a strategy for pressure ulcer prevention. , 2015, Clinical biomechanics.

[31]  M. Maruccia,et al.  Facial skin breakdown in patients with non‐invasive ventilation devices: report of two cases and indications for treatment and prevention , 2015, International wound journal.

[32]  D. Wipke-Tevis,et al.  Elevated sacral skin temperature (T(s)): a risk factor for pressure ulcer development in hospitalized neurologically impaired Thai patients. , 2005, Applied nursing research : ANR.

[33]  Stefano Nava,et al.  Evaluation of patient skin breakdown and comfort with a new face mask for non-invasive ventilation: a multi-center study , 2002, Intensive Care Medicine.

[34]  M. Kollef,et al.  Pressure Ulcer Incidence in Patients Wearing Nasal-Oral Versus Full-Face Noninvasive Ventilation Masks. , 2015, American journal of critical care : an official publication, American Association of Critical-Care Nurses.

[35]  M. Farage,et al.  A noninvasive method to assess skin irritation and compromised skin conditions using simple tape adsorption of molecular markers of inflammation , 2001, Skin research and technology : official journal of International Society for Bioengineering and the Skin (ISBS) [and] International Society for Digital Imaging of Skin (ISDIS) [and] International Society for Skin Imaging.

[36]  Amit Gefen,et al.  How do microclimate factors affect the risk for superficial pressure ulcers: a mathematical modeling study. , 2011, Journal of tissue viability.