Facial Pressure Injuries from Prone Positioning in the COVID‐19 Era

Abstract

Objective/Hypothesis This study aimed to determine the incidence of facial pressure injuries associated with prone positioning for COVID‐19 patients as well as to characterize the location of injuries and treatments provided. Methods This was a retrospective chart review of 263 COVID‐19 positive patients requiring intubation in the intensive care units at MedStar Georgetown University Hospital and MedStar Washington Hospital Center between March 1st and July 26th, 2020. Information regarding proning status, duration of proning, presence, or absence of facial pressure injuries and interventions were collected. Paired two‐tailed t‐test was used to evaluate differences between proned patients who developed pressure injuries with those who did not. Results Overall, 143 COVID‐19 positive patients required proning while intubated with the average duration of proning being 5.15 days. Of those proned, 68 (47.6%) developed a facial pressure injury. The most common site involved was the cheek with a total of 57 (84%) followed by ears (50%). The average duration of proning for patients who developed a pressure injury was significantly longer when compared to those who did not develop pressure injuries (6.79 days vs. 3.64 days, P < .001). Conclusions Facial pressure injuries occur with high incidence in patients with COVID‐19 who undergo prone positioning. Longer duration of proning appears to confer greater risk for developing these pressure injuries. Hence, improved preventative measures and early interventions are needed. Level of Evidence 4 Laryngoscope, 131:E2139–E2142, 2021

Endotracheal Tube Fastening Device-Related Facial Pressure Ulcers

“…Proning plays an important role in the development of facial ulcers as indicated by Shearer et al who observed that 47.6% proned COVID-19 patients developed facial pressure ulcers with 84% of them developing ulcers on the cheeks similar to our patient. They also noted a positive association between the risk of facial pressure ulcers and prolonged proning [ 3 ].…”

“…Coyer et al also observed that frequent repositioning of the tubes prevented the injury [ 5 ]. Silicone-based thin foam dressings used as a barrier between the skin and ETT fastener can prevent the development of facial ulcers [ 3 ].…”

“…Approximately 16% of Coronavirus disease 2019 (COVID19) pneumonia-induced acute respiratory distress syndrome (ARDS) patients may require endotracheal intubation, with an endotracheal tube (ETT) being adhered to the face with the help of an ETT fastener [ 2 ]. Proning has been shown to improve mortality in these patients [ 3 ]. The combined effect of bodyweight forces (proning) and medical device-related forces in these patients can increase the risk of the development of facial pressure ulcers.…”

Oral Complications of ICU Patients with COVID-19: Case-Series and Review of Two Hundred Ten Cases

“…On reviewing the emerging evidence on ICU-related complications in COVID-19 patients, fourteen studies (one cohort study [20], two case-control studies [21,22], one cross-sectional study [23], two case-series [24,25], and eight case-reports [26][27][28][29][30][31][32][33]) with two hundred ten patients met the inclusion criteria. The majority of the cases were from the Americas (USA n = 103, 49.5%; Brazil n = 4, 1.9%), followed by Europe (Spain n = 57, 27.1%; UK n = 16, 7.6%; France n = 2, 1%; and Italy n = 2, 1%), and Middle East (Iran n = 26, 12.4%).…”

“…The perioral (facial) pressure ulcers have been the most prevalent ICU-related oral complication in COVID-19 patients reported by ten studies in one hundred seventy-nine patients; 73.75% of them were males, and the vast majority were of old age [20][21][22][23]25,[29][30][31][32][33]. Prolonged pronation and endotracheal intubation were the most evident risk factors for perioral pressure ulcers.…”