Nasal Columella Injuries in Premature Gestational Age Infants

Purpose: Describe prevention and treatment of nasal columella injuries in premature gestational age infants requiring nasal continuous positive airway pressure (CPAP) with facial masks and nasal prongs.

Background: Premature infants less than 32 weeks gestational age and 1500 grams with greater than 5 days under nasal CPAP and greater than a 14 day stay in the neonatal ICU are susceptible to respiratory
insufficiency requiring ventilator support and increased risk for skin injury. Nasal CPAP devices exert continuous and unrelieved local pressure on the columella and bridge of the nose situated over the
anterior maxillary spine and nasal septum. This pressure compromises perfusion, leading to tissue necrosis.

Description: Three premature 26-weeks gestational age infants in the neonatal intensive care unit experienced full thickness stage 3 injuries of the columella related to use of nasal CPAP prongs. The
oxygen delivery device was examined revealing non-anatomical nasal prong shape, width and projection beyond the columella and alar rim and varying or absence of securement techniques used to
allow for an air-cushion. Limited stock supply was identified resulting in an immediate corrective action. Wound therapy measures consistent with National Pressure Ulcer Advisory Panel (NPUAP) guidelines
were applied. The clinical team partnered to establish a prevention program to address the injuries including team collaboration, instituting consistent prevention measures, medical device supply
review, acquisition and education.

Evaluation and Outcomes: Granulation was achieved over the exposed nasal septum. In one infant with necrosis of the medial crura, columella and quadrangular cartilage, and loss of vertical columella
vertical length, subsequent functional and cosmetic injury will most likely require specialized plastic surgical corrections to restore nasal anatomy and architecture.

Conclusions: Collaborative assessment by nursing and respiratory therapy elevates skin injury prevention and early treatment. Offloading devices hourly for as little as 1-2 minutes allows for air
cushion repositioning and overall pressure relief without excessive stimulation that would impede infant growth and development.