title: Face Masks for Noninvasive Ventilation: Fit, Excess Skin Hydration, and Pressure Ulcers.
abstract: BACKGROUND
  Pressure ulcers (stages III and IV) are serious safety events (ie, never events). Healthcare institutions are no longer reimbursed for costs to care for affected patients. Medical devices are the leading cause of pediatric pressure ulcers. Face masks for noninvasive ventilation were associated with a high percentage of pressure ulcers at our institution.
  
  
  METHODS
  A prospective cohort study investigated factors contributing to pressure ulcer development in 50 subjects using face masks for noninvasive ventilation. Color imaging, 3-dimensional surface imaging, and skin hydration measurements were used to identify early skin compromise and evaluate 3 interventions to reduce trauma: (1) a silicone foam dressing, (2) a water/polyethylene oxide hydrogel dressing, and (3) a flexible cloth mask. A novel mask fit technique was used to examine the impact of fit on the potential for skin compromise.
  
  
  RESULTS
  Fifty subjects age 10.4 ± 9.1 y participated with color images for 22, hydration for 34, and mask fit analysis for 16. Of these, 69% had diagnoses associated with craniofacial anomalies. Stage I pressure ulcers were the most common injury. Skin hydration difference was 317 ± 29 for sites with erythema versus 75 ± 28 for sites without erythema (P < .05) and smallest for the cloth mask (P < .05). Fit distance metrics differed for the nasal, oronasal, and face shield interfaces, with threshold distances being higher for the oronasal mask than the others (P < .05). Areas of high contact were associated with skin erythema and pressure ulcers.
  
  
  CONCLUSIONS
  This fit method is currently being utilized to select best-fit masks from available options, to identify the potential areas of increased tissue pressure, and to prevent skin injuries and their complications. Improvement of mask fit is an important priority for improving respiratory outcomes. Strategies to maintain normal skin hydration are important for protecting tissue integrity.
authors.affiliation: Skin Sciences Program and Division of Plastic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio. marty.visscher@gmail.com.
authors.forename: Marty O
authors.initials: MO
authors.lastname: Visscher
authors.affiliation: Division of Respiratory Care, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
authors.forename: Cynthia C
authors.initials: CC
authors.lastname: White
authors.affiliation: Skin Sciences Program and Division of Plastic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: Jones
authors.affiliation: Division of Respiratory Care, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
authors.forename: Thomas
authors.initials: T
authors.lastname: Cahill
authors.affiliation: Division of Plastic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
authors.forename: Donna C
authors.initials: DC
authors.lastname: Jones
authors.affiliation: Division of Plastic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
authors.forename: Brian S
authors.initials: BS
authors.lastname: Pan
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D003116:Color; D019465:Craniofacial Abnormalities / Q000150:complications; D004890:Erythema / Q000209:etiology / Q000503:physiopathology; D005145:Face; D005148:Facial Dermatoses / Q000209:etiology / Q000517:prevention & control*; D005260:Female; D006801:Humans; D020100:Hydrogels / Q000627:therapeutic use; D021621:Imaging, Three-Dimensional; D007223:Infant; D008297:Male; D008397:Masks / Q000009:adverse effects*; D063087:Noninvasive Ventilation / Q000295:instrumentation*; D010781:Photography; D011092:Polyethylene Glycols / Q000627:therapeutic use; D011312:Pressure / Q000009:adverse effects*; D003668:Pressure Ulcer / Q000209:etiology / Q000517:prevention & control*; D011446:Prospective Studies; D012828:Silicones / Q000627:therapeutic use; D012867:Skin / Q000503:physiopathology*; D013501:Surface-Active Agents / Q000627:therapeutic use; D055815:Young Adult
chemical_list: D020100:Hydrogels; D012828:Silicones; D013501:Surface-Active Agents; D011092:Polyethylene Glycols
keywords: 3-dimensional imaging; color imaging; craniofacial anomaly; erythema; face mask; mask fit; noninvasive ventilation; pressure ulcer; skin compromise; skin hydration