Does using a nasal barrier dressing prevent nasal injury inpremature infants receiving nasal continuous positive airway pressure?

Abstract

Commentary on: Imbulana DI, Owen LS, Dawson JA, Bailey JL, Davis PG, Manley B. A Randomized Controlled Trial of a Barrier Dressing to Reduce Nasal Injury in Preterm Infants Receiving Binasal Noninvasive Respi ratory Support. The Journal of Pediatrics 2018; https://doi.org/10.1016/j.jpeds.2018.05.026. Most widely used and effective interfaces to provide “non-invasive” respiratory support to infants involve binasal prongs, which rely upon a tight fit at the nares to transmit pressure to the distal airways, preventing atelectasis and maintaining functional residual capacity 1. NCPAP-related nasal injury is a common complication of these interfaces 2. Special dressings have been manufactured to prevent this complication and have been found to be effective in larger infants 3-5. The current study aimed to evaluate a barrier dressing in smaller, less mature infants. This manuscript described a single-centre, prospective, randomised trial comparing the use of a nasal barrier dressing to no dressing for the prevention of nasal injury in premature neonates (<30 weeks’ gestation and/or <1250 g) receiving NCPAP. The primary outcome was nasal injury as evaluated by the bedside nursing staff each shift using a standardised chart and staging system. Secondary outcomes included relevant respiratory outcomes as well as common neonatal morbidities and mortality. An additional secondary outcome involved assessment of nasal injury on photograph by a blinded evaluator. Although the study aimed to achieve 80% power to detect a 40% relative reduction in the primary outcome, the recruitment goal was not reached, and the study was stopped early after 16 months due to slow enrolment. No infants were lost during the follow-up period (until 36 weeks’ postmenstrual age). Despite not reaching the accrual goal, the investigators were able to demonstrate a reduction in nasal injury with the use of the dressing with a number needed to treat of five infants to prevent one injury. The cost analysis demonstrated that the intervention is cost-effective at the study centre. The study was underpowered for the subgroup analyses as reported. A weakness of the study relates to the assessment of the primary outcome. The bedside nurses documenting the presence and stage of nasal injury were not blinded to the treatment, introducing risk for bias. Additionally, their ability to assess for nasal injury was often limited by the presence of the nasal barrier, which obstructed the view of the area to be examined. Using photographs and a blinded evaluator would have helped overcome these limitations. This was attempted, but there were a limited number of photographs available for assessment, and ten infants had no photograph at all. This, along with the limited power of the study, renders the finding of no difference between groups in the incidence of nasal injury as found by the blinded observer difficult to interpret. Further research is required into the optimal material, design and protocol for the use of nasal barrier dressings in neonates receiving non-invasive respiratory support. Future studies should blind evaluators to the intervention to reduce the risk for bias. While further study is needed, three prospective trials have now demonstrated the efficacy of barrier dressings at preventing NCPAP-associated nasal injury 2-4. Therefore, consideration should be given to the immediate adoption of nasal barrier dressings as a cost-effective method to prevent nasal injury in this population. https://ebneo.org/2018/09/nasal-barrier-dressing None. None.