Impact of Systematic Training and CPAP Checklist in the Prevention of NCPAP Related Nasal Injuries in Neonates- A Quality Improvement Study

  • Suja Mariam
  • Siddartha BuddhavarapuEmail author
Original Article



Nasal continuous positive airway pressure (NCPAP) related nasal injury in neonates is a type of device-related pressure injury and is a common event with the varying incidence in different hospitals. Understanding and adhering to the recommendation of the manufacturer in fixing the NCPAP interface is vital for the prevention of nasal injuries. A quality improvement initiative was undertaken to decrease the incidence of NCPAP related nasal injuries in a Level 3 neonatal unit by using a customized NCPAP checklist and application of the checklist using Plan-Do-Study-Act (PDSA) cycles.


A baseline audit was conducted for two months. An evidence-based checklist was formed by a quality improvement team and was exercised by a designated CPAP nurse using videos, small seminars, handouts, and hands-on training. Modifications in the checklist were done during the study using three PDSA cycles.


A total of 129 babies with a median gestational age of 31 wk (IQR: 28–34 wk), median birth weight of 1320 g (IQR: 1030–1842 g) were studied. The mean duration of NCPAP was 5.4 d. The incidence of CPAP injuries decreased from 91 per 1000 CPAP days to 8 per 1000 CPAP days over 8 mo. The compliance with fixing NCPAP as per recommendation improved from 35% to 95% during the study with p values <0.05.


Nurses training based on a structured checklist and highlighting important features of standardized NCPAP care helps in preventing NCPAP related nasal injury.


Quality improvement Nasal injury NCPAP Neonatal nurses CPAP checklist 



The authors thank their nursing team members Mrs. Latha. S. Kumari and Ms. Nandhini. S who were members of the quality improvement team.

Authors’ Contribution

SM planned the study, organized training sessions as mentioned, prepared the manuscript; SB approved and supervised the project, reviewed and finalized the manuscript. SB is the guarantor for this article.

Compliance with Ethical Standards

Conflict of Interest



  1. 1.
    Haesler E. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Cambridge Media: Osborne Park; 2014.Google Scholar
  2. 2.
    Squires AJ, Hyndman M. Prevention of nasal injuries secondary to NCPAP application in the ELBW infant. Neonatal Netw. 2009;28:13–27.CrossRefGoogle Scholar
  3. 3.
    Imbulana DI, Manley BJ, Dawson JA, Davis PG, Owen LS. Nasal injury in preterm infants receiving non-invasive respiratory support: a systematic review. Arch Dis Child Fetal Neonatal Ed. 2018;103:F29–35.CrossRefGoogle Scholar
  4. 4.
    do Nascimento RM, Ferreira AL, Coutinho AC, Santos Veríssimo RC. The frequency of nasal injury in newborns due to the use of continuous positive airway pressure with prongs. Rev Lat Am Enfermagem. 2009;17:489–94.CrossRefGoogle Scholar
  5. 5.
    Fischer C, Bertelle V, Hohlfeld J, Forcada-Guex M, Stadelmann-Diaw C, Tolsa JF. Nasal trauma due to continuous positive airway pressure in neonates. Arch Dis Child Fetal Neonatal Ed. 2010;95:F447–51.CrossRefGoogle Scholar
  6. 6.
    DeRowe A, Landsberg R, Fishman G, Halperin D, Fliss D. Neonatal iatrogenic nasal obstruction. Int J Pediatr Otorhinolaryngol. 2004;68:613–7.CrossRefGoogle Scholar
  7. 7.
    Smith LP, Roy S. Treatment strategy for iatrogenic nasal vestibular stenosis in young children. Int J Pediatr Otorhinolaryngol. 2006;70:1369–73.CrossRefGoogle Scholar
  8. 8.
    Verder H, Bohlin K, Kamper J, Lindwall R, Jonsson B. Nasal CPAP and surfactant for treatment of respiratory distress syndrome and prevention of bronchopulmonary dysplasia. Acta Paediatr. 2009;98:1400–8.CrossRefGoogle Scholar
  9. 9.
    Yong SC, Chen SJ, Boo NY. Incidence of nasal trauma associated with nasal prong versus nasal mask during continuous positive airway pressure treatment in very low birthweight infants: a randomised control study. Arch Dis Child Fetal Neonatal Ed. 2005;90:F480–3.CrossRefGoogle Scholar
  10. 10.
    Chandrasekaran A, Thukral A, Jeeva Sankar M, Agarwal R, Paul VK, Deorari AK. Nasal masks or binasal prongs for delivering continuous positive airway pressure in preterm neonates-a randomised trial. Eur J Pediatr. 2017;176:379–86.CrossRefGoogle Scholar
  11. 11.
    Say B, Kanmaz Kutman HG, Oguz SS, et al. Binasal prong versus nasal mask for applying CPAP to preterm infants: a randomized controlled trial. Neonatology. 2016;109:258–64.CrossRefGoogle Scholar
  12. 12.
    Goel S, Mondkar J, Panchal H, Hegde D, Utture A, Manerkar S. Nasal mask versus nasal prongs for delivering nasal continuous positive airway pressure in preterm infants with respiratory distress: a randomized controlled trial. Indian Pediatr. 2015;52:1035–40.CrossRefGoogle Scholar
  13. 13.
    Kieran EA, Twomey AR, Molloy EJ, Murphy JF, O'Donnell CP. Randomized trial of prongs or mask for nasal continuous positive airway pressure in preterm infants. Pediatrics. 2012;130:e1170–6.CrossRefGoogle Scholar
  14. 14.
    Jasani B, Ismail A, Rao S, Patole S. Effectiveness and safety of nasal mask versus binasal prongs for providing continuous positive airway pressure in preterm infants-a systematic review and meta-analysis. Pediatr Pulmonol. 2018;53:987–92.CrossRefGoogle Scholar
  15. 15.
    Newnam KM, McGrath JM, Salyer J, Estes T, Jallo N, Bass WT. A comparative effectiveness study of continuous positive airway pressure-related skin breakdown when using different nasal interfaces in the extremely low birth weight neonate. Appl Nurs Res. 2015;28:36–41.CrossRefGoogle Scholar
  16. 16.
    Newnam KM, McGrath JM, Estes T, Jallo N, Salyer J, Bass WT. An integrative review of skin breakdown in the preterm infant associated with nasal continuous positive airway pressure. J Obstet Gynecol Neonatal Nurs. 2013;42:508–16.CrossRefGoogle Scholar
  17. 17.
    Imbulana DI, Owen LS, Dawson JA, Bailey JL, Davis PG, Manley BJ. A randomized controlled trial of a barrier dressing to reduce nasal injury in preterm infants receiving binasal noninvasive respiratory support. J Pediatr. 2018;201:34–9.e3.CrossRefGoogle Scholar
  18. 18.
    Xie LH. Hydrocolloid dressing in preventing nasal trauma secondary to nasal continuous positive airway pressure in preterm infants. World J Emerg Med. 2014;5:218–22.CrossRefGoogle Scholar
  19. 19.
    Gunlemez A, Isken T, Gokalp AS, Turker G, Arisoy EA. Effect of silicon gel sheeting in nasal injury associated with nasal CPAP in preterm infants. Indian Pediatr. 2010;47:265–7.CrossRefGoogle Scholar
  20. 20.
    Bhat A. Nasal trauma in neonates receiving CPAP and its prevention in tertiary care hospital. J Med Sci. 2017;20:96–100.CrossRefGoogle Scholar
  21. 21.
    Nzegwu NI, Mack T, DellaVentura R, et al. Systematic use of the RAM nasal cannula in the Yale-New Haven Children's hospital neonatal intensive care unit: a quality improvement project. J Matern Fetal Neonatal Med. 2015;28:718–21.CrossRefGoogle Scholar
  22. 22.
    Bonner KM, Mainous RO. The nursing care of the infant receiving bubble CPAP therapy. Adv Neonatal Care. 2008;8:78–95; quiz 6-7.CrossRefGoogle Scholar
  23. 23.
    Khan J, Sundaram V, Murki S, Bhatti A, Saini SS, Kumar P. Nasal injury and comfort with jet versus bubble continuous positive airway pressure delivery systems in preterm infants with respiratory distress. Eur J Pediatr. 2017;176:1629–35.CrossRefGoogle Scholar
  24. 24.
    Langley GLMR, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance, 2nd ed. San Fransico: Jossey-Bass Publisher; 2009.Google Scholar
  25. 25.
    Pressure ulcers in adults: prediction and prevention. Quick reference guide for clinicians. Agency for Health Care Policy And Research. Decubitus. 1992;5:26–30.Google Scholar

Copyright information

© Dr. K C Chaudhuri Foundation 2020

Authors and Affiliations

  1. 1.Division of NeonatologySri Ramakrishna HospitalCoimbatoreIndia

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