Did You Know? A Third of All Pressure Ulcers May be Occurring at Ears!

My Title for this Blog is based on a study I have recently read entitled: “Incidence, Correlates, And Interventions Used For Pressure Ulcers of the Ear” published in “Medsurg Nursing, Sept-Oct 2011, Vol 20, No 5, pages 241-246.

This is an interesting study done in a 550 bed US hospital. This is an issue I have long known exists. As a Respiratory Therapist I have run across it many times. The surprise is the prevalence this article suggests. The other surprise has been the lack of interest this subject is given when pointed out. Oxygen cannula is generally a ‘very’ low interest item in the healthcare system often delegated to purchasing of the lowest cost item on the market despite the negative sequela that can occur for patients. Previous studies I have read have suggested the percentage of pressure ulcers occurring at the ears as around the 4 to 5 % range. This study began as this facility had noted an increasing incidence that had begun around the 2% and been rising to around 12% in their facility. They referenced other studies that had shown similar trends and noted that virtually all pressure ulcer research was for the lower 1/2 of the body with little study of pressure ulcers to the top half.

With this in mind these researchers decided a study of pressure ulcers around the ears might be warranted. Then the unthinkable happened. The numbers jumped from 12% to 37%.

“Results demonstrated an incidence of pressure ulcers of the ear three times higher than noted on the facility’s quarterly skin assessment audits (37%). The research team questioned this result and investigated further by questioning several nurses and the graduate student who participated in data collection. All involved were able to describe accurately the various stages of pressure ulcer development. Upon subsequent quarterly skin assessment audits, this result was validated by an incidence of 36%.”

My Take-Away: This is an issue that needs to be given more serious consideration. There are solutions, prevention is far cheaper (and more compassionate) than treatment.

Declaration: I have been promoting a cannula that could potentially eliminate this issue for two years now with little interest from healthcare workers (mostly due to contractually obligations and the bureaucracy involved in changing). My solutions are not the only ones available (as the article demonstrates) but either way this issue should be studied and addressed. I was happy to find this group who did. I would post the article in its entirety if it were freely available but it is not. Sorry.

A few quotes I liked:

“The one finding of statistical significance indicated patients who are new to oxygen delivery via nasal cannula are the most susceptible to skin breakdown of the ears.”

“Among the assessed patients (n=100, using a confidence interval of 95%), the incidence of skin break-down was 37%, with a range of 28%-47%. Only one patient exhibited pressure ulceration proximal to the ear on admission. Remaining cases were iatrogenic.”

“Once they develop, these chronic wounds are very resistant to any known medical therapy. Estimates of complete healing for pressure ulcers are as low as 10%.”

“A well-educated staff who actively utilize preventive techniques is central to the identification of pressure ulcer risk and prevention of pressure ulcer development.”

“The purpose of this study was to describe the incidence, severity, and demographic and clinical factors associated with the development of pressure ulcers of the ear for patients using oxygen delivered by nasal cannula during hospitalization on an acute medical-surgical unit.”

“With pressure ulcers of the ear in particular, the discomfort associated with the pressure of nasal cannula tubing can lead patients to remove the tubing, thereby compromising their oxygen therapy.”

Anapod: A Heated Anesthesia Circuit

Medical Devices and Pressure Ulcers

This article was published in AUGUST 2012 by ©2012 ECRI Institute PSO

This is an interesting article which supports concerns I have raised over the past few years. It seems that their is little interest in Pressure Ulcer Prevention in the Respiratory Community. As this article points out it is an issue that should be addressed and I expect it will be, just not in a time frame I would likely set.

“Pressure ulcers found on the head or neck are typically associated with devices, while non-device-related pressure ulcers are generally found else-where (e.g., coccyx, buttocks) (Apold and Rydrych). Th e National Pressure Ulcer Advisory Panel (NPUAP) has stated that mucous membranes are “especially vulnerable to pressure from medical devices, ” including oxygen tubing, endotracheal tubes, and bite blocks (NPUAP).”

I suspect much of the reason could be due to some ambiguity as to who’s responsibility these fall under as they are “Respiratory Products” so nursing leaves them alone whole wound prevention and treatment is typically a Nursing issue so Respiratory does not aggressively pursue this. Thus article alludes to some kind of scenario like this in the following statement.

“one study noted that many staff members were unsure of who to contact regarding an incorrectly fitting device or were unaware of what a correctly fitted device looks like (Apold and Rydrych).”

I think the most obvious issues I saw when working in acute care was due poorly fitting CPAP masks used in attempts to avoid intubating patients (a philosophy I still believe in). Unfortunately the facility would routinely purchase “cheap” masks which required too much tension to maintain a proper fit. I was always looking for douderm to prevent the tissue breakdown which would inevitably occur. I suspect a cost analysis would have shown the cheap masks were far more expensive in the long run. The next most common issue I probably noticed was skin breakdown around the mouth due to endotracheal tubes and less than ideal tube fixation devices. As for cannula I paid little attention unless a nurse or patient specifically expressed a concern. At that time the only option I knew was to pad the cannula with some kind of wrapping or padding, after that I left it to nursing. Today there are much better options I have discussed in other posts but despite more and more literature coming out this does not seem to gain much traction. It is a mystery to me why there seems to be such apathy towards this in the Respiratory Community. Until this changes I will continue to address the subject, write posts and talk to those who will listen.

Medical Devices Pressure Ulcers

Declaration: I sell products that address these issues such as the WestMed soft cannula, Tracoe Tracheostomy Products, IPI ETT Fixation Devices, and B&B Tracheostomy products.