Nasal Prongs: Risks, Injuries Incidence and Preventive Approaches Associated with Their Use in Newborns

Figures & data

Table 1 Characteristics of Newborns with and Without Nasal Injuries That Used NIV^a

Variables	NB with Injury (n=55)	NB Without Injury (n=93)	p
Gender (male)	31 (56.36%)	54 (58.06%)	0.865
Gestational Age (weeks)	32.66±4.52	35.23±4.40	0.001*
Birth weight (g)	1935.96±928.10	2376.02±908.90	0.003*
NIV total time (hours)	181.20±129.00	59.21±59.33	0.001*

Notes: ^aValues of the mean±standard deviation or absolute frequency (percentage) of variables of interest in 148 newborns with and without nasal injury. p values associated with the Fisher exact tests and Mann–Whitney. *p < 0.05.

Table 2 Frequency and Severity Nasal Injury in the Evaluated Newborns in the Second Stage of This Study

Gestational Age	<28 Weeks (n=6)	28–31 Weeks (n=7)	32–36 Weeks (n=15)	≥37 Weeks (n=5)
NBs without nasal injury	2 (33.33%)	1 (14.29%)	6 (40.00%)	3 (60.00%)
NBs with Stage I nasal injury	1 (16.67%)	5 (71.42%)	7 (46.67%)	2 (40.00%)
NBs with Stage II nasal injury	3 (50.00%)	1 (14.29%)	2 (13.33%)	0 (0.00%)
Birth weight	<1000 g (n =7)	1000–1499 g (n=8)	1500–2499 g (n=11)	≥2500 g (n=7)
NBs without nasal injury	3 (42.86%)	0 (0.00%)	4 (36.36%)	5 (71.43%)
NBs with Stage 1 nasal injury	1 (14.28%)	6 (75.00%)	6 (54.55%)	2 (28.57%)
NBs with Stage 2 nasal injury	3 (42.86%)	2 (25.00%)	1 (9.09%)	0 (0.00%)
NIV time	24–48 h (n=9)	49–72 h (n=10)	73–96 h (n=5)	> 96 h (n= 9)
NBs without nasal injury	4 (44.44%)	5 (50.00%)	1 (20.00%)	2 (22.22%)
NBs with Stage 1 nasal injury	5 (55.56%)	4 (40.00%)	3 (60.00%)	3 (33.33%)
NBs with Stage 2 nasal injury	0 (0.00%)	1 (10.00%)	1 (20.00%)	4 (44.44%)

Table 3 Preliminary Risk Analysis of the Prong Use in the Newborn

Risk	Cause	Effect	Severity Category	Improvements
Inappropriate binasal prong size	Lack of technical knowledge; Lack of training; Few size variety in the market; Lack of hospital-grade material.	If the prong is smaller than the NB’s nostril, there is: - Increased prong mobility; - Increased friction and pressure on the nasal septum and consequent nasal injury; - Loss of positive pressure and NIV failure. If the prong is larger than the NB’s nostril, there is: - Nostril enlargement and increased pressure on the nasal mucosa, with consequent nasal injury.	III	Following the manufacturer’s instructions is recommended for prong selection; One should use measuring tools provided by the manufacturer to find the adequate prong size for nostrils; In cases in which the prong does not adapt to anatomical characteristics, choosing a prong that does not press the septum is recommended; Manufacturers should develop new sizes that adapt to the NB’s anatomical characteristics.
Binasal prong model	Lack of technical knowledge; Cost reduction.	Prongs with straight insertion catheters may cause nasal injury.	II	Using prong models with adequate curvatures is recommended; One should lubricate the insertion catheters before inserting them into the NB’s nostrils.
Reuse of binasal prongs	Cost reduction; Lack of technical knowledge about the product and the adverse effects of nasal injury.	Prong stiffening, favoring the development of nasal injury.	II	It is recommended that the prong be of single use and disposable; Team awareness programs on the adverse consequences of nasal injury occurrence.
Prolonged NIV use exclusively with binasal prongs	Cost reduction.	Nasal injury due to persistent prong pressure on the same nasal region.	II	Alternation between prongs and masks every 6 hours is recommended; Whenever possible, the interface should be removed and massage should be regularly performed on the nasal septum; Use of nasal protection is recommended; It is recommend using heated and humidified gas flow.
Incorrect binasal prong positioning	Lack of technical knowledge; Lack of professional training; Lack of professional commitment.	Increased prong pressure on nasal structures and consequent nasal injury; Edema and facial deformity; Pain and changes in the sleep and wakefulness state.	II	Training for professionals on adequate prong handling and positioning is recommended, as well as on the adequate positioning of the NB; Regular inspection of the NB and of the NIV circuit; Comfort measures for agitated NBs Velcro using is recommended.
Incorrect NIV circuit positioning	Lack of technical knowledge; Lack of professional training; Lack of professional commitment; Lack of adequate materials to fasten NIV circuit.	Increased prong pressure on nasal structures and consequent nasal injury; Edema and facial deformity; Pain and changes in sleep and wakefulness states.	II	Training for professionals on the correct positioning of the tracheae of the NIV circuit is recommended; Regular inspection of the positioning of the NIV circuit tracheae; Comfort measures for agitated NBs and four-hand care; Providing caps of different sizes and made by adequate material.

Figure 1 Photo of a newborn submitted to NIV through a used but sterilized short binasal prong.

Note: Consent to use the image was obtained by the newborn’s caretaker.

Figure 2 The preventive approaches for nasal injury.