NPIAP Releases Position Statements on N95 Mask Injuries

• By Laurie Watanabe
• Apr 15, 2020

If you’ve closely followed news on the COVID-19 pandemic, you’ve probably seen images of hard-working frontline healthcare professionals with facial and skin injuries — abrasions and open wounds where N95 masks have rubbed and cut into their skin and tissue.

The National Pressure Injury Advisory Panel (NPIAP) has released position statements on mask injuries and how they can be prevented.

In an April 15 bulletin, the NPIAP said, “We applaud the heroes in the healthcare provider workforce. We are deeply concerned about the facial injuries we are seeing in fellow clinicians as a result of prolonged use of N95 respirator masks while caring for patients with COVID-19.”

The NPIAP collaborated with the European Pressure Ulcer Advisory Panel and the Pan Pacific Pressure Injury Alliance to develop “an evidence-based guideline” to help prevent pressure injuries caused by N95 masks. The organizations also kept a critical COVID-19 goal in mind: “The essential function of a Personal Protective Equipment (PPE) mask (i.e., to prevent COVID-19 transmission from patient to provider) cannot be compromised.”

The NPIAP called the resulting position paper “unique” because “it combines current evidence in both pressure injury prevention and PPE science as a basis for recommendations within the context of the COVID-19 crisis. COVID-19 is a novel virus with a relatively high rate of transmission, morbidity and mortality. Where direct evidence was lacking or inconclusive, we placed greater weight on the need to prevent COVID-19 infection. We analyzed the evidence using the Strength of Evidence ratings developed for the 2019 International Pressure Injury Guideline.”

Why Mask Usage Is Causing Pressure Injuries

The position paper noted that pressure and shear, known to cause pressure injuries in patients, are now causing pressure injuries in healthcare providers who, because of the COVID-19 pandemic, are wearing PPE masks, face shields and goggles for long periods at a time, day after day.

“N95 respirator masks have a particularly high risk for injury due to requirements for a tight fit,” the position paper noted. “Skin injury can also occur as a result of friction and the accumulation of moisture under the mask.”

The position paper explains that the intensity of pressure and shear, the duration of the pressure and shear, and each person’s tissue tolerance — which can be impacted by friction and shear — are the factors that could be influenced or controlled to try to prevent injuries.

A possible intervention, for instance, would be to reduce friction by applying a liquid skin sealant or protectant on skin that will be in contact with the mask, and allowing the sealant or protectant to fully dry before donning the mask. Keeping skin clean and appropriately hydrated while avoiding alkaline soaps and harsh chemical solutions is another recommendation.

The NPIAP, however, recommended against using petroleum jelly, mineral oil, or any other product that could cause the mask to slip and therefore make it less effective.

And the position paper did not recommend using a prophylactic dressing under the mask, because though there is some evidence that such dressings could lower pressure injury risk, there are “critical uncertainties” about whether those dressings would also make the masks less effective in preventing COVID-19 spread.

Healthcare professionals who opt to use dressings with their masks are advised in the position paper not to stack multiple dressings and to make sure outer-layer dressings aren’t permeable.

Taking Breaks from Mask Wearing

The position paper recommends removing a mask for 15 minutes every two hours while away from patients. Lifting the sides of the mask for five minutes every two hours is helpful if the healthcare professional can’t take a longer break from mask wearing.

“Any pressure relief will be helpful,” the paper says. “Wash hands before and after touching masks.”

Using prophylactic dressings with surgical masks and other PPE is fine, so long as the function of the devices isn’t compromised, the paper added.

Abrasions should be treated “with topical moisturizers, liquid skin protectants/sealants or cyanoacrylates,” the paper said. “Thin occlusive dressings may be used to protect open wounds if they do not interfere with the mask seal.”

Healthcare professionals presenting with Deep Tissue Injuries, Stage 3, Stage 4, or Unstageable pressure injuries should receive professional wound care assessment and treatment.

To read the position paper in full, click HERE.

To see the infographic on protecting against pressure injuries while wearing N95 masks, click HERE.