Incidence and Risk Factors of Nasal Pressure Injuries in Neonates Receiving Noninvasive Ventilation

<b>Background/Objective:</b> Nasal pressure injuries following non-invasive ventilation (NIV) have remained a common complication. Available evidence on injury severity characteristics, timing, and predictors of progression to moderate-severe injury, especially in large cohorts, is limited. The objective was to assess the incidence, characteristics and risk factors for nasal pressure injuries among neonates on NIV in a large tertiary neonatal intensive care unit (NICU). <b>Methods:</b> This retrospective observational study recruited all infants who experienced nasal pressure injury while on NIV from March 2018 to November 2022. The severity of the injury was categorized by the Fischer classification. Demographics, perinatal, respiratory, and device-related factors were examined. Multivariable logistic regression revealed independent predictors of moderate to severe injury. <b>Results:</b> There were 237 nasal injury episodes in 226 infants (0.406 per 100 device-days), considering 17,004 NICU admissions and 58,363 NIV device-days. Most injuries were mild (Stage I 81%) while 19% were moderate-severe (Stage II-III). Early injuries (≤3 days after NIV) were present in 83.5% of patients and were often related to the nasal bridge. In particular, late-onset injuries (>3 days) were more likely in infants with previous injury, exposure to postnatal steroids, longer prior intubation, or septal involvement. Moreover, multivariable analysis identified three specific independent predictors of moderate-severe injury previous nasal injury (aOR 6.25, 95% CI 1.11-35.35), septal or combined bridge/septum involvement (aOR 2.98, 95% CI 1.04-8.43), and prolonged period of positive pressure ventilation at birth (aOR 1.23 per minute, 95% CI 1.04-1.45). <b>Conclusions:</b> Most nasal pressure injuries seen during NIV are mild and early; however, recurrence, septal involvement, and prolonged resuscitative ventilation markedly increase the risk of severe injury. Improving surveillance on early NIV use, monitoring of septal pressure points, and proactive interventions with interface management will aid in minimizing preventable nasal morbidity.