Preventing Pressure Ulcers

Discover how pressure ulcers form and learn how to prevent pressure ulcers from developing during noninvasive ventilation (NIV). 


What is a pressure ulcer?

A pressure ulcer, also known as a pressure sore or pressure injury, refers to localised damage to the skin and the underlying tissues. These ulcers usually appear on thin tissue covering bony parts of the body that are in contact with hard surfaces such as a bed or a medical device.1

Signs and stages of a pressure ulcer

Signs of a pressure ulcer developing can first be seen when the area on the patient’s skin in contact with the device becomes red and warm to the touch. There are four progressive stages as shown below:
Stage 1
A localized red area that is warm to the touch. The term pressure injury is used as the skin is not yet broken at this stage.
Stage 2
A pressure ulcer is visible as the skin is broken and partially lost.
Stage 3
The pressure ulcer and tissue necrosis extends through all the skin layers. The underlying fat layer is also visible.
Stage 4
The pressure ulcer and tissue necrosis extends down to the fat, muscle and bone or cartilage.

Low pressure for longer periods of time is more likely to cause a pressure ulcer 
than high pressure for a short period of time.3

Factors affecting the formation of pressure ulcers

In order for tissues to carry out their normal functions, they need a healthy supply of blood through blood vessels. Restrictions in blood flow to tissues have been found to contribute to the development of a pressure ulcer.


Excessive pressure from an ill-fitted mask or prolonged pressure from lying in one position for too long can cause vessels to collapse and subsequently hinder the blood supply to that localised pressure point. This causes redness and, over time, contributes to progressive tissue death.1

Friction and shear

If skin is continuously rubbing on a surface, this can cause initial irritation. It can then develop into an abrasion wound. Shear forces between thin tissue and a hard surface pushing in opposing directions, such as sliding down a bed, can cause delicate vessels to stretch and tear resulting in the development of a pressure ulcer.4

Ageing and poor nutrition

The skin and fat layers become thinner with old age or with poor nutrition due to reduced collagen and other components which keep the skin structurally sound. This makes bones protrude more. As a result, older and sicker patients are more prone to developing pressure ulcers.1

Noninvasive masks and pressure ulcers

NIV masks have been cited as one of the leading causes of pressure injuries in the ICU and, with respiratory failure ranking as one of the top patient conditions requiring admission into critical care, patients fitted with NIV masks are at an increased risk of developing pressure ulcers.2
F&P mask sizes

Wrong mask size

A mask that is too big places unnecessary pressure on the face.
A mask that is too small causes unwanted friction.

Shift the mask with ease to ensure comfort

Shifting without adjusting

Shifting the mask without loosening the straps pulls on the face causing unwanted friction and shear forces.

Poor alignment can have negative impact on patient comfort

Poor mask alignment

If the mask is not sitting symmetrically, it may place extra pressure on facial areas.

Risk areas for a pressure ulcer

For NIV to work efficiently, leaks must be minimized, so it can be tempting to overtighten the mask. However, this increases the risk of a pressure ulcer developing as it places excess pressure on the face by the mask and straps.9

It is important to keep in mind that most modern ventilators can compensate for any leak that may occur and often do not require the mask to be heavily tightened.10

Contact points of the mask and headgear are areas to check for pressure ulcer formation.

A common mistake that can cause a pressure ulcer to develop
is when the mask is fitted too tightly.

Minimize the risk of a pressure ulcer from an NIV mask

Comfort is important to improve patient tolerance to NIV. Effective NIV therapy can help reduce time in the ICU and length of stay in the hospital.11

To help prevent the development of a pressure ulcer, finding the perfect balance between a good seal and a mask that does not apply too much pressure is fundamental for a quality patient experience.
Medical staff helping patient to reduce chance of pressure ulcers forming

How to prevent pressure ulcers and pressure injuries

  • Finger to Forehead: Use an interface with supportive headgear that is not too restrictive. Placing two fingers comfortably between the headgear and the forehead can help ensure that it is well fitted.
  • Keep Clean: Maintain good skin and mask hygiene to minimize infection risk.12
  • Try for Size: Have a variety of mask types that the patient can try to ensure that they are wearing the correct mask.13
  • Check Again: Check and readjust the mask often. Swelling can cause the mask to become too tight, even if it was initially fitted correctly. It is important to constantly monitor the fitting.13

Take care of the pressure

Our NIV therapy solutions are thoughtfully designed with you and your patient in mind. 

Facial pressure care, comfort care and ease of care are thoughtfully incorporated into our products.