How to treat nasal cannula-induced nose sores?

Treatment of Nasal Cannula-Induced Nose Sores

For nasal irritation and soreness from nasal cannula use, reduce the oxygen flow rate to 4 L/min or below if clinically feasible, apply topical barrier protection, and consider switching to high-flow humidified nasal cannula (HFNC) or alternative oxygen delivery devices if symptoms persist. 1

Immediate Management Strategies

Flow Rate Optimization

• Reduce oxygen flow to ≤4 L/min whenever possible, as nasal discomfort and dryness commonly occur at flows above 4 L/min with standard nasal cannulae 1
• Titrate flow rates downward in 1 L/min increments while monitoring oxygen saturation to maintain target ranges (94-98% for most patients, or 88-92% for those at risk of hypercapnic respiratory failure) 1
• Allow at least 5 minutes at each dose adjustment before further titration 1

Topical Barrier Protection

• Apply a small amount of topical bacitracin ointment (equal to the surface area of a fingertip) to affected nasal areas 1-3 times daily to provide barrier protection and prevent secondary infection 2
• Clean the affected area before each application 2

Device Modifications

• Replace standard polyvinyl chloride (PVC) nasal cannulae with softer silicone-based cannulae, which significantly reduce pressure injury rates 3
• Ensure proper cannula sizing and positioning to minimize pressure points on the nasal septum and columella 4, 3
• Reposition the cannula every 4 hours to redistribute pressure and prevent sustained compression injury 3

Humidification Considerations

When to Add Humidification

• Add humidification for oxygen flows ≥5 L/min, as this significantly reduces the incidence of severe nasal irritation and epistaxis compared to non-humidified oxygen 5
• For low-flow oxygen (<5 L/min), humidification provides minimal subjective benefit for most patients, though complaints of dry nose and throat remain common regardless 6
• Humidification is particularly important for patients on anticoagulant or antiplatelet therapy to prevent epistaxis 5

High-Flow Humidified Nasal Cannula (HFNC)

• Consider transitioning to HFNC if standard nasal cannulae cause persistent discomfort, as HFNC provides warm, humidified oxygen with superior patient comfort and tolerance 1, 7
• HFNC delivers flows up to 60 L/min with integrated humidification, eliminating nasal dryness while providing better oxygenation 1, 7
• HFNC is preferred over conventional oxygen therapy for patients requiring medium to high-concentration oxygen who experience device-related discomfort 1, 7

Alternative Oxygen Delivery Methods

When Standard Nasal Cannulae Fail

• Switch to a simple face mask at 5-10 L/min if nasal irritation is severe and oxygen requirements allow, though face masks have disadvantages including claustrophobia and interference with eating/speaking 1
• Consider Venturi masks for more precise oxygen delivery if nasal route is not tolerated, using appropriate flow rates (24% at 2-3 L/min, 28% at 4-6 L/min, etc.) 1
• For patients requiring long-term oxygen therapy (LTOT) with persistent nasal issues, evaluate for transtracheal oxygen delivery via percutaneous catheter, particularly for those with high oxygen demands 1

Protective Dressing Application

Evidence-Based Barrier Strategies

• Apply polyvinyl foam barrier dressings to nasal cannula prongs to reduce pressure injury incidence by 6-fold compared to unprotected devices 4
• Place the adhesive side of precut foam barriers against the cannula prongs, not directly on skin 4
• Ensure protective dressings are properly positioned and replaced regularly to maintain effectiveness 3

Monitoring and Reassessment

Follow-Up Protocol

• Reassess nasal skin integrity every 4 hours during oxygen therapy to detect early pressure injury development 3
• Monitor for stage 1 injuries (non-blanchable erythema) and intervene immediately before progression to deeper tissue damage 4, 3
• Evaluate oxygen saturation continuously after any device or flow rate changes to ensure adequate oxygenation is maintained 1

Common Pitfalls to Avoid

• Do not discontinue humidification for high-flow oxygen (≥5 L/min), as this significantly increases epistaxis risk even in the absence of anticoagulation 5
• Avoid using water for nebulization or humidification, as it may cause bronchoconstriction; use 0.9% sodium chloride instead 1
• Do not delay switching to alternative delivery methods if nasal injuries progress beyond stage 1, as continued pressure can lead to columella necrosis 4
• Never assume humidification is unnecessary for all low-flow oxygen—individual patient factors (mucosal dryness, anticoagulation status) should guide this decision 6, 5