Pression‐induced facial ulcers by prone position for COVID‐19 mechanical ventilation

Dear Editor, Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), now widespread throughout the world, is responsible for causing extremely variable clinical situations, from asymptomatic or paucisymptomatic forms to serious cases of pneumonia complicated by acute respiratory distress syndrome (ARDS), whose prevalence among COVID-19 patients is up to 17%. For the airway management in case of moderate to severe ARDS, several mechanical ventilation techniques have been adopted, including the prone position, which has proven to be useful for improving ventilation-perfusion matching, increasing end-expiratory lung volume, and preventing ventilator-induced lung injury. In fact, this method, if used for at least 12 hours a day, has been shown to reduce mortality. Nevertheless, at the same time, it is associated with an increased risk of endotracheal tube obstruction and pressure sores. In relation to the latter, we describe the case of a patient hospitalized for COVID-19 and subjected to mechanical ventilation in prone position, who developed pressure ulcers on the face. Our aim is to further enrich the literature related to the current coronavirus pandemic in order to have as much information as possible for an optimal management of these patients. On 12 March, a 48-year-old man, in good general health except for previous episodes of tachycardia for which he was taking beta-blockers, developed the first symptoms such as fever subsequently accompanied by dyspnea. Therefore, on 18March he was hospitalized, where COVID19 interstitial bilateral pneumonia was diagnosed by nasopharyngeal swab and chest X-ray. After 5 days, his clinical condition was worsening and the respiratory insufficiency increasing, evolving towardsARDS.Continuous positive airway pressure (CPAP) used so far was no longer sufficient and he underwent tracheal intubation and was transferred to the intensive care unit where therapy with hydroxychloroquine and antiviral treatmentwas initiated and for 5 days the patient underwent prone positioning cycles. Hospitalization was further prolonged for 10 days for the development of sepsis, resolvedwith appropriate antibiotic therapies. After this, a dermatologic evaluation was requested for the presence of multiple ulcerative lesions on the face, in particular on the chin and nostrils, attributable to pressure exercised by the devices used for mechanical ventilation in particular during the prone positioning phases. These lesions, larger in size at the chin, had an oval morphology tending to asymmetry, covered by fibrinous tissues and a thick eschar on a small area, with initial centripetal re-epithelialization of the edges. At the level of the left nostril and the tip of the nose, superficial erosions of a few millimeters in diameter were observed (Figure 1). Advanced dressings were prescribed, based on collagenase, in order to dissolve the fibrinous component and the crusts, and polyurethane foam with an absorbent and protective function. Currently, the patient is still undergoing medication, with further improvement, as well as his general clinical condition. The emergency we have been experiencing in recent months is putting the whole medical class in front of new challenges in managing a pathology that is not yet known. The consultation of several specialists may be potentially required, therefore cooperation appears fundamental.