METHODS OF COMPRESSION

THERAPY

PUTTIN THE SQUEEZE ON!!

NORTHEAST WYOMING SKIN AND WOUND SYMPOSIUM

OBJECTIVES

• 1. Understand the role compression play in wound care

• 2. Understand the types of compression options available in wound care

• 3. Recognize the appropriate patient for compression therapy

• 4. Apply various products for compression therapy.

COMPRESSION THERAPYWHAT???

• Compression therapy is the application of pressure to the lower extremities. It is recognized treatment of choice for recurrent venous leg ulcers.

• Compression therapy systems include hosiery, tubular bandages and bandage systems

comprising two or more components. These systems aim to provide graduated compression to

the lower limb in order to improve venous return and to reduce edema

http://wwundsinternational.com/pdf/content_10802.pdfw.wo

HOW DO WE DEFINE THIS IN PRACTICE

• ELASTIC• INEALSTIC• STATIC• DYNAMIC• WRAPS• HOSE

•HELP!!!!!

PURPOSE

1. Counteract the force of gravity and promote the normal flow of venous blood up the leg

2. Acts on the venous and lymphatic systems to improve venous and lymph return and reduce edema

Meissner,M, Lower Extremity Venous Anatomy, Interventional Radiology, Sept. 2005, ; 22(3): 147-158

WHAT IS NORMAL????

WHAT IS “NORMAL”STRUCTURE

VENOUS SYSTEM

• DEEP VEINS• SUPERFICIAL VEINS• PERFORATORS

Semin Intervent Radiol. Sep 2005; 22(3): 147–156.

FUNCTION

Reflow of the oxygen-poor blood from the muscles and tissues to the heart.

VENOUS VALVES function in a one-way direction

2011 Dr. Peter-Michael Rücker

WHAT IS ABNORMAL??

ANATOMICAL FAILURE

Venous Wall Physical Properties: Reduced Strength

Venous ValvesPrimary Venous Disease: degenerative damage

Secondary Venous Disease: DVT

Calf Pump

90% of venous return is through these 3

Fletcher, Moffatt, Partsch, Vowden, Vowden: Principles of Compression in venous disease, a practioner’s guide to treatment and prevention of venous leg ulcers; Wounds International: 2013

LYMPHATICS

MEM: Manual Edema Mobilization

“Pre” Lymphedema

High Protein Edema

VENOUS PRESSURE = EDEMA

Ambulatory Venous Hypertension:The elevated pressure in the leg

vein during walking.

Partsch, H; compression therpay of venous ulcers;, Hemodynamic effects depend on interface pressure and stiffness; EWMA Journal 2006, vol 6 NO2.

How Much Pressure Is Normal??

Resting Pressure: -40 mmHG

Standing: + 30-40 mmHG

Ambulation: -70-90 mmHg

Partsch H, Annuals Vascular Disease 2012

DOES EDEMA EFFECT WOUND HEALING???

• Inflammation• Fibrosis• Induration• Ischemia

Beidler et al, Multiplexed analysis of matrix metalloproteinases in leg ulcer tissue of patients with chronic venous insufficiency before and after compression therapy. Wound Rep Regen 16:642-648, 2008.

Elevated MMP-1 in Venous Ulcers

NO COMPRESSION/ COMPRESSION

Common Clinical Presentation

WHAT MUST WE DO ABOUT IT?

COUNTERACT GRAVITY

COMPRESSION THERAPY

La Places Law• Pressure = N x T x 4620• C x W• ■ N = Number of• layers applied – the• more layers, the• greater the pressure• ■ T = Bandage• tension – the greater• the force applied,• the greater the• pressure• ■ C = Limb• circumference/• shape – the smaller• the circumference• at any given point,• the greater the• pressure• ■ W = Bandage width• – the narrower the• bandage, the• greater the pressure

World Union of Wound Healing societies (WUWHS). Principles of best practice: Compression in venous leg ulcers. A consensus document. London: MEP Ltd,2008

WHAT TO DO BEFORE COMPRESSION

ABI: ANKLE/BRACHIAL INDEX• Greater than 0.90 = normal • 0.71 – 0.90 = mild obstruction • 0.41 – 0.70 = moderate obstruction • Less than 0.40 = severe obstruction

WHAT IS ADAQUATE COMPRESSION

Overcome intravenous pressure, adjusted to body position

Exert a sub-bandage resting pressure that is well tolerated in a resting position

Provides a pressure increase when the patient rises to a standing position: (50-70mmHG)

Provide external compression improving venous reflux during walking

Fletcher, Moffatt, Partsch, Vowden, Vowden: Principles of Compression in venous disease, a practioner’s guide to treatment and prevention of venous leg ulcers; Wounds International: 2013

Partsch, H; compression therpay of venous ulcers;, Hemodynamic effects depend on interface pressure and stiffness; EWMA Journal 2006, vol 6 NO2.

STIFFNESSThe relationship between the resting and working pressures of a compression device

Achieved through use of inelastic bandages in multiple layers

Measured in SSI(Static Stiffness Index)LOW SSI: <10: KNITTED STOCKING, ELASTIC BANDAGESMED SSI: FLAT KNITTED STOCKINGHIGH SSI: >10 SHORT STRETCH ,MULTICOMPONENT BANDAGES, ZINC PASTE WRAPS, VELCRO WRAPS

Partsch, H; compression therpay of venous ulcers;, Hemodynamic effects depend on interface pressure and stiffness; EWMA Journal 2006, vol 6 NO2.

Types of Bandages

Non-Stretch

Short –Stretch

Long -Stretch

Non-Stretch

ZINC PASTE BANDAGES

Short Stretch

Bandages that stretch to less than 100% of their original length: minimal extensibility

High Working Pressure/Low Resting Pressure

Long Stretch

Expands over 100% of its original length

Low Working Pressure/High Resting Pressure

Contains Elastomeric Fibers: fibers that are able to stretch and return to almost their original size.

World Union of Wound Healing societies (WUWHS). Principles of best practice: Compression in venous leg ulcers. A consensus document. London: MEP Ltd,2008

NOTEBECAUSE OF THEIR ABILITY TO SUSTAIN PRESSURE, SOME CLINICIANS BELIEVE THAT ELASTIC MATERIAL MAY BE MORE EFFECTIVE THAN INELASTIC MATERIALS FOR IMMOBILE PATIENT OR THOSE WITH A FIXED ANKLE, BUT LESS APPRIOPRIATE AND MORE UNCOMFORTAVLE FOR PATIENT WITH IMPAIRED PERIPHERAL PERFUSION. FURTHER RESEEARCH IS REQUIRED TO CONFIRM THIS AND CLINICIANS SHOULD BE AWARE THAT INELASTIC MATERIAL CAN PROVDE PRESSURE PEAKS EVEN DURING SMALL ANKLE FLEXIONS. World Union of Wound Healing societies (WUWHS). Principles of best practice: Compression in venous leg ulcers. A consensus document. London: MEP Ltd,2008

Other compression devices

Hose/Support Stockings

Made of elasticated textile

STYLES: KNEE, THIGH, PANTYHOSE LENGTHS

CUSTOM OR OFF THE SHELF

Can be used as first line treatment in patient with small ulcers. 2-component systems

LEVELS OF COMPRESSION

Class I: 14-18 mmhg: Anti-Embolism hoseNot a therapeutic level of compression

Class II: 18-24 mmhg: dependent edema, non-ambulatory, CHFClass III: 25-35mmhg: Venous InsufficiencyClass IV: Lymphedema, need to have active muscle movement

Intermittent Pneumatic Compression

EVIDENCE SUGGESTS

A boot comprising air-filled chambers attached to an electric pump- used in combination with compression bandaging may be more effective that bandaging alone.

Schuler JJ, Maibenco T, Megerman J, Ware M, Montalvo J; Treatment of chronic venous ulcers using sequential gradient intermittent pneumatic compression; Phlebology / Venous Forum of the Royal Society of Medicine; 1996, vol 11,issue 3.

Things To Consider

ETIOLOGY OF WOUNDPATIENTS MOBILITY

PATIENTS ACCESS TO CAREULCER SITE

PATIENTS TOLERANCE

TAKE HOME PEARLS

• CONSIDER COMPRESSION IN LOWER EXTREMITY ULCERS

• DO ARTERIAL SCREENING• BE COMPETENT IN COMPRESSION WRAPPING• PICK YOUR PATIENTS• EXERCISE!!!

EXERCISE!!

CALF RAISESCALF STRETCHESMARCHESDAILY WALKINGUP AND DOWN STAIRSSWIMMING

FUNCASES

PLAYING WITH DOCTORS

EVEN CROSS-FIT HAS WOUNDS!!

Case Study

• Etiology: 47 year old male ,DFU/cellulitis: left great toe: suspected osteomylitis, able to probe to bone

• PMHX: DM, PVD, obesity, LE edema, CABG x 3 • Age: 4 weeks old• Previous treatment: Gauze packing, sorbact,

hydrofera blue , hypochlorous acid

• Wound Dimensions :Pre: 1.2 cm x 1.3 cm x 1.2 cm Post: closed

• Treatment: Endoform, hydrofera blue: both moistened with hypochlorous acid, as healing progressed did also use adaptic and non-adherent dressing, compression and TCC

• Length of Treatment: 10/21-11/11: endoform treatment

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1.2 x 1.3 x 1.2 cm: undermining: 11:00/2.0 cm

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.4 x .4 x .3 cm/ undermining 12-6 /2 mm and 6-12/ 2 mm

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.5 x .5 x .3 cm/ no undermining.

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.2 x .2 x .1 cm

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.1 x .1 x .1 cm

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closed

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Case Study

• Etiology: DFU: heel left foot, in a 49 year old male, second wound in the same location

• Age: approximately 10 months old, re-occurring wound x 2, had 7 months of treatment prior to us seeing us

• Previous treatment: CROW walker, topical wound care• Wound Dimensions :Pre: 2.5 x 4 x .1 cm/Post: closed

• Treatment• Length of Treatment

• Treatment: Endoform, Hydrofera blue: moistened with hypochlorous , absorptive dressings , compression and TCC

• Length of Treatment: began endoform: 10/21-12/9, wound closed 12/16

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4.0 x 2.5 x .1 cm

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4.0 x 2.1 x .1 cm

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3.0 x 3.5 x .1 cm

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1.0 x 3.4 x .1 cm: islands of epithelium developing

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Photos (2 minimum)

1.5 x 3.1 x .1 cm

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3.0x 2.0 x .1 cm

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Three small areas now1.0 x .3 x .11.0 x .2 x .1.2 x .2 x .1

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.3 x .2 x .1cm

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closed

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Case Study

• Etiology: DFU in a 59 year old male , ulcer present for over one year.

• Age: one year• Previous treatment: telfa, and foam• Wound Dimensions : Pre: 2.2 x 2.2 x .2 cm/

Post: closed

• Treatment: Endoform, Hydrofera blue: both moistened with hypochlorous acid , compression and TCC

• Length of Treatment: started endoform 11/25, 12/2

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1.5 x 1.9 x .1 cm

1.5 x 1.9 x .1 cm

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.7 x .5 x .1 cm

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closed

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THANK YOU!!!!