METHODS OF COMPRESSION THERAPY PUTTIN THE SQUEEZE ON!! NORTHEAST WYOMING SKIN AND WOUND SYMPOSIUM.
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Transcript of METHODS OF COMPRESSION THERAPY PUTTIN THE SQUEEZE ON!! NORTHEAST WYOMING SKIN AND WOUND SYMPOSIUM.
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
45
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
51
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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60
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
69
closed
70
THANK YOU!!!!