So You Thought You Knew All the Answers About Compression...

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  • So You Thought You Knew All So You Thought You Knew All the Answers About

    Compression Therapy!Terry Treadwell, MD, FACS

    Medical DirectorMedical DirectorInstitute for Advanced Wound Care

    Montgomery, Alabama

  • Compression Questionsp Q1. Are all compression bandages the same?p g2. Can compression therapy be used in the patient with edema

    and an ABI < 0.8? 3 Can compression therapy be used in the patient with edema 3. Can compression therapy be used in the patient with edema

    and cellulitis? 4. Does compression therapy improve the skin of patients with

    d titi ? venous dermatitis? 5. Can compression therapy be used in the patient with edema

    and congestive heart failure? g6. Can compression therapy be used in the patient with edema

    and acute deep venous thrombophlebitis?7 Do patients care which compression bandage is used?7. Do patients care which compression bandage is used?

  • Looking for the Evidence??Looking for the Evidence??

  • Are all compression bandages the same?

  • Compression Therapyp py Short stretch or inelastic Elastic

    Si l l Single layer Multiple layersp y High pressure

    L Low pressure

  • Working vs. Resting PressuresR l f C i M t i lRole of Compression Material

    EmptyingEmptyingp y g

    e(P

    T)

    Emptying

    essu

    reue

    Pre

    Tiss

    u

    TimeDr. HN Mayrovitz

    Time

  • Can compression Can compression therapy be used in the therapy be used in the patient with edema pand an ABI < 0.8?

  • Arterial Flow Pulses

    Control Leg Below Knee Blood Flow via Nuclear Magnetic Resonance

    Treated LegControl Leg

    BeforeBandage

    ml/min

    Treated Leg

    Bandage

    WithBandage

    ml/min

    Bandage

    Dr. HN Mayrovitz, Univ of Miami

  • Compression Therapy and Circulationp py

    ABI Bandage Sub-bandageABI Bandage Sub bandage pressure (mm Hg)

    > 0.8 4-layer 35-400 8 aye 35 0

    0.7 2-layer 17-25

    0.6 2-layer 17-25

  • Compression and Arterial Insufficiency

    15 patients suffering from peripheral arterial occlusive disease with an ankle brachial pressure index (ABPI) of 0.5-0.8

    1) 5 patients with ABPI of 0.5 and 0.6 2) 4 patients with ABPI of >0.6 and 0.7 3) 6 patients with ABPI of >0 7 and 0 83) 6 patients with ABPI of >0.7 and 0.8

    All patients treated with 3M Coban 2 Layer Lite Compression System Compression System

    Bandage remained on the leg 1 to 4 days Study stopped after 14 days Study stopped after 14 days

    Data on file 3M

  • Results of 3MCoban 2 Layer Lite Compression System Study

    An average supine subbandage pressure of ~ 28mmHg was measured just above the medial g jankle after bandage application

    No pressure-related skin damage occurred in patients No pressure related skin damage occurred in patients with reduced arterial perfusion

    No pain related to tissue hypoxia was detected

    Data on file 3M

  • Results of 3MCoban 2 Layer Lite Compression S stem St d Lite Compression System Study

    Laser doppler fluxmetry demonstrated positive effects on pp y pmicrocirculation including: Increased overall tissue microperfusion Reduced respiratory reflux in limbs with venous

    insufficiency Maintained stable capillary perfusion

    Limb volume reduction (reduced edema) compared to baseline

    High wearing comfort

    Data on file 3M

  • Conclusions: 3MCoban 2 Layer Lite Compression System Study

    Compression with Coban 2 Layer Lite Compression System is safe and well tolerated by patients with System is safe and well tolerated by patients with reduced peripheral arterial perfusion

    Results of the laser doppler fluxmetry measurements pp yindicate significant improvements of the dermal microcirculation under this compression therapy

    Data on file 3M

  • Venous UlcerVenous Ulcer99 year old lady with ulcer for 8 months

    ABI - 0.45

    Informed that BKInformed that BK amputation was the only therapy

    Treated with lightTreated with light compression and bi-layered tissue engineered skin

    Wound healed after 47 weeks

  • Can compression ptherapy be used in

    the patient with d d edema and cellulitis?cellulitis?

    Treadwell TA, Fowler E, Bates-Jensen BB. Management of Edema in Wound Care: A Collaborative Practice Manual for Health Professionals, 4th Edition, Ed. BB Bates-Jensen, in press

  • Edema and Compression Therapy in Cellulitis

    1. Normal anti-Streptococcal properties of skin are inactivated by edema fluid

    2. Compression therapy: Removes protein-containing fluid from the p g

    subcutaneous tissues Increases blood flow to tissues Increases antibiotic concentration in tissues

  • Cellulitis of LegCellulitis of Leg

    Healed after10 days of

    antibiotics andantibiotics and 5 weeks of

    compression therapy

  • Does compression therapy improve

    fthe skin of patients with venous with venous dermatitis?dermatitis?

  • Properties of Edema Fluid

    1. Edema fluid inhibits mitogenic activity and DNA g ysynthesis

    2. Cytokine environment in edema fluid is more yproinflammatory

    3. Protease activity is higher in edema fluidy g4. Growth factor levels are decreased in edema fluid

  • Proteases and Compression TherapyRelative MMP Levels in Healthy and Ulcer Tissue

    Before and After Compression Therapyp py

    500

    600 HealthyBefore TXAfter TXro

    tein N=21

    200

    300

    400

    g to

    tal pr

    0100200pg

    /

    Marston WA, Beider S, Davies S, Berndt DF. Protease and Cytokine Levels in Non-Healing Venous Leg Ulcers Before and After Compression Therapy. Presented at Symposium on Advanced Wound Care/Wound

    Healing Society Meeting, San Diego, CA. April 25, 2008

  • Inflammatory Cytokines and Compression Therapy

    Interleukins

    0 0060.008

    0.010.0120.0140.0160.018

    0.02

    0.1

    0.15

    0.2

    0.25

    0.3

    Interleukins

    810

    121416

    Il-80.080.1

    0.120.140.160.18

    Il-1b

    normal before after0

    0.0020.0040.006

    Normal Before Afternormal before after0

    0.05

    0.1

    normal before afternormal before after024

    6

    normal tissue ulcer before Rx ulcer after Rx\normal tissue ulcer before RX ulcer after RX

    1.4

    1.6

    1.8

    00.020.040.060.08

    normal before Afternormal before after

    normal before after

    TNF-alpha IFN-gamma

    0

    0.2

    0.4

    0.6

    0.8

    1

    1.2

    norm al before after

    IL12p40

    normal before after

    Marston WA, Beider S, Davies S, Berndt DF. Protease and Cytokine Levels in Non-Healing Venous Leg Ulcers Before and After Compression Therapy Presented at Symposium onVenous Leg Ulcers Before and After Compression Therapy. Presented at Symposium on Advanced Wound Care/Wound Healing Society Meeting, San Diego, CA. April 25, 2008

  • Effect of Compression TherapyEffect of Compression Therapy

    1 Week of Compression

  • Stasis Dermatitis Stasis Dermatitis

    Improvement after 22

    weeks ofweeks of compression

    therapy

  • Can compression therapy Can compression therapy be used in the patient with p

    edema and congestive heart failure?

  • Massive Edema and CHFMassive Edema and CHF

    Photo used with permission

  • Congestive Heart Failure and Compression Therapy

    No acute pulmonary edemaO t t t t t d ith Once treatment started with cardiostimulatory medications and diureticsdiuretics

    Treadwell TA Fowler E Bates Jensen BB Management of Edema in Wound Care:Treadwell TA, Fowler E, Bates-Jensen BB. Management of Edema in Wound Care: A Collaborative Practice Manual for Health Professionals, 4th Edition, Ed. BB Bates-Jensen, in press

  • Can compression therapy be used in the patient with edema and patient with edema and

    acute deep venous pthrombophlebitis?

  • Compression Therapy and Acute Deep Venous Thrombophlebitis

    Increases venous flow Prevents further clotting Prevents further clotting Occludes superficial veins that could clot Does not cause an increase in pulmonary

    embolism

    Dale AW. The Swollen Limb. Current Problems in Surgery, Year Book Medical Publishers, Inc., USA 1973 (September) p 18USA. 1973 (September), p 18

    Treadwell TA, Fowler E, Bates-Jensen BB. Management of Edema in Wound Care: A Collaborative Practice Manual for Health Professionals, 4th Edition, Ed. BB Bates-Jensen, in press

  • Contraindication to Compression in A t D V Th b hl bitiAcute Deep Venous Thrombophlebitis

    Leg so painful that compression cannot be toleratedLeg so painful that compression cannot be tolerated.

    Dale AW. The Swollen Limb. Current Problems in Surgery, Year Book Medical Publishers, Inc., USA. 1973 (September), p 18

  • Do patients care which i b d compression bandage

    is used?is used?

  • Fact: Patients dont like i b d !compression bandages!

    Only 48 8% of patients wore their compression bandages *Only 48.8% of patients wore their compression bandages

    May be as high as 80% *

    Determinants for NOT wearing compression bandages:a. Ageb. Pain c. Wound sized Wound depthd. Wound depth

    * Miller C, Kapp S, Newell N, et al. Predicting Concordance with Multilayer Compression Bandaging. Jour Wound Care 2011;20(3):101-112

  • Is this comfortable?Is this comfortable?