Demystifying              Compression    Terry Treadwell, MD, FACS    Medical Director    Institute for Advanced Wound Car...
Compression Q                          p        Questions 1.           Are all compression bandages the same?             ...
Looking for the Evidence??(c) 3M 2012
Are all compression              bandages the same?(c) 3M 2012
Compression Therapy                 p             py              •   Short stretch or inelastic              •   Elastic ...
Compartments         p                                                   Tibia                                            ...
Pressures of Interest                                                         Tibia       • Sub‐bandage                   ...
Resting Pressure                                                 LaPlace’s Pressure (P)  Due to                           ...
Working (Dynamic) Pressure       Muscles                                                        Bandage        Contract   ...
Dynamic Pressure Depends on                                Bandage Material Features                                   For...
Working vs. Resting Pressures                       Role f C                       R l of Compression Materiall           ...
Pascal’s Law                              Equal                          Distribution of                            Pressu...
Short Stretch Vs. Multi-stretch • Short stretch systems are effective at a lower resting   pressure than multi-stretch sys...
Can compression   therapy be used in the   p   patient with edema   and an ABI < 0.8?(c) 3M 2012
Venous Ulcers and PVD    1416 leg ulcers with venous reflux                                               2%              ...
Venous Ulcer Healing    Marston W et al, J Vasc    Surg 1999; 30:491(c) 3M 2012
Arterial Flow Pulses         Below Knee Blood Flow via Nuclear Magnetic Resonance                 Control Leg            T...
Compression Therapy and Circulation             p             py              ABI          Bandage                Sub band...
Compression and Arterial Insufficiency      • 15 patients suffering from peripheral arterial        occlusive disease with...
Results of 3M™Coban 2 Layer Lite                  Compression System Study         • An average supine subbandage pressur...
Results of 3M™Coban 2 Layer              Lite Compression System Study                               S stem St d • Laser ...
Conclusions:              3M™Coban 2 Layer Lite              Compression System Study                 p         y        ...
UNDER the Bandage: Increase of Flow                             g(c) 3M 2012
DISTAL to the Bandage                        Toe pressure                             TcPO2         100                   ...
Inelastic Compression Improves Venous                              Pump                              P                    ...
Venous Ulcer               99 year old lady               with ulcer for 8               months               ABI - 0.45  ...
Compression Bandage Too Tight Over                     Bony Prominences                     B     P i(c) 3M 2012
Warning!!!              Sustained bandage pressure should never                exceed the arterial perfusion pressure     ...
Can compression              p    therapy be used in      the patient with        edema and         d         d         ce...
Edema and Compression                  Therapy in Cellulitis         1. Normal anti-Streptococcal properties of skin      ...
Cellulitis of Leg                     Healed after                      10 days of                    antibiotics and     ...
Does compression therapy improve the skin of patients           f with venous dermatitis?(c) 3M 2012
Properties of Edema Fluid   1. Edema fluid inhibits mitogenic activity and DNA      synthesis.   2. Cytokine environment i...
Fibroblast Senescence and Venous Ulcers                           Patient                   Normal (%)   Wound (%)        ...
Fibroblasts and Chronic Wound Fluid                              60,000                                                   ...
Proteases and Compression Therapy                               Relative MMP Levels in Healthy and Ulcer Tissue           ...
Inflammatory Cytokines and                                        Compression Therapy                                     ...
Effect of Compression Therapy                           1 Week of Compression(c) 3M 2012
Stasis Dermatitis                  Improvement                    after 22                    weeks of                  co...
Can compression therapy              be used in the patient with                             p                edema and co...
Massive Edema and CHF              Photo used with permission(c) 3M 2012
Congestive Heart Failure and                    Compression Therapy              • No acute pulmonary edema              •...
Can compression  therapy be used in the  patient with edema and    acute deep venous               p     thrombophlebitis?...
Compression Therapy and Acute Deep        Venous Thrombophlebitis                •    Increases venous flow               ...
Contraindication to Compression                       iin A t D                           Acute Deep V                    ...
Do patients care which              compression bandage                         i b d                     is used?(c) 3M 2...
Fact: Patients don’t like                  compression bandages!                           i b d          !    • Only 48 8...
Is this comfortable?(c) 3M 2012
actico         k-two    profore      profore lite   proguide   short stretch    long stretch     rosidal sys   coban 2 lay...
Patient Preference for                      Compression Therapy                      C         i Th         • 72% of patie...
Compression Questions 1.           Are all compression bandages the same? NO                             p          g 2.  ...
“It is the individual patient who we treat, not the disease.                 It is the patient who recovers or dies, not t...
Sponsored by an educational grant from 3M                              For more information on                            ...
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WEBCAST PRESENTATION | 3M Health Care | Demystifing Compression with Dr. Terry Treadwell

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WEBCAST PRESENTATION | 3M Health Care | Demystifing Compression with Dr. Terry Treadwell. Visit the Coban 2 Layer site at http://go.3M.com/FreeCECourse_SlideShare

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WEBCAST PRESENTATION | 3M Health Care | Demystifing Compression with Dr. Terry Treadwell

  1. 1. Demystifying Compression Terry Treadwell, MD, FACS Medical Director Institute for Advanced Wound Care Montgomery, Alabama(c) 3M 2012
  2. 2. Compression Q p Questions 1. Are all compression bandages the same? p g 2. Can compression therapy be used in the patient with edema and an ABI < 0.8? 3. 3 Can compression therapy be used in the patient with edema and cellulitis? 4. Does compression therapy improve the skin of patients with venous dermatitis? d titi ? 5. Can compression therapy be used in the patient with edema and congestive heart failure? g 6. Can compression therapy be used in the patient with edema and acute deep venous thrombophlebitis? 7. 7 Do patients care which compression bandage is used?(c) 3M 2012
  3. 3. Looking for the Evidence??(c) 3M 2012
  4. 4. Are all compression bandages the same?(c) 3M 2012
  5. 5. Compression Therapy p py • Short stretch or inelastic • Elastic • Single Si l llayer • Multiple layers p y • High pressure • Low L pressure(c) 3M 2012
  6. 6. Compartments p Tibia Greater  Anterior  Saphenous Tibial Anterior Deep Later Posterior Posterior  Posterior ral Fibula Fib l Tibial Superficial Posterior i Peroneal Skin Lesser Saphenous Dr. HN Mayrovitz(c) 3M 2012
  7. 7. Pressures of Interest Tibia • Sub‐bandage • Surface • Contact Tibialis m. Peroneu Popliteus m. Tibialis m. Compression Fibula Fib l us Bandage  Soleus m or Device Gastroc m. •Tissue Skin •Interstitial • Intramuscular Dr. HN Mayrovitz(c) 3M 2012
  8. 8. Resting Pressure LaPlace’s Pressure (P)  Due to  Law R Tension (T) of  g Bandage and  T the Radius (R)  of the Leg P~ R Superficial vessels affected the most Superficial vessels affected the most Dr. HN Mayrovitz(c) 3M 2012
  9. 9. Working (Dynamic) Pressure Muscles  Bandage  Contract Restricts  Muscle  Contraction High  Pressure   Develops on  Deeper  Deeper Tissues Pressure Is From WITHIN Dr. HN Mayrovitz(c) 3M 2012
  10. 10. Dynamic Pressure Depends on Bandage Material Features Form-fitted Steel Pipe (Cast) ure Dynam Pressu Inelastic mic (short stretch) Elastic (long stretch) No External Compression 0 Bandage “Stretchability” B d “St t h bilit ” Mayrovitz HN, et al. Clin Physiol. 1997;17(1):105‐117.(c) 3M 2012
  11. 11. Working vs. Resting Pressures Role f C R l of Compression Materiall i M t i Emptying py g Emptying ue essure (PT)Tissu Pre e Time Time Dr. HN Mayrovitz (c) 3M 2012
  12. 12. Pascal’s Law Equal Distribution of Pressure Throughout the Th h t th Leg with Muscle Contraction(c) 3M 2012
  13. 13. Short Stretch Vs. Multi-stretch • Short stretch systems are effective at a lower resting pressure than multi-stretch systems • A lower resting pressure offers safer compression in the compromised limb • Both systems can produce effective, dynamic working and resting pressures.(c) 3M 2012
  14. 14. Can compression therapy be used in the p patient with edema and an ABI < 0.8?(c) 3M 2012
  15. 15. Venous Ulcers and PVD 1416 leg ulcers with venous reflux 2% 14% ABPI >1 ABPI >1 0,85‐0,5 <0,5 84% Humphreys ML et al. Br J Surg. 2007 Sep;94(9):1104‐7(c) 3M 2012
  16. 16. Venous Ulcer Healing Marston W et al, J Vasc Surg 1999; 30:491(c) 3M 2012
  17. 17. Arterial Flow Pulses Below Knee Blood Flow via Nuclear Magnetic Resonance Control Leg Treated Leg ml/min Before Bandage ml/min With Bandage Dr. HN Mayrovitz, Univ of Miami(c) 3M 2012
  18. 18. Compression Therapy and Circulation p py ABI Bandage Sub bandage Sub-bandage pressure (mm Hg) > 0.8 08 4-layer aye 35 0 35-40 0.7 2-layer 17-25 0.6 2-layer 17-25 <0.5 Only with medical --- supervision Moffatt C. www.worldwidewounds.com (12/5/09)(c) 3M 2012
  19. 19. 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 8 0.7 0.8 • All patients treated with 3M Coban 2 Layer Lite Compression System • Bandage remained on the leg 1 to 4 days • Study stopped after 14 days Data on file – 3M(c) 3M 2012
  20. 20. Results of 3M™Coban 2 Layer Lite Compression System Study • An average supine subbandage pressure of ~ 28mmHg was measured jjust above the medial g ankle after bandage application • No pressure-related skin damage occurred in patients pressure related with reduced arterial perfusion • No pain related to tissue hypoxia was detected Data on file – 3M(c) 3M 2012
  21. 21. Results of 3M™Coban 2 Layer Lite Compression System Study S stem St d • Laser doppler fluxmetry demonstrated p pp y positive effects on microcirculation 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(c) 3M 2012
  22. 22. Conclusions: 3M™Coban 2 Layer Lite Compression System Study p y y • Compression with Coban 2 Layer Lite Compression System is safe and well tolerated by patients with reduced peripheral arterial perfusion • Results of the laser doppler fluxmetry measurements pp y indicate significant improvements of the dermal microcirculation under this compression therapy Data on file – 3M(c) 3M 2012
  23. 23. UNDER the Bandage: Increase of Flow g(c) 3M 2012
  24. 24. DISTAL to the Bandage Toe pressure TcPO2 100 70 +6% +9% +13% 60 +7% 80 50 mm Hg 60 mm Hg 40 H 40 30 20 20 n.s *** *** *** 10 . 0 0 No impairment of arterial flow up to a pressure of 40 mmHg(c) 3M 2012
  25. 25. Inelastic Compression Improves Venous Pump P Ejection fraction 80 70 normal range g 60 50 % 40 30 +72% +103% 20 10 *** *** 0 0 0 0 -3 -4 20 31(c) 3M 2012
  26. 26. Venous Ulcer 99 year old lady with ulcer for 8 months ABI - 0.45 Informed that BK amputation was the only therapy Treated with light compression and bi-layered tissue engineered skin Wound healed after 47 weeks(c) 3M 2012
  27. 27. Compression Bandage Too Tight Over Bony Prominences B P i(c) 3M 2012
  28. 28. Warning!!! Sustained bandage pressure should never exceed the arterial perfusion pressure (= ankle pressure)! Persisting or increasing pain: Remove the bandage!(c) 3M 2012
  29. 29. Can compression p therapy be used in the patient with edema and d d 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(c) 3M 2012
  30. 30. 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(c) 3M 2012
  31. 31. Cellulitis of Leg Healed after 10 days of antibiotics and 5 weeks of compression therapy(c) 3M 2012
  32. 32. Does compression therapy improve the skin of patients f with venous dermatitis?(c) 3M 2012
  33. 33. Properties of Edema Fluid 1. Edema fluid inhibits mitogenic activity and DNA synthesis. 2. Cytokine environment in edema fluid is more proinflammatory. 3. Protease activity is higher in edema fluid. 4. 4 Growth factors levels are decreased in edema fluid. 1. Ratliff, C R "W 1 R tliff C. R. "Wound exudate: an influential factor in healing." Adv.Nurse Pract. 16.7 (2008):32-35. d d t i fl ti l f t i h li " Ad N P t 16 7 (2008) 32 35 2. Trengove, N. J., H. Bielefeldt-Ohmann, and M. C. Stacey. "Mitogenic activity and cytokine levels in non-healing and healing chronic leg ulcers." Wound Repair Regen. 8.1 (2000):13-25. 3. Trengove, N. J., S. R. Langton, and M. C. Stacey. "Biochemical analysis of wound fluid from nonhealing and healing chronic leg ulcers." Wound Repair Regen. 4.2 (1996): 234-39.(c) 3M 2012
  34. 34. Fibroblast Senescence and Venous Ulcers Patient Normal (%) Wound (%) KM 1 14.9 BB 1 12.6 SK 0.33 4.0 AS 0.66 17.6 OB 1.33 1 33 14.3 14 3 RG 0.33 21 FF 2.33 26.3 Stanley A, et al. J Vasc Surg. 2001;33(6):1206‐1211.(c) 3M 2012
  35. 35. Fibroblasts and Chronic Wound Fluid 60,000 40 50,000 s/day) ositive Cell (%) † ls Growth Rate (cells 40,000 40 000 30 30,000 20 SA--Gal Po 20,000 10 10,000 * 0 0 CM VUWF CM VUWF *P = .006; †P<.03. CM = complete media; VUWF = venous ulcer wound fluid; SA‐‐Gal = senescence‐associated ‐galactosidase activity. Mendez MV, et. al. J Vasc Surg. 1999;30:734‐743.(c) 3M 2012
  36. 36. Proteases and Compression Therapy Relative MMP Levels in Healthy and Ulcer Tissue Before and After Compression Therapy p py 600 Healthy Before TX N=21 rotein 500 After TX pg/µg total pr 400 300 200 100 0 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(c) 3M 2012
  37. 37. Inflammatory Cytokines and Compression Therapy Interleukins 0.02 0.3 0.018 16 0.016 0.25 0.18 0.16 14 0.014 0.2 0.14 12 0.012 0.12 10 0.01 0.15 0.1 0.008 8 0.08 Il-1b Il-8 0.1 6 0.006 0 006 0.06 4 0.004 0.05 0.04 2 0.002 0.02 0 0 0 0 normal before before After after normal Normal before Before after After normal before after normaltissue normal before after normal ulcer before Rx ulcer after Rx normal normal before after tissue ulcer before RX ulcer after RX 1.8 1.6 1.4 TNF-alpha IFN-gamma 1.2 1 0.8 IL12p40 0.6 0.4 0.2 0 normal before after normal norm al before before after 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 on Therapy Advanced Wound Care/Wound Healing Society Meeting, San Diego, CA. April 25, 2008(c) 3M 2012
  38. 38. Effect of Compression Therapy 1 Week of Compression(c) 3M 2012
  39. 39. Stasis Dermatitis Improvement after 22 weeks of compression therapy(c) 3M 2012
  40. 40. Can compression therapy be used in the patient with p edema and congestive heart failure?(c) 3M 2012
  41. 41. Massive Edema and CHF Photo used with permission(c) 3M 2012
  42. 42. Congestive Heart Failure and Compression Therapy • No acute pulmonary edema • O Once t t treatment started with t t t d ith cardiostimulatory medications and diuretics Treadwell TA Fowler E Bates Jensen BB Management of Edema in Wound Care: TA, E, Bates-Jensen BB. A Collaborative Practice Manual for Health Professionals, 4th Edition, Ed. BB Bates- Jensen, in press(c) 3M 2012
  43. 43. Can compression therapy be used in the patient with edema and acute deep venous p thrombophlebitis?(c) 3M 2012
  44. 44. Compression Therapy and Acute Deep Venous Thrombophlebitis • Increases venous flow • 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. USA 1973 (September) p 18 (September), 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(c) 3M 2012
  45. 45. Contraindication to Compression iin A t D Acute Deep V Venous Thrombophlebitis Leg so painful that compression cannot be tolerated tolerated. Dale AW. The Swollen Limb. Current Problems in Surgery, Year Book Medical Publishers, Inc., USA. 1973 (September), p 18(c) 3M 2012
  46. 46. Do patients care which compression bandage i b d is used?(c) 3M 2012
  47. 47. Fact: Patients don’t like compression bandages! i b d ! • Only 48 8% of patients wore their compression bandages * 48.8% • May be as high as 80% * • Determinants for NOT wearing compression bandages: a. Age b. Pain c. Wound size d. d Wound depth * Miller C, Kapp S, Newell N, et al. Predicting Concordance with Multilayer Compression Bandaging. Jour Wound Care 2011;20(3):101-112(c) 3M 2012
  48. 48. Is this comfortable?(c) 3M 2012
  49. 49. actico k-two profore profore lite proguide short stretch long stretch rosidal sys coban 2 layer coban 2 lite10 Slippage in cm: after 24 and 48 hours9 After 48 hours of wear876543210 actico k-two profore profore lite proguide short stretch long stretch rosidal sys coban 2 layer coban 2 lite (c) 3M 2012
  50. 50. Patient Preference for Compression Therapy C i Th • 72% of patients preferred Coban 2 Layer Compression System over Profore when treated with both for venous y ulcer • Coban 2 Layer Compression System showed less slippage than Profore • Quality of Life assessments were better with Coban 2 Layer Compression System than with Profore (p<0.05)Moffatt CJ, Edwards L, Collier M, Treadwell T Miller M, Shafer L, Sibbald G Brassard A McIntosh A CJ L M T, M L G, A, A,Ryzelman A, Price P, Kraus SM, Walters SA, Harding K. Randomized Controlled 8-Week CrossoverClinical Evaluation of the 3M Coban 2 Layer Compression System Versus Profore to Evaluate the Productperformance in Patients with Venous Leg Ulcers. Int Wound Journal 2008; 5:267-279.(c) 3M 2012
  51. 51. Compression Questions 1. Are all compression bandages the same? NO p g 2. Can compression therapy be used in the patient with edema and an ABI < 0.8? YES 3. 3 Can compression therapy be used in the patient with edema and cellulitis? YES 4. Does compression therapy improve the skin of patients with venous dermatitis? d titi ? YES 5. Can compression therapy be used in the patient with edema and congestive heart failure? YES g 6. Can compression therapy be used in the patient with edema and acute deep venous thrombophlebitis? YES 7. 7 Do patients care which compression bandage is used? YES(c) 3M 2012
  52. 52. “It is the individual patient who we treat, not the disease. It is the patient who recovers or dies, not the illness.” James Peck, MD, Am. Jour. Surg. 2004;187:569-574(c) 3M 2012
  53. 53. Sponsored by an educational grant from 3M For more information on 3M Compression Therapy visit www.3m.com/coban2layer3M is a provider approved by the California Board of Registered Nursing, Provider Number CEP 5770.Nurse participants may receive continuing education credit upon completion of education module.(c) 3M 2012
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