Demystifying Demystifying CompressionCompression

Terry Treadwell, MD, FACSMedical DirectorMedical DirectorInstitute for Advanced Wound CareMontgomery, Alabama

(c) 3M 2012

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?

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

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Are all compression bandages the same?

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Compression Therapyp py• Short stretch or inelastic • Elastic

Si l l• Single layer• Multiple layersp y• High pressure

L • Low pressure

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Compartmentsp

Tibia

AnteriorAnterior Tibial

Greater Saphenous

DeepPosterior

Later

Fib l Posterior

Superficiali

ralFibula Posterior Tibial

PosteriorSkinPeroneal

Lesser Saphenous

Dr. HN Mayrovitz(c) 3M 2012

Pressures of Interest

• Sub‐bandage• Surface

Tibia

Tibialis m.

• Surface• Contact

Popliteus m.Tibialis m.

PeroneuFib lCompression

Soleus m

usFibula Bandage or Device

Gastroc m.•Tissue•Interstitial

• Intramuscular

Skin

• Intramuscular

Dr. HN Mayrovitz

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Resting Pressure

Pressure (P) LaPlace’sLaw

RDue to Tension (T) of Bandage and 

Law

TTgthe Radius (R) of the Leg

P ~P ~ T T RR

Superficial vessels affected the mostSuperficial vessels affected the mostDr. HN Mayrovitz

(c) 3M 2012

Working (Dynamic) Pressure

Muscles Contract Bandage Contract

Restricts Muscle 

Contraction

High 

Contraction

Pressure  Develops on DeeperDeeper Tissues

Pressure Is From WITHINDr. HN Mayrovitz

(c) 3M 2012

Dynamic Pressure Depends onBandage Material Features

Form-fitted Steel Pipe(Cast)

ure

Inelastic(short stretch)

mic

Pre

ssu

No External Compression

Elastic(long stretch)D

ynam

B d “St t h bilit ”0

Mayrovitz HN, et al. Clin Physiol. 1997;17(1):105‐117.

Bandage “Stretchability”

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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(c) 3M 2012

Pascal’s Law

Equal Distribution of

Pressure Th h t thThroughout the

Leg with MuscleMuscle

Contraction

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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.

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

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Venous Ulcers and PVDVenous Ulcers and PVD1416 leg ulcers with venous reflux

14% 2%

ABPI >1ABPI >10,85‐0,5<0,5

84%84%

Humphreys ML et al. Br J Surg. 2007 Sep;94(9):1104‐7

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Venous Ulcer Healing

Marston W et al, J VascSurg 1999; 30:491

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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

(c) 3M 2012

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

<0.5 Only with medical supervision

---

Moffatt C. www.worldwidewounds.com (12/5/09)

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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

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Results of 3M™Coban 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

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Results of 3M™Coban 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

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Conclusions: 3M™Coban 2 Layer Lite 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 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

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UNDER the Bandage: Increase of Flowg

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DISTAL to the Bandage

Toe pressure100

TcPO2

60

80

100

+6% +9% +13%

Hg

40

50

60

70

+7%

Hg

20

40

n.s *** ***

mm

10

20

30

40

***

mm

H

0.

0

No impairment of arterial flow up to a pressure of 40 mmHg

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Inelastic Compression Improves Venous P

Ejection fraction

PumpEjection fraction

7080

normal range

405060

g%

203040

+72% +103%

%

0 0 0

010 *** ***

0

20-30

31-40

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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

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Compression Bandage Too Tight Over B P iBony Prominences

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Warning!!!Warning!!!

Sustained bandage pressure should never exceed the arterial perfusion pressure

(= ankle pressure)!

Persisting or increasing pain:Remove the bandage!

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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

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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

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Cellulitis of LegCellulitis of Leg

Healed after10 days of

antibiotics andantibiotics and 5 weeks of

compression therapy

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Does compression therapy improve

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

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Properties of Edema FluidProperties of Edema Fluid

1. Edema fluid inhibits mitogenic activity and DNA synthesis.synthesis.

2. Cytokine environment in edema fluid is more proinflammatory.proinflammatory.

3. Protease activity is higher in edema fluid.4 Growth factors levels are decreased in edema 4. Growth factors levels are decreased in edema

fluid.1 R tliff C R "W d d t i fl ti l f t i h li " Ad N P t 16 7 (2008) 32 351. Ratliff, C. R. "Wound exudate: an influential factor in healing." Adv.Nurse Pract. 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.

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Fibroblast Senescence and Venous Ulcers

Wound (%)Normal (%)Patient

12.61BB

14.91KM

14 31 33OB

17.60.66AS

4.00.33SK

26.32.33FF

210.33RG

14.31.33OB

Stanley A, et al. J Vasc Surg. 2001;33(6):1206‐1211.

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Fibroblasts and Chronic Wound Fluid

60,000

50,000

40 000s/da

y)

40

30ls(%

)

†

40,000

30,000

Rat

e (c

ells 30

20

ositi

ve C

ell

20,000

10,000Gro

wth

*10

A-

-Gal

Po

0CM VUWF

0S

CM VUWF

*P = .006; †P<.03.CM = complete media; VUWF = venous ulcer wound fluid; SA‐‐Gal = senescence‐associated ‐galactosidaseactivity.Mendez MV, et. al. J Vasc Surg. 1999;30:734‐743.

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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

µg 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

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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

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Effect of Compression TherapyEffect of Compression Therapy

1 Week of Compression(c) 3M 2012

Stasis Dermatitis Stasis Dermatitis

Improvement after 22

weeks ofweeks of compression

therapy

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

edema and congestive heart failure?

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Massive Edema and CHFMassive Edema and CHF

Photo used with permission

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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

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

acute deep venous pthrombophlebitis?

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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

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Contraindication to Compression i A t D V in Acute Deep Venous

ThrombophlebitisThrombophlebitis

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

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Do patients care which i b d compression bandage

is used?is used?

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Fact: Patients don’t 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

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Is this comfortable?Is this comfortable?

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9

10Slippage in cm: after 24 and 48 hours

actico k-two profore profore lite proguide short stretch long stretch rosidal sys coban 2 layer coban 2 lite

After 48 hours of wear

6

7

8

After 48 hours of wear

3

4

5

0

1

2

actico k-two profore profore lite proguide short stretch long stretch rosidal sys coban 2 layer coban 2 lite

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Patient Preference for C i ThCompression Therapy

• 72% of patients preferred Coban 2 Layer Compression System over Profore when treated with both for venous yulcer

• 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 AMoffatt CJ, Edwards L, Collier M, Treadwell T, Miller M, Shafer L, Sibbald G, Brassard A, McIntosh A, Ryzelman A, Price P, Kraus SM, Walters SA, Harding K. Randomized Controlled 8-Week Crossover Clinical Evaluation of the 3M Coban 2 Layer Compression System Versus Profore to Evaluate the Product performance in Patients with Venous Leg Ulcers. Int Wound Journal 2008; 5:267-279.

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Compression Questions

1. Are all compression bandages the same? NOp g2. Can compression therapy be used in the patient with edema and

an ABI < 0.8? YES3 Can compression therapy be used in the patient with edema and 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

d titi ? YESdermatitis? YES5. Can compression therapy be used in the patient with edema and

congestive heart failure? YESg6. Can compression therapy be used in the patient with edema and

acute deep venous thrombophlebitis? YES7 Do patients care which compression bandage is used? YES7. Do patients care which compression bandage is used? YES

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“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

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Sponsored by an educational grant from 3MSponsored by an educational grant from 3M

For more information on For more information on 3M Compression Therapy visit

www.3m.com/coban2layer

3M 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