The Importance of Compression in the Outpatient Wound Center

  Walking into the wound center treatment room to assess a patient with a lower extremity ulcer, you really already know what you’ll diagnosis. If you were to venture to guess that chronic venous insufficiency (CVI) would accompany the ulcer, you’d be correct 70-90% of the time.¹ Venous leg ulcers (VLUs) affect more than 2 million patients in the US each year, a number that could be underestimated when considering patients who treat themselves without consulting a healthcare provider.^2,3 VLUs often occur in “working aged” adults, and it has been reported that more than 2 million workdays are lost in the US each year due to the associated morbidity of post-phlebitic syndrome. Hence, these are often the patients who arrive at the outpatient wound center, in numbers perhaps equal to or slightly less than those living with diabetic foot ulcers.   Clinicians who have gone through basic training for chronic wound management are all taught that lower extremity compression is the “gold standard” for management of ulcers caused by CVI, as long as there is no co-existing arterial disease significant enough to prevent the use of compression therapy.   In fact, the evidence base for compression in the treatment of VLUs is probably the strongest of any treatment in wound care. That said, it would seem that many people would be walking around with some sort of compression therapy on their legs each day. That may not, however, be the case. In 2010, Caroline Fife et al published an often-cited article4 that accessed a large wound care registry of 2,139 patients representing 4,364 ulcers. Only 17% of those patients had received adequate compression, with inadequate compression defined as using AceTM wraps, T.E.D.® hose, or Kerlix.TM   A reason cited for non-compliance with this evidence-based guideline is lack of awareness by community-based physicians on the need for compression. But this is unacceptable for wound care centers and is beneath standard of care. With that, let’s explore options for the treatment phase of CVI ulcers. For the purposes of this article, only disposable compression options will be discussed. For reusable wraps, garments, and devices, see “Compression Therapy to Control Edema and Prevent Re-ulceration” on page 12.

Compression Considerations

  The amount of compression used is determined by diagnosis, comorbidities, and the patient’s tolerance. In general, the recommended pressures have been classified as:⁵     • Mild: <20 mmHg     • Moderate: 21-40 mmHg     • Strong: 41-60 mmHg     • Very strong: >60 mmHg   Patient acceptance of compression therapy is also a force to be dealt with. Complaints and concerns with heat, discomfort of compression wraps, odor, sanitation, inability to shower “normally” or wear “normal” shoes are heard frequently. Most clinicians probably would have the same concerns, so empathy is a must. However, we must provide patients with detailed education related to the disease process and on the importance of compression therapy.   The application of compression bandaging and wraps requires a skill that should be competency-based for staff members who apply it. Depending on the type and manufacturer of the different wraps and kits, the goal of applying a particular level of compression (ie, 30-40 mmHg) is assumed to be achieved if applied correctly, but unfortunately this is not an easily measured outcome. Differences in these outcomes may be apparent when new clinic staff is learning the “art” of applying compression wraps.   When choosing the type and level of compression to be applied, some key factors must be considered, including:     1. Vascular status. For patients with co-existing occlusive disease of the lower extremity (an ankle/brachial index [ABI]>0.8), high-level compression therapy is contraindicated.6 There are “light” options to several available wraps that reduce compression from the standard 30-40 mmHg to 15-20 mmHg. Depending on the manufacturer, these lighter wraps can be used with patients with ABIs much lower (0.5 or 0.6). The decision to use this must be made in concert with the provider, a thorough vascular exam, and according to the instructions/guidelines of the particular manufacturer of the wrap used.     2. Level of sensation. Patients with co-existing diabetic neuropathy are less likely to feel if an area of the wrap is rubbing or causing traumatic injury. As with contact casting, changing the first wrap in 2-3 days to assess for injury may be warranted. Also, additional padding to areas of bony prominence can avert potential injury.     3. Ambulatory status. The decision to use rigid/short-stretch compression versus long-stretch/sustained compression will be driven by the patient’s ability to use his/her calf muscle in order to maximize the effectiveness of the product. For short-stretch, inelastic wraps to be effective, the patient must be ambulatory. If the patient is non-ambulatory, the only benefit that would be realized would be no worsening of the edema present at the time of application.     4. Presence of actual or potential infection. While conventional wisdom provides that systemic antibiotics will be more effective in a non-edematous leg, care must be taken when choosing to wrap an infected leg for an extended period of time. The inability to monitor the status of the infection and manage the exudate would make compression that can be removed and changed daily a safer choice early in the treatment course.     5. Dexterity and flexibility. Patients with the dexterity and flexibility to don and doff reusable treatment garments or have assistance at home to do so, and who prove they will comply with daily wear, can be provided with this option.

Disposable Compression Options

  Tubular bandages: At the lower end of compression delivered, tubular bandages reportedly deliver 10-15 mmHg when applied as a double layer. Made of circular elastic threads in fabric, these bandages conform comfortably to the leg when appropriately sized. Tubular bandages are not designed for the management of CVI or VLUs, but for general edema management only. When used according to a manufacturer’s sizing chart on a relatively normal-shaped limb, they can be useful when frequent observation of an ulcer site is desired or when dressing-change frequency prohibits use of a non-removable wrap for patients living with co-existing arterial disease or those who cannot otherwise tolerate longer-wearing wraps. There is a nice alternative to these tubular bandages: Tubigrip™ (Mölnlycke Healthcare, Norcross, GA) Shaped Support Bandage. A support bandage used to aid venous and lymphatic return in the management of venous disorders of the legs and arms, this reusable alternative comes in 5 full-leg and 3 below-knee sizes for a more custom fit.   Clinical Pearls:     • Cut the tubular bandage a bit longer than needed to allow for shrinkage.     • Dispensing at least 2 sets allows patients to have 1 to wear and 1 to wash (they need only wear on the affected leg).     • Patients have the option of removing at night for sleep and reapplying upon awakening.     • These bandages can be washed and reused many times; patients should be instructed to allow to air dry versus putting into a dryer to prevent shrinking.   Unna’s boots: Roll gauze impregnated primarily with zinc oxide, gelatin, and (in some brands) calamine to counteract itching, Unna’s boot was originally designed to serve as both a dressing and a rigid method of compression as it dried. With the advent of moist wound healing, the use of dressings such as hydrocolloids, foams, and other dressing materials ideally suited to manage exudate has contributed to an improved wound environment. Additionally, the availability of paste boots made with gauze rolls with some stretch and the use of cohesive bandaging over the entire length of the wrap has added an elastic component for improved sustained compression. Clinical Pearls:     • The drying effect of Unna’s boots, particularly those with a calamine component, can exacerbate already dry, itchy skin. If this occurs, use of a non-sensitizing moisturizer prior to application may help.     • Because of the rigid nature of the boot as it dries, applying the boot in overlapping strips or with pleats can minimize discomfort or potential injury if swelling of the limb should occur.   Multilayered compression: Most often provided as kits with 3 or 4 layers, multilayer dressings are probably the most common types of compression used. Both utilize a cotton layer next to the skin for protection, absorption, and padding to enhance the limb shape in the presence of an exceptionally thin ankle (<18 cm).⁷ The second layer is a non-stretch crepe roll applied in a circular, 50% overlapping fashion which will smooth out the first layer and enhance absorption. The third layer (in the 4-layer bandage only) is a long-stretch bandage applied in a 50% stretch and 50% overlapping figure-of-8 fashion, while the outer layer of both 3- and 4-layer wraps utilizes a cohesive bandage wrapped in a spiral fashion.   Clinical Pearls:     • The application technique is key to patient comfort and treatment success, and should be a skill that is proctored until mastered.     • Patients should be instructed to be aware of pain or throbbing associated with the wrap and to elevate their leg should it become too tight. They could also be advised to remove the outer layer or cut it off completely if toes swell or pain is too intense and to notify the clinic if any of these issues arise.     • The weight of these wraps can cause them to slip, especially in legs in which the ankle is very narrow as compared to the calf. Padding the ankle to enlarge is helpful; also, applying a tacky layer to the skin prior to application of the cotton layer is helpful. Use of products meant to aid in keeping stockings up; on-zinc-based barrier ointments; or even a singular, non-overlapping strip of Unna’s boot material can provide the tackiness needed to reduce slippage.     • In areas of bony or tendon prominence, padding with additional cotton or foam dressings can enhance comfort and reduce potential for injury.     • Because the cohesive bandage outer layer tends to be “sticky,” it can adhere to clothing and sheets, creating an annoyance to patients. Applying a layer of stockinet over the wrap can eliminate this as well as keep the bandage clean. Cutting extra lengths for the patients to change mid-week can improve their feeling of cleanliness, especially if they work outside or if the outer layer becomes soiled.     • The wraps consisting of multiple layers become thick and often prevent patients from reapplying the shoe that they wore into the clinic. Many clinics utilize inexpensive post-operative shoes to provide the patient with a safe walking sole to leave in, but patients should be encouraged to return to shoe wearing that they can fit over the bandage, as post-operative shoes tend to have stiff soles that reduce the flexing of the calf muscle during ambulation.   2-Layer Compression Wrap: Another alternative to the 3- and 4-layer wraps is the unique bandage system Coban™ 2 Layer Compression System (3M, Saint Paul, MN) that consists of a comfort foam layer followed with a short-stretch cohesive bandage designed to be applied at full stretch. The 2 layers cohere to form an inelastic sleeve. Though minimally stretchy, this bandage provides sustained compression while providing a thinner, lighter wrap. Pieces of the foam layer can be utilized to pad the anterior tibial area, bony prominences, etc. The application is in a spiral, overlapped fashion and the wrap is also available in a lighter compression alternative.   Compression bandaging for the patient living with a VLU is a compulsory part of evidence-based wound management. Compression does not always fit with a patient’s lifestyle and, more importantly, his/her ability to work (if special shoes, etc. are required in the workplace). We may need to be open to alternative treatment plans in terms of the type of compression in order to allow the patient to continue to work. Ongoing education is also critical so that the patient is prepared to move on to lifelong management of venous disease as healing progresses and the wound closes, and in order to prevent recurrence of their ulcers if possible. Dot Weir is co-editor of Today’s Wound Clinic. She may be reached at dorothy.weir@HCAhealthcare.com. Susie Seaman is a nurse practitioner and runs the wound clinic at Sharp Rees-Stealy Medical Group, San Diego, CA, and is a member of the TWC editorial board. She may be reached at susie.seaman@sharp.com.

References

1. Sieggreen MY, Kline RA. Venous disease and lymphedema management. In Baranoski S, Ayello EA (eds) Wound Care Essentials, Practice Principles, 3rd Edition. Lippincott Williams & Wilkins. 2012;360. 2. Gillespie DL, et al. Venous ulcer diagnosis, treatment & prevention of recurrences. J Vasc Surg. 2010; 52(suppl): 8S-14S. 3. Nelzen O, et al. The prevalence of chronic lower-limb ulceration has been underestimated: results of a validated population questionnaire. Br J Surg. 83(2):255-58. 4. Fife C, Carter MJ, Walker D. Why is it so hard to do the right thing in wound care? Wound Repair Regen.2010;18(2):154-8. 5. Partsch H, Clark M, Mosti G, et al. Classification of compression bandages: practical aspects. Derm Surg. 2008;34:600-609. 6. Four-Layer Bandaging: From Concept to Practice Part 2: Application of the Four-Layer System. www.worldwidewounds.com/2005/march/Moffatt/Four-Layer-Bandage-System-Part2.html (Accessed Nov. 28, 2012). 7. Hopkins A. Technical guide: how to apply effective multilayer compression bandaging. Wound Essentials. 2006;1.