Compression Therapy: Inside the Wrap
- Fri, 9/25/09 - 4:47am
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Mr. RU Swollen is referred to your clinic from his primary care provider. He walks into the clinic with an antalgic gait then rests in the waiting room. On examination, both lower extremities are edematous, the left greater than the right. He has purulent draining ulcers over the left foot and leg as well as the right leg. Pedal pulses are weakly palpable and his blood glucose level is 196 mg/dL. Should this patient receive compression for his lower extremities?
Compression therapy is considered a standard of care for chronic venous insufficiency (CVI) patients. A wound care practitioner’s instinctive response is to compress the edematous leg in an effort to control the cause of the wound rather than to simply dress the ulcer. Knowing when to apply compression, what compression or support to utilize, and how to safely compress are critical in the care of these patients.
The Overall Picture
Assessment. The bedrock of the treatment plan must be a comprehensive patient assessment. Through appropriate clinical testing, the root cause of the edema must be determined. Does the patient have lymphedema, CVI, or a combination of the two? Is the patient experiencing an acute flare or episode related to another diagnosis such as deep vein thrombosis or congestive heart failure (CHF) exacerbation? A thorough history and exam should rule out disease processes (eg, arterial occlusive disease) that would put the limb at greater risk with the addition of a compression therapy. If arterial patency is in question, comprehensive arterial studies should be done before compression therapy is applied. Special consideration and precaution should be given to diabetic patients who may have a deceptively elevated ankle/brachial index (ABI) secondary to disease related atherosclerotic changes and calcification of vessels.
If it has been established that the patient’s lower extremity arterial system is adequate and compression would be of benefit, the source of the swelling (ie, edema or lymphedema) must be determined. Patients with lymphedema ideally should have been seen and treated by a clinician trained in manual lymphatic drainage (MLD) and complete decongestive therapy (CDT), a certified CLT-LANA therapist. Although edema and lymphedema patients both are treated with compression therapy, the lymphedema therapy regimen may be quite different from the management of edema resulting from CVI.
Wrap of choice. Multiple types of compression wraps are available for use in wound clinics. Selection of the wrap or bandage type requires not only a comprehensive assessment of the patient and the wound, but also a thorough understanding of the patient’s lifestyle including occupational and social needs, shoe wear, and functional status. For example, a construction or landscape worker likely would be challenged to wear a wrap for a full week due to perspiration and potential for external soiling. Additionally, that same construction worker may be required to wear high boots that would not fit over a multilayered wrap. Missing work is not an option for this patient. What are the alternatives?
Access to multiple types of wraps and compression systems is not a supply redundancy. Rather, it is almost imperative for the wound center treating large numbers of patients with edema to have multiple options available to meet the needs of this large patient group. The ability to match the compression choice with the patient’s body, leg type and shape, occupation, shoe requirements, and the like is imperative.
Options for Compression
Tubular bandages. Tubular bandages are fabric tubes with horizontal rings of elastic. Used as single or double layer, available with latex or latex-free, they are supplied primarily in rolls, but also in single patient “unit dose” type of packaging. A single layer provides approximately 8 mm Hg of compression. Because they are available in a variety of graduated sizes, each manufacturer provides a measuring tape to determine the appropriate choice based on the size of the patients calf, and the degree of stretch, low, medium or high. While not an ideal delivery system for adequate long-term compression, these bandages are an alternative when vascular status is being evaluated or when other options fail. Tubular bandages can be removed at night and may be washed and reused.
Examples: Tubigrip (Convatec, Skillman, NJ), Comperm LF (Hartmann-Conco, Rock Hill, SC). (See Figure 1).
Long-stretch bandages. Typically, these elastic bandages offer sustained pressure over a longer period of time. They exert pressure from the outside of the leg, expanding and recoiling as the calf muscles contract and relax. These wraps often are inexpensive compared to wraps; they are are washable, reusable, and easy to apply. Most brands are available premarked with guides to indicate the appropriate amount of stretch. Cotton padding can be applied as a first layer to make the wrap more comfortable.
Examples: SurePress and SetoPress (Convatec, Skillman, NJ). (See Figure 2).
1. Brown AC, Coutts P, Sibbald RG. Compression therapies. In: Krasner DL, Rodeheaver GT, Sibbald RG (eds). Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, Third Edition. Wayne, Pa: HMP Communications; 2001:517–524. 2. Homa L, Macdonald, J, Seaman S. Compression Modalities in Chronic Wound Care: What to Use and When to Use It. Post Conference session presented at the Symposium on Advanced Wound Care and Wound Healing Society Meeting.Tampa, Fla. May 1, 2007. 3. Weir D. Pearls of compression. In Falabella AF, Kirsner RS (eds). Wound Healing. Boca Raton, Fla: Taylor & Francis Group 2005:423–437.