Join Matthew G. Garoufalis, DPM, FACFAOM, FACFAS, FASPS as he discusses the use of mechanically powered disposable negative pressure wound therapy, shares his case studies and recommendations for dressing application.
Hi, everyone. Thank you for joining us. And thank you for sharing some of your time with us to view this presentation. Today. I'll be talking about the utilization of mechanically powered disposable negative pressure wound therapy and how we use this in our patients. This slide is from three M, and they want some information shared with you. But I'm not gonna read the slide. I just put it up your to show you some information. And these are my disclosures. And the objectives of this program are going to be sharing a background on diabetic foot ulcers. And the impact on patient lives illustrate the time principle as it pertains to disposable negative pressure wound therapy. And of course, I want to share with you some interesting case studies that demonstrates how are we use snap in the diabetic foot ulcer. So let's it started with this pathology from from Armstrong at all on diabetic foot ulcers in the pathology. And we see here that diabetes and where it is in terms of the numbers in the U. S. Population and this data is several years old, so the numbers are even higher than we have on the slide. But diabetes is complicated by peripheral neuropathy and peripheral arterial disease. This hand in hand helps to cause foot ulcers in critical limb ischemia and the resulting limb loss that we're all faced with our patients that have diabetic foot ulcers. So, as we see in this slide, the neuropathic ulcer five year mortality rate and this slide just tells you how horrendous this diseases and and what it does to people. We can see the Neuropathic Ulster five year mortality rated at 45% and the ischemic ulcer rate for DF use at 56% which means our patients don't really stand a chance once they have a diabetic foot ulcer with and the disease process that they have not to mention what their other cool mobility's might be, which can contribute to their mortality. So we look at this in relationship to other cancers, and you can see that while other cancers and we we know that cancers are very terrible. Um, but they don't have this same five year mortality rate that are diabetic patients have once they also rate. So we have to do everything in our power two. He's hell, these ulcers and to prevent re occurrence so that we can extend the lives of our patients that we care for so dearly. So we talk about mortality rates. Let's talk about the financial impact also, and we know that diabetic limb complications have a huge financial impact on our health care system. And here the red bar is the diabetic limb complications and comparing it to other cancers in terms of cost. And we have breast cancer, colorectal cancer, lung cancer, prostate cancer and leukemia and G diabetic limb complications beat all those. So it's a pretty severe situation that we're in. But luckily, we have devices to help bring this under control and heal these wounds. The stairway toe amputation This was talked about by Armstrong a few years ago, and we see this happening to our patients time and time again. They start with diabetes. They go on to neuropathy, which leads to alteration. These alterations become infected, and because of their lack of blood flow, they become esque emmick, and as a result, they go toe amputation because there's nothing else that we can do to help them. So it's a it's a huge problem. One thing that's really nice is we have this consensus document that was produced in 2019, and in this consensus document we have the ability to look at some really interesting data that's produced. We have some coding guidelines. We have some recommendations that pertain to optimal patient and wound selection. In this document, we talk about wound bed preparation, patient training, the use of various types of wounds and the clinical techniques used in application off mechanically powered negative pressure wound therapy. So this is a wonderful document and a great resource for us now. We know that when we look at traditional negative pressure therapy, we look at some of the things that are promoted were in using it. We know that it claims the wound. We know that it removes infectious waste. We know that it controls the oedema exit date and manages that it helps with regulation tissue. And most importantly, it helps with profusion. So these air all things that when we apply negative pressure that we hope to instill in this wound and for the good of the patient to get this wound to close as quickly as possible. So let's look at the time principle because the time principle has been used in in treating these wounds since 2000 and three when it was first developed. In this, the time principal talks about the tissue, the infection, the moisture balance and what is really important and healing diabetic foot ulcers, edge of the wound or not advancing or undetermined. So we we need to make sure that we we do all these things in tissue management. We need to do breed the wound. We need to restore the base and and get those proteins going so that we can build tissue. We, of course, need to control infection and inflammation. Moisture balance. We know in any type of wound care is important whether we don't have enough moisture or we have too much moisture. We need to be able to control the moisture in that wound and advancing the edge. This is how we close the wound, and we can see that in all of these categories, negative pressure wound therapy plays an important role. So at any level in the wound healing cascade, we can use a negative pressure wound therapy to help augment the healing of this diabetic foot ulcer. Now, here is some of the mechanisms of actions off snap. We know that it does draw the wounded jizz together as traditional negative pressure does. We know that it removes infectious material because of the negative pressure and exit date. It draws that fluid away from the wound when it's unnecessary. And so we get many of the same mechanisms of action that we see in traditional negative pressure wound therapy in snap in disposable negative pressure wound therapy. And this all helps us to control that wound environment and help this wound close. What's really fascinating about using snap is the quality of life issues, and this is where snap scores very, very highly. We know that the snap system is less noise. It's absolutely silent because it's worn, as you see in the diagram on the patient on the patient's leg. In this case, there's less disruption during social situations. Many times nobody even knows the patient is on negative pressure room therapy. When a snap is being worn, it's less interference with daily activities and something that we don't think about in wound care is less interference with sleep because this is so lightweight and it can actually strapped to the patient's leg. They have less sleep disturbances, and we know that in order to heal these wounds, the patient has to be properly rested. But many times, because of the dressings or the devices placed on these patients, they're not able to be comfortable enough to rest successfully. So something we don't think about a lot is interference with sleep and snap really is one of the best products available for us to use is a modality that has the least amount of sleep interference. So let's take a look at the snap therapy system, and the diagram that you have on your right is the snap therapy system right there. That's the whole system. That's all there is to it. So one thing that's nice because it's so small, indiscreet, we have great patient adherence. It's very easy to use. I mentioned quality of life. It's Medicare reimbursed. It can be used as a step down or step up therapy, depending on where the patient is transitioning to. So that's really a nice way to accommodate our patients. As I said, it's very lightweight. These canisters have a pressure off 125 mg the dressing is a blue foam, and it's sealed with this hydroxyl iPad. So it's a continuous therapy. The pressure is continuous, and what's really nice or what most people think is really nice is the alarm. It's not audible. There is no audible alarm. The Onley alarm system on the snap system is a red line indicator on the canister itself, so there's nothing that will wake the patient up or disturb their surroundings. So another nice thing about this and those of us that have toiled applying traditional negative pressure wound therapy. Uh, there's no picture framing required, so the application is extremely easy. You can built in with the tube length how far away you need to have the canister. Many patients strap it to their lower leg if they're treating a diabetic foot ulcer. Some patients want a little bit longer tubing so they can wear it on their belt or put it in their pants pocket. So there's a lot of flexibility is to how we can use this'll, canister and the tubing length for the patient's own comfort. Yeah, so here is the cut the length tubing, as I just mentioned, so the tubing is comes very long in the package, and you can cut it to whatever desired length you want. The micro port is right in the middle of the pad, and the pad can also be trimmed to fit the specific location where it's being applied. There's a nice grid system on the pad, so it allows you to measure the area and cut it so that it conforms very nicely. And this is great for those difficult to treat areas. And I have a great case study coming up that will show you exactly how we do this. So the power source is the canister itself. There's a spring loaded mechanism in the canister that causes the negative pressure it controls contains all the exit date within that system. And as I mentioned before, the Onley alarm is a visual indicator. A red bar that would indicate if there is no longer a seal or if there's a problem with the canister. So it's Ah, it's very, very easy. We call it smart negative pressure therapy because it's small, lightweight, great for clinicians, their studies that I'm going to go over momentarily that speak to the value of using a product like this and for facilities. It's very easy because it's off the shelf and you have it in stock. Pull it down, apply it right away and takes no time at all. So these are some tips, um, for the recommended wound characteristics usually smaller wounds that aren't quite a deep. They don't have a lot of eggs a date. Um, we like the wound to be offloaded, and we can offload these wounds very nicely. I have a case study that that demonstrates this a lot. Eso that we can see that even in the most difficult types of wounds, we can still apply this and have the patient continue on a normal course off the activities of daily living. So one of the magical parts and most important parts about snap is the securing. And the reason why I call it magical is because it allows us to get a seal just about every time we use it. Now, both of us that have been using traditional negative pressure for a number of years? No, that that is one of the most challenging things about negative pressure. Wound therapy is getting that seal. Well, snap has allowed us to use the secure ring and because we can use this with the snap very easily. We almost always get a seal, and we don't have to worry about window painting or anything like that. And I will show you exactly how we use this securing because it works beautifully with staff. So let's look at a little bit of the evidence. I mentioned that we had some articles to go over, So let me go over some of the evidence to demonstrate how effective this is. Here's Lumens article from 2000 and 10 and he looked at 42 patient controlled study. He found that 100% of the snap treated patients demonstrated improvement, which is really nice. Patients with staff system benefited from the effects of being in this experimental trial also, and we also found that 50% absolute time to healing was significantly less for subjects treated with a snap system. So here in this first study, we begun to see that we have good evidence showing that snap is very effective. This is from Armstrong a couple years after that, in 2012, and what he showed us is that primary endpoint analysis off wound size reduction found that the SAP systems demonstrated non inferiority to the back therapy subjects, which is huge. So we now know that if we have a choice between the vac and the snap in terms of efficiency, we're not gonna go wrong no matter which way we go. Because systems worked very, very similarly and work very well in our strong study, he found that snap system patients reported less interruption of activities of daily living. We also saw so that other benefits noted by the authors were shorter time to dressing, application and ease of use, something that we now talk about all the time when we talk about snap Marston Study in 2015 Looking at Venus Leg ulcers showed a primary endpoint analysis of wound reduction found that the staff system treated subjects significantly greater wound size reduction than the back. So again, we're showing that the snap system definitely holds its own and in some cases does a bit of a better job in some patients than traditional back therapy. This is a result of Marston study, so because of these studies, we can now use the snap and feel a very very confident that we're giving the patient the best possible therapy we can when it comes to negative pressure wound therapy. So that's the didactic part. Now we want to go to the fun stuff, which is the case studies. As you can see, this is a transmitter. Tar still amputation. This is a non diabetic patient, but he's neuropathic, had palpable pulses and a positive probe to bone at the time that we did the procedure. Except he wasn't very compliant. As you can see, the stitches are still in. And the reason why the wound looks like that is because this patient decided to go for a walk with his wife at the mall and he put on his old shoes. So, of course, you know there's no filler in the shoe, nothing to keep the wound intact or pressure on that wound. And as a result of walking on this transmitted partial amputation site so quickly after the procedure, I mean stitches air still in, Um, he he popped a few stitches and re ulcerated the area now, needless to say, very noncompliant patient, so I'm not in a big hurry to go back to the O R and do some more work on this. So what we decided to do is just clean it up, take the suitors out and apply negative pressure to this area to get a closed as quickly as possible. And that's exactly what we did. We cleaned it up. We applied snap. But we bolstered an amniotic mesh graft underneath the phone, and you can see that yellow arrow is pointing to the graft. And I love using combination therapy when I use negative pressure so I very often will use a collagen or amniotic mesh graft and bolster it with the foam into the wound. So here we are, putting the foam into the wound, and this is where that fantastic hydro college ring comes into play. We take that ring and we break it up out of the package and roll it in our hands. It's 100 call. It rings, So the warmth of your hands is gonna soften it up as you roll it, just like you did with Clay when you were a kid made little snakes out of play. Well, you're doing the same thing with the hydroxyl ring. You're warming it in your hand you're rolling it around. You make this ring and you lay it down around the wound. The arrow is pointing to the hydro colored ring that we put on this patient. This will assure us getting a nice seal when we put the dressing down on top of the wound. And here we are, doing exactly that. The port is in the middle of the wound over the foam, and you can see the hydroxyl lead ring well adhered to the hydro core, Lloyd, pad off the staff dressing and we got a seal in a matter of seconds. So it worked out extremely well, and this makes it so easy to apply. We also see in the picture on the right. You can tell that we have some wrinkles in the dressing. Now we're taught when we use traditional negative pressure therapy. Please, No wrinkles don't have any wrinkles. Otherwise you'll get a leak. Well, guess what? When you use the hydro college ring, you don't have to worry about that. Because as long as you can get adherence all the way around that ring, you could have wrinkles. It doesn't have to look pretty is long as it works. So in this case, we did have a few wrinkles. And it's not a problem because the hydroxyl ring allowed us to get a 100% seal. This patient went on to close very, very quickly as a result, off using Ah, snap, negative pressure system. This is the way you're not supposed to use the hydra quality ring. In this particular case, you can see they took it right out of the package, slapped it on the wound. And there's so many things wrong with this. I mean, the the phone is peeking out from underneath the ring. If you see the bottom part of that picture, um, it's just a terrible application of the hydro coid ring. This is how you don't use it. So here's a real tricky, tricky patient. This patient had 1/4 digit amputation. He has charcoal foot neuropathy, and it was just the isolated fourth digit that became necrotic. So they went in and we did a rare section on it, and we wanted to apply a snap. But it was a very difficult area to apply any sort of addressing, let alone negative pressure. You can see that the wound was not responsive after three months, So then they sent them over to my clinic and they said, Well, Dr G, why don't you take a shot at this? Because we give you all the tough patients and I said, Okay, we'll do it and we apply to snap to this. And we had great success with Snap because were ableto to fill in this wound very quickly. This is the picture at two weeks and at four weeks after snap therapy, and this picture on the left demonstrates how we use the hydroxyl Lloyd Ring to place addressing between the toes and get a seal using traditional negative pressure therapy. This is almost unthinkable. But using snap, we can make this happen, and we did make it happen. And we heal this patient very successfully. And here we are at eight weeks and at 10 weeks, the wound is apathy analyzed, whereas before it had been opened for three months with very little movement as faras granule ation of that wound. So we were pretty thrilled that we were able to accomplish this and the patient was pretty happy also. So here's a way that we can treat planter wounds and awful of them and even allow the patient to shower. We have this bridging system with the snap, and here's a traditional plantar ulceration that we can bridge using Snap Bridget to the top and you see the port up around the ankle. Then the tubing goes up his leg. And because this is a waterproof dressing, if you have a compliant patient, you can even let them shower. Here's another type of wound where we did the same thing. The Hydra collard rain comes into play here to make sure that we get a seal. We bridge this dressing around to the top of his foot, and this patient can actually if they wanted to. And if they're compliant and if they're careful, take a shower, which for patients with wounds that's almost unheard off. And yet here we are, increasing this patient's quality of life because we've decided to use snap negative pressure on this patient. So again, just some tips for the optimal type of dressing application. Make sure that the area is nice and dry. Remove any drier Scalea skin. Apply a non adherent layer over any expose structures. Ensure the dressing contact is around the entire wound bed. Overlap the hydro collard layer at least one centimeter of intact skin. Apply the 100 quality draped with as few wrinkles as possible that's always preferred and then cut your tubing. And remember, always use that securing and applied around the wound. That would almost guarantee that you will have great success when applying is down. So this is an off the shelf products. Remember that. That's what makes it so easy to use. Continuous negative pressure therapy. Single use. Very disposable. Very discreet, very quiet. Our patients love that, especially those patients who have been on traditional negative therapy and have had leak issues with that alarm going off when they get to a snap. When we transition them to a snap, they asked, Why didn't you use this before? And, well, there's other reasons why we didn't use it before, but they love the snap. Those patients that are now on snap love it so it is mechanically powered and extremely portable. So thank you for your attention. I really appreciate it. And I hope that you got something out of this presentation. Have a great day