topical oxygen therapy in - wound care today · wound swab indicated she required a further course...
TRANSCRIPT
Topical oxygen therapy in the treatment of diabetic
foot ulcers
Overview — oxygen therapy
• Why is it needed?
• What does it do?
• How is it used?
• What are the results?
Learning objectives
1. Understand why oxygen is crucial to wound healing
2. Understand how oxygen is delivered to cells in the healthy body
3. Understand why chronic wounds are associated with low oxygen levels
4. Understand how oxygen therapy can facilitate chronic wound healing
The need
• 23 amputations per day• 70,000 people in England
have a diabetic foot ulcer (DFU)
• Much of this suffering is avoidable
• NHS England spends over £1bn a year on DFUs
• £5.7m per clinical commissioning group (CCG)
• This cost could be considerably reduced
• Poor diabetic foot care often costs more than good care
• Reducing the prevalence of severe ulcers by a third would save the average CCG £1m a year
https://www.improvingdiabeticfootcare.com/ - accessed 28/01/2019
Wound healing factors
Healed wound
Nutrition
Moisture
InfectionUndisturbed
wound healing
Oxygen
Wound healing factors
Healed wound
Nutrition
Moisture
InfectionUndisturbed
wound healing
Oxygen
Wound healing factors
Healed wound
Nutrition
Moisture
InfectionUndisturbed
wound healing
Oxygen
Wound healing factors
Healed wound
Nutrition
Moisture
InfectionUndisturbed
wound healing
Oxygen
Wound healing factors
Healed wound
Nutrition
Moisture
InfectionUndisturbed
wound healing
Oxygen
Oxygen
Wound healing factors
Oxygen in wound healing: supply and demand
Reduced supply Increased demand
Modified from - Continuing education in anaesthesia, Critical Care & pain; volume 4 number 4 2004; pg 123-126; S.A. McLellan, T.S. Walsh
Decreased oxygen supply
Hypoxic / ischaemic tissue condition
Venous insufficiency
• Oedema
• Capillary rarefaction
• Ambulatory venous hypertension
• Prolonged diffusion distances
Arterial occlusive diseases
• Constricted lumina
• Reduced blood flow
• Stenosis
Diabetes mellitus
• Basal membrane thickening > constricted lumina
• Dysfunction in vascular tone regulation (neuropathia)
• Concomitant pAOD (50%)
• Shunt building
Pressure ulcers
• Blood undersupply
• Capillary rarefication
• ‘Squeeze out’ effect in tissue perfusion
Data held on file.
Increased oxygen demand
Energy metabolism
Angiogenesis
Collagen maturation
Oxygen free radicals
1 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2704021/ - accessed 07/03/2019.
No oxygen = no wound healing
1 Runagsetakit Chinsakchai Mahawongkajit et al (2010) Transcutaneous Oxygen tension predictor of ulcer healing in limb ischemia. JWC 19.
No oxygen = no wound healing
Factors causing a worse outcome on patients being
alive and ulcer free
Factors that cause an increased number of
admissions
Factors that cause an increased chance of major
amputation
https://files.digital.nhs.uk/50/8E75BA/NDFA%204AR%20-%20Main%20Report%20v1.0.pdf - accessed 23/08/2019 .
Oxygen in wound healing: supply and demand• We know chronic wounds are an issue in the UK
• We know that chronic wounds require more oxygen, but often have a lower supply due to underlying conditions
• National diabetic foot audit has shown:
• Ischaemic wounds less likely to heal• Ischaemic wounds are more likely to cause hospital admission• Ischaemic wounds are more likely to lead to major amputations
• What don’t we know?• How the healthy human body delivers and regulates oxygen
Healthy human body
Diffusion Haemoglobin Diffusion
1. http://mammothmemory.net/biology/movement-in-and-out-of-cells/diffusion/diffusion-in-biology.html - accessed 07/03/20192. https://mrssmithsbiology.wordpress.com/national-5-biology/unit-2-multicellular-organisms/ch15-animal-transport-exchange-systems/ - accessed 07/03/2019
Regulation
100%
75%
25%
104 40 20
% O
2sa
tura
tio
n o
f H
ae
mo
glo
bin
PO2 mmHg
O2 pressure in alveoli —104mmHg
O2 pressure in resting cell —40mmHg
O2 pressure in active cell —20mmHg
Modified from - Transport of Oxygen and Carbon Dioxide in Blood and Tissue Fluids, Domenic Bell http://slideplayer.com/slide/10560062/ - accessed 07/03/2019
Chronic wound: oxygen in the air• Blood supply is compromised• What about oxygen in the air?
- The atmosphere has 21% oxygen
- But only 1% of that can diffuse across a 0.1mm fluid barrier
- Even in a healthy, moist healing environment, exudate can block a significant amount of oxygen
Einstein-Smoluchowski relation for water, Data on File
Choices
What do we do?
1. Revascularise
2. Dry out the wound
3. Find a way to transport the oxygen through the exudate
Oxygen therapy
Oxygen therapy
Hyperbaric therapy (HBOT)
SYSTEMICTHERAPIES
Pressure delivery (PDO)
Dressing and gel release (OWD)
Continuous delivery (CDO)
Oxygen diffusion enhancer (ODE)
TOPICAL THERAPIES
1 Gottrup F, Dissemond J, Baines et al. Use of oxygen therapies in wound healing, with special focus on topical and hyperbaric oxygen treatment. J Wound Care, 2017; 26(5), Suppl, S1–S42..
Systemic review versus standard of care
•27 unique comparative studies
•8 meeting criteria
•6 studies: diabetic foot ulcer
Hyperbaric therapy
•26 unique comparative studies
•8 meeting criteria
•7 studies: diabetic foot ulcer
Topical oxygen therapy
•25 unique comparative studies
•7 meeting criteria
•3 studies: diabetic foot ulcer
Facilitated diffusion
1 Gottrup F, Dissemond J, Baines et al. Use of oxygen therapies in wound healing, with special focus on topical and hyperbaric oxygen treatment. J Wound Care, 2017; 26(5), Suppl, S1–S42
Oxygen therapy• High ease of use
• Low cost
• Patient home use possible
• Low ease of use
• High cost
• Specialised centres required
ODEOxygen
diffusion enhancer
Oxygendiffusion enhancer
HAEMOGLOBIN
OWDOxygen releasing
wounddressing
Oxygen releasing wound
dressing
CDOContinuous delivery of
oxygen
Topicaloxygen
perfusors
PDOPressurised delivery of
oxygen
Topicaloxygen
chambers
HBOTHyperbaric
oxygen therapy
Hyperbaricchambers
1 Gottrup F, Dissemond J, Baines et al. Use of oxygen therapies in wound healing, with special focus on topical and hyperbaric oxygen treatment. J Wound Care, 2017; 26(5), Suppl, S1–S42..
Case report• This lady had type 2 diabetes of 10 years’ duration, with neuropathic
and peripheral vascular disease (PVD) in her left foot
• She was initially referred with cellulitis to her left foot and a plantar ulcer over the first metatarsophalangeal joint (MPJ)
• Her diabetes was poorly controlled (HbA1c at 95mmols/mol); BMI was 32.2; weight 76.4kg; smoker; cholesterol 7.6 — LDL of 5.3, HDL of 1.30; serum creatinine 54; estimated glomerular filtration rate (eGFR) of 90; toe brachial index (TBI), right at 0.98 and left at 0.43
Case report• Her current medication was NovaMix insulin, tramadol, duloxetine and
simvastatin
• She had several admissions for intravenous (IV) antibiotics and on her last admission had a ray amputation of her left 2nd toe due to osteomyelitis
• The ray amputation site was initially dressed with a hydrofibre dressing, as the wound bed was sloughy, but this did not improve over the next few weeks
Case report
Case report• By the beginning of May, she reluctantly had treatment with biosurgery,
which cleared the wound bed to healthy granulation tissue within five days
• To maintain a healthy wound bed, it was dressed with a lipo-colloidal wound contact dressing for four weeks
• The wound continued to develop slough and recent cultures from a wound swab indicated she required a further course of oral antibiotics
Case report• She was reviewed in our department a week later, with her practice
nurse redressing twice in that week with a hydrofibre dressing and, although the infection had diminished, the wound bed was not improving
• Granulox® was added to this dressing regimen and within a week the wound bed showed signs of healthy granulation tissue
• The wound was dressed twice a week with Granulox® until healed by the beginning of September that year
May to September
When to use?
• Chadwick et al – 2019, The Diabetic Foot Journal
• An overview of topical oxygen therapy
• Development of an algorithm for diabetic foot ulcer
When to use?
When to use?Conclusion
‘Topical oxygen therapy should be considered as an adjunct to best practice for DFUs as it has been shown to be beneficial and improve outcomes in suitable patients.’
When to use?Thank you
For a free copy of the report, please email:
Summary and conclusions
•Chronic wounds are often hypoxic
•Oxygen is crucial to wound healing
•Oxygen therapy can be a useful adjunct when
dealing with chronic wounds that are ischaemic
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