Pneumatic Devices and Compression Garments Minerva Zaniebeth A. Gomez, PTRP Faculty Department of Physical Therapy University of the Philippines -Manila

OBJECTIVES Differentiate the various pneumatic devices and compression garments according to function/ purpose. Identify the physiological effects of compression devices.

OBJECTIVES Differentiate the indications, precautions and contraindication of the pneumatic devices and compression garments.

PHYSIOLOGICAL EFFECTS Increased pressure in the interstitial fluids enhance venous and lymphatic return Decreased capillary perfusion: decreased cellular activity and collagen synthesis

PNEUMATIC DEVICES Apply external pressure to an extremity through an inflatable appliance (sleeve) Come in a variety of sizes Can be applied simultaneously with cold using a coolant (50°- 77° F) pumped through an inflatable sleeve. The compression units are designed in such a way that it inflates either a single compartment, producing uniform circumferential pressure on the extremity or multiple compartments applying pressure in a sequential manner. Pressure is greater in distal compartments and lesser in proximal compartments. Picture – these are what you call boots or sleeves attaches to the rubber hose of the machine. A stockinette is always used before applying the boots or sleeves.

Intermittent mechanical Compression Jobst, Kendall, Chattanooga Can be used in cases of chronic edema, lymphedema, stasis ulcer, traumatic edema, venous insufficiency, amputation Generally set at an Inflation and deflation ratio of 3:1; to shape residual limb 4:1 1st picture – this is a Jobst compression device single chamber compression 2nd picture – still a jobst compression device but a sequential compression type 3rd picture – Kendall sequential compression device 4th picture – Chattanooga sequential compression device

45-90 seconds on/ 15-30 seconds off, for edema reduction Pressure should never exceed the patient’s diastolic BP UE: Should not exceed 40-60 mmHg LE: Should not exceed 40-70 mmHg 2nd bullet- to prevent occlusion of blood vessels; although some advise that pressure can fall between the DBP and SBP since the pressure is applied for only a short period of time.

Duration of treatment: 2-3 hours – lymphedema 2 hours – traumatic edema 2.5 hours (3X/week) - venous ulcers 4 hours (1-3 hour sessions) – residual limb reduction These are only suggested dosages based on the Jobst compression device, so it may very depending on the machine you are using. A table on dosages for different conditions can be found in Hecox page 424

Pneumatic End-Diastolic Leg Compression a.k.a. Intermittent Venous Occlusion Used for chronic arterial occlusion Delivers short pulses of 80-100 mmHg every 20 seconds INSERT PIC FROM BRADDOM page 1292. The mechanism is the same as the pumping action of the calf muscles on veins during walking. A cuff is strapped to the leg and connected to a compressor that rapidly inflates the cuff with air (80-100mmHg every 20 seconds). Improve blood flow and reduce dependent edema.

Remember! ALWAYS take the Patient’s BP before treatment ALWAYS cover any open wounds with sterile gauze ALWAYS use a stockinette Amputated limbs: stockinette applied over elastic bandage ALWAYS elevate the limb being treated for edema reduction

Sequential vs single chamber compression What is the evidence? Pilch, U., Wozniewski, M. and Szuba, A. (2009). Influence of compression cycle time and number of sleeve chambers on upper extremity lymphedema volume reduction during intermittent pneumatic compression. Dittmar, A. and Krause D. (1990). A comparison of intermittent compression with single and multi-chamber systems in treatment of secondary arm lymphedema following mastectomy Both studies concluded that both types can reduce edema and that there is no difference between the two with regards to lymphedema reduction. The study by Pilch found that a shorter cycle duration (1:1) with 3-chamber compression has better efficacy in edema reduction.

COMPRESSIVE GARMENTS Rigid, semi-rigid or soft as condition requires.

Removable Rigid Dressings Made of plaster of paris or fiberglass cast Used after limb amputation to prevent post-operative edema Can also reduce post-operative pain and enhance wound healing 1st bullet – suspended by a stockinet and supracondylar cuff adjusted by adding/ removing stockings

Semi-Rigid Dressing Examples: Unna paste, air splint, controlled environment treatment (CET) Used to control post-operative edema in limb amputations Can also reduce post-operative pain and enhance wound healing Removable rigid and semi-rigid dressing are both applied in the operating room

Unna Paste Has self-suspension Can be changed easily an conforms to residual limb Allows free motion in the proximal joints Not as durable as the rigid dressing Needs frequent changing than a rigid dressing Last picture: unna boot – usually used for stasis ulcers

Air Splint Has a plastic double wall bag pumped to a desired level of rigidity Inexpensive and allows early ambulation Plastic is hot and humid INSERT PIC of air splint from O’Sullivan page 190 1st bullet – has a zippper which encases the entire extremity 3rd bullet – constant pressure does not conform to the limb and the plastic material can cause discomfort

Controlled environment treatment (CET) Consists of a console and a polyvinyl bag Has a sterilizing component Allows active exercises of the involved limb and standing at bedside Size hinders ambulation Bag interferes with lying prone CET – controlled environment treatment 2nd bullet – provided by the console

Soft Dressing Oldest method of limb amputation management Relatively inexpensive Poor control of edema Requires skill in proper application Can slip and form a tourniquet May be indicated in local infection 2nd bullet – light weight and readily available 4th bullet – needs frequent reapplication, loosens through time, applied from distal to proximal with decreasing pressure as you go through. 6th bullet – but not the treatment of choice

They are different kinds of soft dressings, the most popular of which are the bandages. They can be made of different types of materials such as cotton. Cotton bandages are not as flexible as the elastic bandages. Bandages are considered as the least effective of shrinkage devices used in amputations. If poorly applied, can cause circumferential constriction with distal edema. 4-inch bandages are used for the legs and arms, 6-inch bandages are used for thighs and big arms. There are adhesive bandages as well especially used in sports injuries. Elastic compression garments provides 30-40 mmHg continuously depending on the brand. Coban wraps can be applied to each finger to reduce edema of the hand

Elastic Bandages Least effective- - shaping residual limb Can cause circumferential constriction Provide 30-40 mmHg continuous pressure depending on brand

Elastic Shrinkers Easy to apply Provide uniform compression More expensive than bandages Worn 24 hours/day except for bathing

Compressive Stockings Chronic venous insufficiency 30-40 mmHg Lymphedema 30-40 mmHg or 40-50 mmHg 40-50 mmHg or 50-60 mmHg – selective refractory patients 1st bullet – pressure gradient of 30-40mmHg Both conditions usually use a knee-high length with a thigh-high stocking don over for lymphedema

Compressive Garments Burns At least 25 mmHg Applied at least 23 hours/ day Applied until the scar is mature 1st bullet – to exceed normal capillary pressure

Compression Gloves Made of nylon spandex Used in hand edema such as in RA or hand injuries

INDICATIONS Post-amputation Chronic venous & arterial insufficiency Lymphedema – i.e. post-mastectomy Stasis ulcer Burns RA Sports injuries Prevention of DVT 2. Circulatory impairments - such as arterial and venous insufficiency, prevention of DVT in bed ridden patients like in cases of SCI, Stroke, TBI For chronic venous insufficiency and lymphedema – IPC, compressive garments in between pumping sessions and when volume stabilizes, compressive stockings No.3 – compression therapy is the mainstay treatment. Non-elastic compression such as the Unna paste boot is usually used. Elastic compression may also be used, but the pressure provided may not be enough to heal stasis ulcers. No. 5 – edema post-burn can be addressed with IPCs No. 7 – compression can be applied by elastic wraps initially (i.e. ace bandages) and re-wrapping should be performed every 4 hours. IPCs with ice is can also be done. No.8 – like in case of SCI, IPC and gradient elastic stockings can be used IPCs can also be used in RSD

PRECAUTIONS Impaired sensation Uncontrolled HTN

CONTRAINDICATIONS Acute edema Acute inflammation Acute DVT Acute pulmonary edema Loss of sensation Edema with cardiac or renal impairment 1. Acute edema in cases of acute traumatic injury, fracture

CONTRAINDICATIONS Cancer Impaired cognition Presence of infection Obstructed lymph and vascular channels Very old and very young patients

DOCUMENTATION Type of device Parameters used: settings, duration Patient position Goal of treatment (FOR format) Response of patient

REFERENCES Braddom, R. (2000). Physical Medicine and Rehabilitation. Singapore: Elsevier Science (Singapore) PTE LTD. Delisa, J. (1993). Rehabilitation Medicine: Principles and Practice 2nd Ed. USA: JB Lippincott Company.

REFERENCES Hecox, B., Mehreteab TA, Weisberg J. (1994). Physical Agents: A Comprehensive Text for Physical Therapists. USA: Appleton & Lange.

REFERENCES O' Sullivan, S. (1988). Physical Rehabilitation: Assessment and Treatment 2nd Ed. USA: FA Davis Company. O' Sullivan, S., & Siegelman, R. (2007). National Physical Therapy Examination. Review and Study Guide . USA: International Educational Resources Ltd.