Negative-pressure wound therapy (NPWT), also known as a vacuum assisted closure (VAC), is a

therapeutic A therapy or medical treatment (often abbreviated tx, Tx, or Tx) is the attempted remediation of a health problem, usually following a medical diagnosis. As a rule, each therapy has indications and contraindications. There are many different ...

technique using a suction pump, tubing and a dressing to remove excess exudate and promote healing in acute or

chronic wound A chronic wound is a wound that does not heal in an orderly set of stages and in a predictable amount of time the way most wounds do; wounds that do not heal within three months are often considered chronic. Chronic wounds seem to be detained in one ...

s and second- and third-degree burns. The therapy involves the controlled application of subatmospheric pressure to the local wound environment using a sealed wound dressing connected to a vacuum pump. The use of this technique in wound management started in the 1990s and this technique is often recommended for treatment of a range of wounds including dehisced surgical wounds, closed surgical wounds, open abdominal wounds, open fractures, pressure injuries or

pressure ulcer Pressure ulcers, also known as pressure sores, bed sores or pressure injuries, are localised damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure, or pressure in combi ...

diabetic foot ulcer Diabetic foot ulcer is a major complication of diabetes mellitus, and probably the major component of the diabetic foot. Wound healing is an innate mechanism of action that works reliably most of the time. A key feature of wound healing is step ...

s, venous insufficiency ulcers, some types of

skin grafts Skin grafting, a type of graft surgery, involves the transplantation of skin. The transplanted tissue is called a skin graft. Surgeons may use skin grafting to treat: * extensive wounding or trauma * burns * areas of extensive skin loss du ...

, burns, sternal wounds. It may also be considered after a clean surgery in a person who is obese. NPWT is performed by applying a

vacuum A vacuum is a space devoid of matter. The word is derived from the Latin adjective ''vacuus'' for "vacant" or " void". An approximation to such vacuum is a region with a gaseous pressure much less than atmospheric pressure. Physicists often di ...

through a special sealed dressing. The continued vacuum draws out fluid from the wound and increases blood flow to the area. The vacuum may be applied continuously or intermittently, depending on the type of wound being treated and the clinical objectives. Typically, the dressing is changed two to three times per week. The dressings used for the technique include foam dressings and gauze, sealed with an occlusive dressing intended to contain the vacuum at the wound site. Where NPWT devices allow delivery of fluids, such as saline or

antibiotics An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting bacterial infections, and antibiotic medications are widely used in the treatment and prevention o ...

to irrigate the wound, intermittent removal of used fluid supports the cleaning and drainage of the wound bed. In 1995, Kinetic Concepts was the first company to have a NPWT product cleared by the US

Food and Drug Administration The United States Food and Drug Administration (FDA or US FDA) is a List of United States federal agencies, federal agency of the United States Department of Health and Human Services, Department of Health and Human Services. The FDA is respon ...

. Following increased use of the technique by hospitals in the US, the procedure was approved for reimbursement by the Centers for Medicare and Medicaid Services in 2001.

Technique

General technique for NPWT is as follows: A dressing or filler material is fitted to the contours of a wound to protect the periwound and the overlying foam or gauze is then sealed with a transparent film. A drainage tube is then connected to the dressing through an opening of the transparent film. Tubing is connected through an opening in the film drape to a canister on the side of a

vacuum pump A vacuum pump is a device that draws gas molecules from a sealed volume in order to leave behind a partial vacuum. The job of a vacuum pump is to generate a relative vacuum within a capacity. The first vacuum pump was invented in 1650 by Otto ...

. This turns an open wound into a controlled, closed wound with an airtight seal while removing excess fluid from the wound bed to enhance circulation and remove wound fluids. This creates a moist healing environment and reduces edema. There are four types of dressings used over the wound surface:

foam Foams are materials formed by trapping pockets of gas in a liquid or solid. A bath sponge and the head on a glass of beer are examples of foams. In most foams, the volume of gas is large, with thin films of liquid or solid separating the ...

or gauze, a transparent film and a non-adherent (woven or non-woven) contact layer if necessary. Foam dressings or woven gauze are used to fill open cavity wounds. Foam can be cut to size to fit wounds. Once the wound is filled, then a transparent film is applied over the top to create a seal around the dressing. The tubing is then attached and connected to the pump. Once the dressing is sealed, the vacuum pump can be set to deliver continuous or intermittent pressures, with levels of pressure depending on the device used, varying between −200 and −40 mmHg depending on the material used and patient tolerance. Pressure can be applied constantly or intermittently.

The dressing type used depends on the type of wound, clinical objectives and patient. For pain sensitive patients with shallow or irregular wounds, wounds with undermining or explored tracts or tunnels, gauze may be used, while foam may be cut easily to fit a patient's wound that has a regular contour and perform better when aggressive granulation formation and wound contraction is the desired goal.

Contraindications

Contraindications In medicine, a contraindication is a condition that serves as a reason not to take a certain medical treatment due to the harm that it would cause the patient. Contraindication is the opposite of indication, which is a reason to use a certain tre ...

for NPWT use include: # Malignancy in the wound # Untreated

osteomyelitis Osteomyelitis (OM) is an infection of bone. Symptoms may include pain in a specific bone with overlying redness, fever, and weakness. The long bones of the arms and legs are most commonly involved in children e.g. the femur and humerus, while the ...

# Non enteric and unexplored

fistula A fistula (plural: fistulas or fistulae ; from Latin ''fistula'', "tube, pipe") in anatomy is an abnormal connection between two hollow spaces (technically, two epithelialized surfaces), such as blood vessels, intestines, or other hollow or ...

s # Necrotic tissue with

eschar An eschar (; Greek: ''ἐσχάρᾱ'', ''eskhara''; Latin: ''eschara'') is a slough or piece of dead tissue that is cast off from the surface of the skin, particularly after a burn injury, but also seen in gangrene, ulcer, fungal infections, ...

present # Exposed blood vessels, anastomotic sites, organs and nerves in the periwound area (must avoid direct foam contact with these structures)

Effectiveness

Negative pressure wound therapy is usually used with

s or wounds that are expected to present difficulties while healing (such as those associated with

diabetes Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level ( hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ...

). Negative pressure wound therapy is approved by the FDA and numerous randomized controlled trials have been conducted on this technique, however, the evidence supporting how effective NPWT is compared to standard wound care dressings is not clear. Low-level evidence indicates that there may be a lower risk of death and less surgical site infections associated with NPWT compared to standard dressing care, however there may not be a difference in the risk of wound reopening when comparing the two approaches. NPWT may increase the risk of skin blistering compared to standard wound care. NPWT may be a more cost effective approach for closing wounds following a caesarean section in women who are obese, however, NPWT is not likely as cost effective for closing wounds associated with fracture surgeries. It is not clear if NPWT is cost effective for closing wounds associated with other types of surgery. NPWT has been used to treat non-trauma patients after abdominal surgery. Non-trauma patients are people who might need surgery for conditions such as abdominal infections or cancer. However, it is still not clear how safe and effective NPWT is for treating non-trauma patients with open abdomens. For treating diabetic ulcers of the feet, "consistent evidence of the benefit of NPWT" in the treatment of diabetic ulcers of the feet has been reported. Results for

bedsore Pressure ulcers, also known as pressure sores, bed sores or pressure injuries, are localised damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure, or pressure in combi ...

s were conflicting and research on mixed wounds was of poor quality, but promising. The review did not find evidence of increased significant complications. The review concluded "There is now sufficient evidence to show that NPWT is safe, and will accelerate healing, to justify its use in the treatment of diabetes-associated chronic leg wounds. There is also evidence, though of poor quality, to suggest that healing of other wounds may also be accelerated." The use of NPWT to enhance wound healing by removing excess extracellular fluid and decreasing tissue edema, which leads to increased blood flow and stabilization of the wound environment. A reduction in systemic (e.g. interleukins, monocytes) and local mediators of inflammation has been demonstrated in experimental models, while decreased matrix metalloproteinase activity and bacterial burden have been documented clinically. In vivo, NPWT has been shown to increase fibroblast proliferation and migration, collagen organization, and to increase the expression of vascular endothelial growth factor and fibroblast growth factor-2, thereby enhancing wound healing.

References

{{Authority control Medical treatments Medical pumps Medical equipment Plastic surgery