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How to Select Adequate Compression Therapy Pressure Levels and Products

How to Select Adequate Compression Therapy Pressure Levels and Products

How to Select Adequate Compression Therapy Pressure Levels and Products

INTRODUCTION

Overview

Compression therapy is considered the mainstay of venous leg ulcer (VLU) treatment [1] and along with standard care, has the potential to heal 50%-75% of VLUs [1][2]. Despite existing guidance, many patients with VLU who are treated at primary care settings do not receive adequate compression therapy due to several factors, some related to patients (e.g., adherence) and to clinicians (e.g, application skills, etc).[3]

Compression is delivered through several types of devices, such as bandages, wraps or gradient compression stockings. Therapy usually starts with compression bandages or wraps and then transitions to gradient compression stockings once edema subsides and ulcer is healed. 

This topic provides practical guidance to wound care clinicians on the selection of appropriate compression devices and pressure levels for persons with leg ulcers who are candidates for compression therapy. Algorithms illustrate how audible handheld Doppler ultrasound and waveform analysis or ankle-brachial index (ABI) can be utilized to determine appropriate pressure levels and types of compression across different clinical scenarios. For interpretation of audible handheld Doppler ultrasound and waveform, see topic "Audible Handheld Doppler Ultrasound and Waveforms"  For background information on compression therapy, see  "Compression Therapy". For a list of brands of commonly used compression products, see  "Compression Brands Quick Reference". For assessment, treatment and prevention of VLU see  "Venous ulcers"

INSTRUCTIONS

Indications for this clinical decision support tool

For which patients: 

Patients with conditions below, being considered for compression therapy:

  • VLU
  • Varicose veins and edema
  • Lymphedema
  • Post-thrombotic syndrome
  • Prevention of deep venous thrombosis (DVT)

When to use this tool: 

  • During initial assessment
  • Every 6 months if compression > 20 mmHg
  • If ulcer deteriorates
  • If ulcer is not closed within 12 weeks 
  • If recurrence
  • If increased pain and/or exudate, change in wound bed color

How to use this tool:

  • Conduct comprehensive assessment of the patient and wound
    • Rule out absolute contraindications to any form of compression therapy:
      • Severe peripheral artery disease (PAD) with signs and symptoms of critical limb ischemia [4]
        • Rest pain: constant pain in the forefoot, relieved by dependency and worsened by elevation
        • Gangrene 
      • Acute arterial occlusion: include pain, pallor, poikilothermia, pulselessness, paresthesia, and paralysis
      • Unstable congestive heart failure (CHF) with pulmonary edema [4]
  • Assess lower limb blood supply following one of the algorithms below:
  • Determine ulcer healability, create care plan, discuss with patient and caregivers
  • Apply compression bandage/wrap 
  • Follow up in 24 to 48 hours after compression is applied to assess adherence, adverse effects and effectiveness.

ALGORITHMS

Based on ABI

Non-compressible arteries
(See Table 3)

Arterial calcification may be present. Apply modified low compression (10 mmHg). 
(See Brands)
Refer to vascular lab for TBI or other noninvasive arterial tests 
(See Table 1)
Start with ABI (handheld Doppler or automatic ankle brachial index system)
ABI 0.8-1.3

ABI >1.3


ABI 0.8-0.5 
PAD
ABI <0.5
 severe PAD (CLI)
Apply modified low compression (10 mmHg) (See Brands)
 
Refer to vascular lab for macro/ microcirculation examination (See Table 1)
PAD
May be a non-healable mixed arterial ulcer  
(See Table 3)

Do not apply compression, refer to emergency department or vascular specialist. Compression may be applied under close supervision by vascular specialist
Mixed arterial ulcer 
> is it healable? (See Table 2)
Healable, mixed arterial ulcer   (See Table 3)

Apply modified compression (20-30 mmHg) with low resting pressure 
(See Brands)
Healable, simple VLU   (See Table 3)

Apply standard compression
(See Brands)
  VLU 
> Is the ulcer healable? (See Table 2)
> Is the VLU complex or simple? (See Table 3)
Healable, complex VLU 
(See Table 3)

Apply standard or modified compression depending on accompanying factors  
(See Brands)
Healable lymphedema

Apply standard compression
Other conditions
(compression levels depend on condition)
Signs or symptoms of mild/moderate PAD? (e.g, claudication, atypical leg pain 
NO PAD
PAD: peripheral artery disease, CLI: critical limb ischemia, VLU: venous leg ulcer
NO
YES

Based on audible handheld Doppler ultrasound or continuous waveform analysis

 Start with handheld audible Doppler or Doppler waveform analysis 
Triphasic
Normal flow [Alavi 2015a](*)
Healable, simple VLU (See Table 3)

Apply standard compression
(See Brands)
Biphasic
May reflect normal or abnormal flow (Scissons 2012)
Not suggestive of relevant tissue hypoxia 
Mixed arterial ulcer 
> is it healable? (See Table 2)
Monophasic
 Abnormal flow due to moderate or severe stenosis
Non-healable mixed arterial ulcer  
(See Table 3)

Do not apply compression, refer to emergency department vascular specialist
No flow
Is TP or SPP > 30 mmHg? (See Table 1)
YES
Is the patient at high-risk for PAD (See Box 1)? Are there signs/symptoms of PAD (atypical leg symptoms, claudication, rest pain)?
NO
May have PAD > Perform bedside TP, SPP, or other bedside microvascular test (See Table 1[Alavi 2015b]
YES
Box 1. High risk for PAD (Weir, 2014)
- Family or personal history of diabetes or arterial disease.
- High blood pressure
- High cholesterol 
- Body mass index > 25 Kg/m2
- Smoking
  VLU 
> Is the ulcer healable? (See Table 2)
> Is the VLU complex or simple? (See Table 3)
Healable lymphedema

Apply standard compression 
(See Brands)
Other conditions
(Pressure levels depend on condition)
Healable, complex VLU (See Table 3)

Apply standard or modified compression depending on accompanying factors  
(See Brands)

Healable, mixed arterial ulcer 
 
(See Table 3)
  1. Apply modified compression (20-30 mmHg) with low resting pressure (See Brands)
  2. Measure TP or SPP immediately after compression is applied.
  3. If perfusion improves as expected (e.g., TP>40 mmHg) keep modified compression on patient (Mosti 2014)
NO
PAD: peripheral artery disease, VLU: venous leg ulcer, TP: toe pressure, SPP: skin perfusion pressure, 
(*) If triphasic, there is no need to conduct other vascular tests [Alavi, 2015], but might consider ABI if clinically indicated

Table 1. Arterial noninvasive bedside tests and likely interpretation

See Algorithms: Based on ankle brachial index (ABI) or Based on audible handheld Doppler ultrasound or continuous waveform analysis 

ABI: ankle brachial pressure, AP: ankle systolic pressure, TP: toe systolic pressure, TcPO2 or TCOM: transcutaneous oxygen pressure, TBI: toe brachial index, SPP: skin perfusion pressure.( *ABI, toe pressure, TBI values are frequently falsely elevated in patients with diabetes. Patients with diabetes should have TP measurements [7][11]. If arterial calcification precludes reliable ABI or TP measurements, or if ABI is non-compressible (>1.3), ischemia should be documented by TcPO2, SPP, or Doppler continuous waveform analysis [7][12] . (**) Biphasic waveform may be normal in older individuals or when there is no clear transition from triphasic signal along the vascular tree .

Interpretation

ABI (no diabetes)  [7]

ABI (with diabetes)*  [8]

Ankle Pressure (mmHg)  [7] 

TcPO2 or TCOM (mmHg)  [11] 

Toe Pressure   (mmHg)  [7]

Doppler waveform  [8][13]

TBI (diabetes)   [8][13]

Skin Perfusion Pressure (mmHg)   [8] [14]

Non-compressible arteries >1.3  >1.3





No relevant ischemia 0.8-1.3 0.9-1.3  >100 >40 >=60

triphasic or

biphasic **

>=0.75 >40
Mild/ Moderate ischemia 0.4-0.79  0.5 -0.89  50-100 30-40 30-59

biphasic or

biphasic/monophasic

0.25-0.74 30-40
Severe ischemia <0.4 <0.5 <50 >40 <30 monophasic <0.25 >30


Table 2. Determining ulcer healability

See Algorithms: Based on ankle brachial index (ABI) or Based on audible handheld Doppler ultrasound or continuous waveform analysis 

( *As determined by comprehensive patient assessment. (**For persons without diabetes, inadequate blood supply is objectively confirmed by ankle-brachial index (ABI) < 0.5, monophasic doppler waveform, skin perfusion pressure < 30mmHg, transcutaneous oxygen < 30mmHg, absolute systolic ankle pressure < 50 mmHg OR toe pressure < 30mmHg. For persons with diabetes, perform any other testing listed above besides ABI as ABI can be falsely elevated 

Can underlying cause be treated?How is blood supply to the wound?Co-existing medical conditions/drugs...Then wound prognosis is...
YesAdequateAre not an obstacle for healingHealable
No (*)AdequateMay or may not prevent healingMaintenance
NoUsually inadequate (**)May inhibit healingNon-healable

Modified from Sibbald RG et al. 2011[15]


Table 3. Management of simple, complex and mixed VLU

See Algorithms: Based on ankle brachial index (ABI) or Based on audible handheld Doppler ultrasound or continuous waveform analysis 

Standard compression: 30-40 mmHg resting pressure; modified compression: low resting pressure, i.e., 20-30 mmHg. Both standard and modified levels measured at the ankle level, applied with high stiffness device. For examples of different brands, see "Compression Brands Quick Reference". VLU: venous leg ulcer, ABI: ankle brachial index, CHF: congestive heart failure, PAD: peripheral arterial disease

Condition

Pressure

Comments Follow up Referrals
Healable, simple VLU: ABI 0.8-1.3, can be treated at primary care or community setting
Area < 100 cm2 and onset < 6 months Standard If low adherence, start with lower level compression and increase gradually (e.g., tubular dressing with 10 mmHg in the first week, then 2 layers of tubular dressing in the second week, and 3 layers in the third week) 48h

Wound specialist if:

  • VLU has not decreased by 30% in 4 weeks despite adequate treatment
  • Edema does not improve in 2 weeks
  • Any of the conditions below arise
Healable, complex VLU: ABI 0.8-1.3, treated at specialized service/clinic that also manages VLU 

Area > 100 cm2 and/or wound onset > 6 months (no other co-morbidities)

Standard
  • Reassess, revisit differential diagnoses, consider malignancy
  • Review compression and wound management
  • Assess adherence
  • Consider skin grafting if wound >25cm2 [16]
48h As needed, according to reassessment findings
Wound area has not decreased by 30% in 4 weeks despite adequate treatment Standard
  • Same as above
  • Consider adjunctive therapies (See Venous ulcers)
48h As needed, according to reassessment findings
Lymphovenous disease Standard
  • Specialized bandaging techniques may be required if unusual limb shape
  • Skin care due to increased risk of infection
48h Lymphedema therapist
Leg/ ulcer infection 

Standard

(or 

Modified)

  • Current: manage as appropriate (see Venous ulcers), may apply compression after 24 hours of systemic antibiotics and if afebrile. Consider reducing level of compression if difficult to tolerate. Inspect dressing more frequently to monitor infection
  • Recurrent: examine wound regularly and mitigate factors that may contribute to recurrenceupdate VLU link

24h


48h

If needed, infectious disease specialist
History of non-adherence

Standard

or 

Modified

  • Reassess, revisit differential diagnoses 
  • Determine reasons for non-adherence and address modifiable reasons
  • Start with lower level compression and increase gradually (e.g., tubular dressing with 10 mmHg in the first week, then 2 layers of tubular dressing in the second week, and 3 layers in the third week)
  • Consider use of ulcer gradient compression stocking or intermittent pneumatic compression if within indications
48h
Stable CHF

Modified


  • Ensure CHF is stable due to risk of pulmonary edema once leg edema starts to clear
  • Diuretics can be increased upon application of compression for the first time 
  • Monitor closely for sigs of CHF instability, such as peripheral edema, dyspnea, altered mental status, etc. 
24h Cardiologist
Maintenance or non-healable VLU without PAD
Cause not treatable with conservative interventions due to patient risk factors, comorbidities, lifestyle (See table 2)

-

  • May apply low pressure levels (e.g, tubular dressing, with 10 mmHg)

As needed, depending on findings
Mixed etiology leg ulcers: ABI <0.8 or >1.3, treated at specialized service/clinic or with collaboration with specialist who manages VLU
Non-compressible arteries

 -

  • May apply tubular dressing (10 mmHg) while waiting for vascular assessment
48h Vascular specialist
Healable mixed arterial ulcer with mild/moderate ischemia

Modified

  • May apply modified compression with low resting pressure (high stiffness), with instructions to contact provider if increased pain, changes in limb color/perfusion, frequent assessment and monitoring for ischemia and pressure damage
24h Vascular specialist
Non-healable mixed arterial ulcer with severe ischemia -
  • Ulcer will not heal without prior revascularization to increase blood supply to lower limb
-

Vascular specialist

Emergency department

Modified from Harding et al. 2015 [3]

FOLLOW UP AFTER INITIAL APPLICATION

Follow up within 24 hours of initial application 

Follow up within 24 hours if patient has current local infection (e.g., cellulitis), CHF, mixed venous arterial ulcer.

  • Assess and address issue if present:
    • Peripheral circulation
    • Adverse effects (e.g., pain, circulatory problems, decreased mobility, etc) See 'Troubleshooting adverse effects'
    • Effectiveness of compression: calf circumference and edema reduction, resulting increased exudate
    • Patient's adherence, tolerance to compression
  • If a face-to-face encounter is not feasible within 24h, may follow up with a phone call or Telehealth Conferencing Tool
  • Re-apply compression and reassess items above at least weekly
  • Once edema subsides, at least the edge of the tibia, the fibula head, and the ankle region should be padded to avoid pressure damage

Follow up within 48 hours of initial application 

Follow up within 48 hours if patient has simple or complex VLU, and no PAD, CHF or infection:

  • Assess and address issue if present:
    • Adverse effects (e.g., pain, decreased mobility, etc) See 'Troubleshooting adverse effects'
    • Effectiveness of compression: calf circumference and edema reduction, resulting increased exudate
    • Patient's adherence, tolerance to compression
  • If a face-to-face encounter is not feasible within 48h, may follow up with a phone call or Telehealth Conferencing Tool
  • Re-apply compression and reassess items above at least weekly
  • Once edema subsides, at least the edge of the tibia, the fibula head, and the ankle region should be padded to avoid pressure damage

TROUBLESHOOTING ADVERSE EFFECTS

  • Slippage of compression bandages: frequently seen as edema subsidizes or in legs with uneven contour (e.g. inverted champagne bottle). May lead to discomfort, pain, trauma to the skin, new ulcers, decreased patient adherence. Tourniquet effect, caused by excessive pressure over areas of wrinkling can increase risk for tissue ischemia [17]ref
    • If due to expected edema reduction, change compression more frequently during this initial edema reduction phase
    • If due to uneven contour, provide additional bulk to the concave region of the leg before applying 4-layer compression [17]
  • Skin problems: can arise due to excessive exudate or allergic reactions. Suggestions based on expert opinion include:
    • Fungal infection: excessive exudate can lead to fungal infection. Fungal infection needs to be treated to resolution before reapplication of occlusive dressings and compression. Prevent fungal infections by adequately managing exudate and increasing frequency of dressing and compression system change until exudate is controlled.
    • Contact dermatitis: susceptible patients may develop contact dermatitis from one of the components of the compression system (e.g., latex, zinc, wool). Remove irritant or use a cotton stockinette liner or paste bandage against the skin to avoid irritation from wool padding.
  • Pain: compression, when applied appropriately should reduce pain. However, effective compression may cause initial discomfort and anxiety. 
    • Rule out any other causes of pain, such as infection, dermatitis, or PAD. Teach patient to recognize signs of PAD (e.g., changes in limb color/perfusion)
    • If pain is related to compression: offer analgesics during the initial phase (1-2 weeks) until discomfort subsides, and consider starting with a lower pressure level (i.e., modified pressure - See "Compression Brands Quick Reference")
    • If pain remains uncontrolled, perform full reassessment (see “Venous Ulcer”, section on ‘Plan Reassessment’)
  • Pressure Damage: may happen once edema subsides and pressure caused by compression device over bony prominences increases (edge of the tibia, the fibula head, and the ankle). Signs of pressure damage resulting from compression therapy are erythema, blistering, altered limb shape. Among risk factors are: patients with impaired peripheral perfusion, thin or altered limb shape, foot deformities, reduced sensation/pain sensation, long-term systemic steroid use and presence of a chronic disease (eg rheumatoid arthritis) associated with reduced mobility, loss of calf muscle and foot/ankle deformity. 
    • Apply extra padding over bony prominences, especially as edema subsides
    • Ensure bandage is not too tight and overlap is correct mainly at the dorsum of the foot, ankle and calf, as per manufacturer's instructions
    • Avoid strong, sustained compression. Consider using inelastic compression or intermittent pneumatic compression associated with gradient compression stocking
  • Circulatory problems: 
    • If signs of decreased blood supply distal to the compression bandage or stocking (e.g., pallor, decreased temperature, numbness), remove device immediately. Reassess blood supply through one of the Algorithms above. 
    •  If patient has CHF, monitor for signs of unstable CHF and pulmonary edema (e.g, dyspnea, tachycardia, decreased diuresis, etc) 
  • Loss of calf muscle: may be seen in patients receiving long-term compression, most likely due to reduced patient activity and underlying comorbidities (as opposed to compression itself). 
    • Ensure compression allows patient to flex knee and ankle at or near 90 degrees
    • Ensure shoes do not restrict patient’s ankle range of motion. Flat, comfortable shoes are preferred
    • Encourage calf muscle exercise

TRANSITIONING TO STOCKINGS

  • For simple VLU, when adherence is not an issue and patient is able to don gradient compression stockings: as ulcer is decreasing in size and complete healing is likely in about 2 weeks, gradient compression stockings can be prescribed and ordered (covered by Medicare if ulcer is active, not healed). After ulcer is healed, compression bandages may be applied for 1-2 weeks to avoid damaging fragile wound area. 
  • For complex VLU, mixed etiology leg ulcers or when adherence is an issue: consult edema management specialist (e.g, physical therapist) early on (e.g, after initial evaluation), as patient education and choice of long-term compression according to patient preference and life-style may take several weeks.  
  • See indications, contraindications and how to use gradient compression stockings in " Compression: Gradient compression stockings"

REVISION UPDATES

DateDescription
4/23/19Added links to new topic Audible Handheld Doppler Ultrasound and Waveforms, updated references


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NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.

REFERENCES

  1. O'Meara, Susan; Cullum, Nicky; Nelson, E Andrea; Dumville, Jo C et al. Compression for venous leg ulcers. Cochrane Database of Systematic Reviews. 2012;volume 11():CD000265.
  2. Kirsner, Robert S et al. Compression of venous ulcers: standardizing standard care. JAMA dermatology. 2014;volume 150(7):736-737.
  3. Harding, Keith; Dowsett, Caroline; Fias, Lore; et, al et al. Simplifying venous leg ulcer management. Consensus recommendations. . 2017;.
  4. Andriessen A, Apelqvist J, Mosti G, Partsch H, Gonska C, Abel M et al. Compression therapy for venous leg ulcers: risk factors for adverse events and complications, contraindications - a review of present guidelines. Journal of the European Academy of Dermatology and Venereology : JEADV. 2017;volume 31(9):1562-1568.
  5. Alavi A, Sibbald RG, Nabavizadeh R, Valaei F, Coutts P, Mayer D et al. Audible handheld Doppler ultrasound determines reliable and inexpensive exclusion of significant peripheral arterial disease. Vascular. 2015;volume 23(6):622-9.
  6. Alavi A, Sibbald RG, Mayer D et al. Reply to letter to editor: Audible handheld Doppler ultrasound determines reliable and inexpensive exclusion of significant peripheral arterial disease. Vascular. 2015;volume 23(4):445-6.
  7. Mills, Joseph L; Conte, Michael S; Armstrong, David G; Pomposelli, Frank B; Schanzer, Andres; Sidawy, Anton N; Andros, George; Society for Vascular Surgery Lower Extremity Guidelines Committ... et al. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on wound, ischemia, and foot infection (WIfI). Journal of Vascular Surgery. 2014;volume 59(1):220-34.e1.
  8. Hinchliffe, R J; Brownrigg, J R W; Apelqvist, J; Boyko, E J; Fitridge, R; Mills, J L; Reekers, J; Shearman, C P; Zierler, R E; Schaper, N C; International Working Group on the Diabetic Foot et al. IWGDF guidance on the diagnosis, prognosis and management of peripheral artery disease in patients with foot ulcers in diabetes. Diabetes/Metabolism Research and Reviews. 2016;volume 32 Suppl 1():37-44.
  9. Hingorani, Anil; LaMuraglia, Glenn M; Henke, Peter; Meissner, Mark H; Loretz, Lorraine; Zinszer, Kathya M; Driver, Vickie R; Frykberg, Robert; Carman, Teresa L; Marston, William; Mills, Jose... et al. The management of diabetic foot: A clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine. Journal of Vascular Surgery. 2016;volume 63(2 Suppl):3S-21S.
  10. The British Lymphology Society. Position Paper on Ankle Brachial Pressure Index (ABPI). Informing decision making prior to the application of compression therapy . 2018;.
  11. Lavery, Lawrence A; Davis, Kathryn E; Berriman, Sandra J; Braun, Liza; Nichols, Adam; Kim, Paul J; Margolis, David; Peters, Edgar J; Attinger, Chris et al. WHS guidelines update: Diabetic foot ulcer treatment guidelines. Wound Repair and Regeneration. 2016;volume 24(1):112-126.
  12. Sibley RC 3rd, Reis SP, MacFarlane JJ, Reddick MA, Kalva SP, Sutphin PD et al. Noninvasive Physiologic Vascular Studies: A Guide to Diagnosing Peripheral Arterial Disease. Radiographics : a review publication of the Radiological Society of North America, Inc. 2017;volume 37(1):346-357.
  13. Andersen CA. Noninvasive assessment of lower extremity hemodynamics in individuals with diabetes mellitus. Journal of vascular surgery. 2010;volume 52(3 Suppl):76S-80S.
  14. Tsai FW, Tulsyan N, Jones DN, Abdel-Al N, Castronuovo JJ Jr, Carter SA et al. Skin perfusion pressure of the foot is a good substitute for toe pressure in the assessment of limb ischemia. Journal of vascular surgery. 2000;volume 32(1):32-6.
  15. Sibbald RG, Goodman L, Woo KY, Krasner DL, Smart H, Tariq G, Ayello EA, Burrell RE, Keast DH, Mayer D, Norton L, Salcido RS et al. Special considerations in wound bed preparation 2011: an update©. Advances in skin & wound care. 2011;volume 24(9):415-36; quiz 437-8.
  16. O'Donnell, Thomas F; Passman, Marc A; Marston, William A; Ennis, William J; Dalsing, Michael; Kistner, Robert L; Lurie, Fedor; Henke, Peter K; Gloviczki, Monika L; Eklöf, Bo G; Stoughton, Ju... et al. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery ® and the American Venous Forum. Journal of Vascular Surgery. 2014;volume 60(2 Suppl):3S-59S.
  17. Richmond, NA, Vivas AC, Lamel SA, Braun LR; Kirsner RS et al. Practical Magic: Reducing Slippage of Multilayer Compression Bandages in Patients with a Venous Leg Ulcer and the Typical “Inverted Champagne Bottle” Leg Ostomy Wound Management. 2013;.
Topic 946 Version 2.0

Subtopics

Audible handheld Doppler ultrasound and waveforms have been gaining acceptance as a tool for bedside non-invasive arterial assessment of lower limbs. This topic provides a primer (includes videos) on how to perform and interpret audible handheld doppler and waveforms to detect peripheral artery disease.