Negative Pressure Wound Therapy (NPWT) is a significantly essential alternative on serious wound management, for instance, diabetic foot ulcers, several literature reviews for studies have been conducted making a comparison of diabetic stage III foot ulcers treatment outcomes on elderly patients using NPWT and outcomes for patients treated using Standard Moist Wound Therapy (SMWT). Among Ovoid databases and as well PubMed database used encompasses the subsequent search terms; SMWT, NPWT and Vacuum-Assisted Closure (VAT). Research studies to critic the efficiency were restrained to the outcomes of the experimental studies of clinical randomized trials on elderly patients suffering from diabetic foot wounds by way of inclusion strategy. 4 studies have been determined to have attained set strategies. Regardless of the difference in the added outcome variables studied, methodology and the total population of the patients, NPWT systems were portrayed as being more effective as compared to SMWT in relation to the rate of wound closure and the significant portion of wound healed. The vital initial step in wound care is surgical debridement and ought to be instigated before using NPWT. However, NPWT can be utilized for either promotion of wound healing or wound preparation for surgical closure. Therefore, it is justified that NPWT together with the set standards of care guideline facilitates effective healing and diabetic foot wounds closure for the elderly diabetic patients.
Diabetes mellitus has been described to be a set of ailments branded by the high blood glucose rate as a result of defected production and action of insulin or even both (Baranoski & Ayello, 2016). The most prevalent is diabetes type 2, previously referred to as non-insulin-independent diabetes mellitus. Diabetes prevalence is outrageous, the American Association asserted that by 2010, about 25.8 million United States citizens suffered from diabetes, that being 8.4% affected out of the entire population (Malsiner et al, 2015). The treatment cost for diabetes mellitus initially was $175 by 2008, though advanced diagnosing instruments, increased healthcare resulting into longevity, and advanced reporting methods bring about a greater annual cost projected for the future. It is perceived that in 2010 about $1 in every $10 healthcare dollars was allocated for diabetes mellitus (Role of Negative Pressure Wound Therapy, 2011). However, there are some indirect costs incurred which include; low productivity, lost productivity capability and absenteeism as a result of disease-related mortality and morbidity.
Moreover, diabetes is concomitant to a surfeit of comorbid illnesses such as diabetic foot ulcers. These diabetic foot wounds majorly result in limb amputation and hospitalization. Neuropathy is the main contributing factor resulting in increased foot ulcers growth rate (Wang et al., 2017). It’s interconnected through chronic hyperglycemia which changes at the microvasculature resulting in advancing sensory fibers damage which usually gives a signal of the imminent foot impairment and increasing risk of acquiring unanticipated foot ulcers. It is estimated that the mean lifespan risk rate to develop foot ulcer to be 25%, while foot ulcers and associated complications take up about 16% of overall hospital admissions (Brem et al, 2006). Curing diabetes foot ulcer entails proper inflammation processes, epithelialization, scar tissue maturity and granulation tissue formation in order to provide proper skin restoration and tissue integrity. Typically, diabetic wound therapy centers on SMWT to be the ordinal treatment sequence, according to a 1963 research which ultimately determined that a clean moist and sealed wound healed quickly as compared to an open wound. Therefore, the standard and the supplement wound therapy is the moist wound therapy (“Erratum to Evaluation of Wound Care,” 2014). Different diabetes foot ulcers treatments’ reports have been made in the literature inclusive of the Standard Moist Wound Therapy, growth aspects, Negative Pressure Wound Therapy, and bioengineered tissue. Successfulness of the treatment relies on the patient’s compliance, proper appendage offloading, mechanisms of actions and ulcer chronicity.
The Negative Pressure Wound Therapy, since 1940s, is termed in studies whereby Vacuum-assisted Closure (VAC) systems has been mostly utilized in open wounds treatment based on anecdote and in smaller studies as from 1980s (Driver et al, 2016). Basic mechanisms for VAC instruments entailed open cell polymer, which kowtows near wound bed, transparent sheet utilized in covering the dressing, which is the drainage tube made of plastic, connected with the collecting containment and also the vacuum pump providing constant pressure between -25 mmHg and -200 mmHg (Driver et al, 2016). Negative pressure in the pump makes the dressing to contract and the cells to deform and have been found to arouse formation of granulation tissue and neo-angiogenesis. Moreover, wound exudates removal and minimization of edema is facilitated by the negative pressure which enhances perfusion. Various types of health care settings perform this sort of wound treatment entailing; home care, and outpatient although it usually has to be monitored through the aid of the health practitioner regularly checking the wound progress through tracking fluid removal, and wound size and granulation tissue development progress.
Reports of small comparative studies as well as case studies have been made making a comparison between the outcomes of wound healing for elderly patients treated with NPWT and outcomes for those treated with SMWT. Nonetheless, routine management changes need to be recommended for diabetic foot ulcers demonstrating an advantage across numerous studies with numerous patients most precisely research concerning diabetes foot ulcers (Krasner, Rodeheaver, & Sibbald, 2007). Moreover, it is significant to take into consideration treatment cost as well as when related to the results because of the substantial costly value of as compared to SMWT. Also, therapy executed by VAC might attest as being better and economical as compared to SMWT, suppose therapy executed by VAC offers substantial reduced healing and general use of resources (Krasner et al., 2007). The literature review conducted intends to answer the subsequent questions: Does NPWT facilitates enhanced healing of foot wounds more than SMWT in old diabetes patients within stage III? Does NPWT promote quick wound closure compare to SMWT? What is the efficacy NPWT as compare to SMWT in old diabetes patients within stage III foot ulcer, in regards to safety and secondary complication reduction?
A review of PubMed and OVID, a vast nursing journal databases was accomplished utilizing, NPWT, VAC, SMWT, and diabetes wounds as keywords. Inclusion criteria for the review entailed randomized clinical trials encompassing old diabetes patients within stage III foot ulcer making a comparison between NPWT and SMWT. Six studies in total were found and at least four studies out of it met the inclusion criteria.
The elderly patients in the four studies had acute or chronic diabetic stage III foot ulcer wounds albeit the severity and the condition of the wounds varied. However, patient demographics including, age, population, ethnic group, race etc. the criteria for exclusion differed from study to study. The patients in all the study were between the age of 58 and 79 years. For instance, Etoz excluded arterial insufficient patients as demonstrated by pedal pulse absence (Etoz & Kahveci, 2007). This exclusion criterion was not applied in the other three studies. Sepsis, underlying osteomyelitis, pregnancy, present treatment with radiotherapy or corticosteroids, nursing mothers and ulcer malignancy were the exclusion strategies which were constant in the four researches.
In all the four studies, before the treatment commenced, non-viable tissues were removed from the wound. Systematic antibiotic therapy was offered in three of the studies to every patient for prophylaxis for the surgical debridement. A random assignment of patients for the experimental intervention was done in all the studies. None of the studies were determined in NPWT strategies but rather through VAC. The continuous negative pressure amount was -125 mmHg in accordance with the standard treatment procedures (Etoz & Kahveci, 2007). There was a variance in dressing changes from every twenty-four hours to every forty-eight hours to three times weekly.
Alternatively, the comparison group of patients obtained SMWT. Nonetheless, variances in SMWT were identified. The moist saline dressing in Etoz study was change two times a day for the patients, while in Blume and his colleague’s study, the participating patients obtained advanced dressing most preferably hydrogels and alginates as per the guidelines set through the World Health Organization (Blume PA et al, 2008). Also in Armstrong and his colleagues’ study, the comparing group patients received advanced wound dressings which are hydrogels, foams, hydrocolloids or alginates (Armstrong DG, Lavery LA, & Diabetic Foot Study Consortium, 2005). The attending health practitioner chose a particular dressing on the basis of the guidelines in place and the individual evaluation of wound situation. Sepulveda and Colleagues’ study, a particular dressing was selected based on the second bandage’s saturation. Suppose the bandage offered a lower rate than 50% of saturation, they used a tulle, bandage and hydrocolloid gel to dress the wound (Brem H et al., 2006). In contrast, a bandage and an alginate would be used to cover a wound suppose there was a greater saturation rate than 50%.
Question 1: Does NPWT facilitate enhanced healing of foot wounds more than SMWT in old diabetes patients within stage III?
It is evident from these studies that they suggest that NPWT by use of a VAC system facilitates diabetic stage III foot ulcers healing and in some instances enhance comprehensive re-epithelialization. In Blume and his colleagues’ study, it had a substantially greater portion of ulcers with thorough closure (P=.007) NPWT managed patients than those managed through SMWT (Blume PA et al., 2008). Correspondingly, in Armstrong and Colleagues’ study, a higher rate of 57 % of NPWT healed patients was attained more than 38 % for the control treatment (P=040) (Blume PA et al., 2008). Apparently, Etoz also noted a substantial variance in total days needed to have wound bed’s full granulation free from any infection, with 10 days for NPWT group while 14.8 days for SMWT patients (P=.06) (Blume PA et al., 2008a). In the research carried out by Sepulveda and his colleagues, it covered 19.7 days that NPWT patients for a 90% granulation to occur while SMWT managed patients took 32.3 days (P=.007). All studies had the same endpoints. The Blume study’s main endpoint was complete ulcer enclosure, termed as 100% re-epithelialization (Blume PA et al., 2008). Sepulveda and his colleague have described their endpoint as 90% granulation, while even though Etoz failed to make a definition of endpoint absolutely through full granulation, by observing that the endpoint strategy was never a signage of irritation with promptness to acquire surgical closure nearly full granulation lacking inflammation symptoms. Nevertheless, some patients in the researched attained endpoint treatment. It is actually factual for SMWT patients. A study by Armstrong & Colleague, the experiment group received treatment till they fully healed, that is until they completed the 112 days of active treatment (Armstrong DG et al., 2005).
It is considerable collective evidence out of these four studies suggesting NPWT to be more operational compared to SMWT in old diabetes patients within stage III healing. Particularly, the number of patients acknowledged wound improvement through NPWT management compares to SMWT.
Question 2: Does NPWT promote quick wound closure as compared to SMWT?
It is asserted that interstitial edema and bacterial colonization is minimized by NPWT. NPWT is also reported to increase capillary blood flow and removal of wound fluid, which is thus alleged to enhance fast granulation tissue formation which is the need for wound enclosure (Wang et al., 2017). Moreover, wound surface are is reduced through the traction negative pressure force by NPWT and also accelerate mitotic activity in cells accountable for the synthesis of collagen and resurfacing of the epithelial.
According to Etoz, he measures the wound size after 48 hours generally for the comparison as well as treatment groups (Etoz & Kahveci, 2007). Apparently, wound therapy got sustained to a point that the wound bed nearly entirely granulates and there was the absence of inflammation signs. Prior to treatment, the mean surface is of the wound was quite different from the control and experimental groups. Therefore, in one week time, accelerating granulation tissue growth as well as decreased nonviable tissues on the wound of the NPWT group. Evidently, the wound surface is minimized of 20.2cm² towards the study’s endpoint of the NPWT manage the group in comparison to the control group’s an average decrease of 9.4 cm² (Etoz & Kahveci, 2007). This variance was arithmetically vital. (P=.033).
According to Armstrong and his colleagues’, wound healing was high with regards to complete enclosure time for NPWT patients as compared to the control patients (P=.007) together with granulation tissue development level with regards to the time of 70% – 100% development at the wound bed being rapid for NPWT managed patients than control patients. (P=.002) (Armstrong DG et al., 2005).
The reduction of the surface area of the wound in a given term period indicate ulcers healing rate. Albeit not attaining complete closure, Blume and his colleagues alleged that NPWT managed group’s wound surface areas smaller than those of SMWT (P=.032) (Blume PA et al., 2008a). On day 28, a substantial size difference was also observed ant the 75% closure time was incredible; that is that is 54 days versus 84 days respectively (P=.014) (Blume PA et al., 2008). To summarize, the inference data obtained from these studies recommend that NPWT by use of the VAC system facilitates quicker wound closure more than SMWT.
Question 3: What is the efficacy NPWT as compare to SMWT in old diabetes patients within stage III foot ulcer, in regards to safety and secondary complication reduction?
There is a variance of secondary complication related to diabetic foot ulcers, though usually entail different infectious complications as well as worsening of the wound leading to amputation. The studies reviewed portrays wound complications were archetypal for diabetic foot ulcers for the elderly in stage III and involved osteomyelitis, edema, amputation, wound infection and cellulitis (Blume PA et al., 2008). Blume and colleagues identified ominously few secondary amputations for NPWT managed the group of patients versus the SWMT managed group.
Contrary, Armstrong failed to identify any substantial variation in secondary amputation in comparison between SMWT and NPWT. The risk ratio is relatively 0:225 indicating that NPWT treated patients had minimal chances of undergoing a secondary amputation than for the control patients. Considerably, this outcome ought to be viewed cautiously with regards to the 95% confidence interval of 0.06 to 1.1 (Armstrong DG et al., 2005).
Blume and colleagues for six months did the evaluation for the difference between SMWT and NPMT groups with regards to osteomyelitis, edema, wound infection incidences and cellulitis but did not find any statistical substantial difference (Blume PA et al., 2008). The groups for Armstrong too did not find any noteworthy differences in the severity and rate of occurrence of the adversative activities between the two groups (P=.875) (Armstrong DG et al., 2005).
Apelqvist and colleagues scrutinized data gathered in Armstrong’s study and observed that ominously more surgical strategies inclusive of debridement were carried out in SMWT control patients more than was done in NPWT patients (Daar et al, 2017). This discovery recommends that reoccurrence of the non-viable tissue was more likely to be prevalent in the SMWT managed group, which is in line with Etoz outcome alleging that NPWT patients depicted to have exhibited increasing granulation tissue as well as decreasing nonviable tissue when equated to SMWT group. Both the diabetic foot ulcers surface area and the extremities’ edema in patients of both groups (P=.05).
It is evident that all these four studies’ findings suggest that outcomes from NPWT use through the VAC system were found to be favorable than SMWT for treating elderly diabetic patients with stage III foot ulcers. Precisely, data acquired indicates that VAC therapy enhance rapid wound surface area decrease by the formation of granulation tissue and re-epithelization, lessen healing time and might reduce infectious complication cases.
These data portrays that NPWT is connected with fewer consequences compared to SMWT. Nonetheless, NPWT needs investigation like the most ideal aspect of a inclusive wound management program which involves plantar surface ulcers offloading with taut additional to traditional wound managements (Malsiner et al., 2015). Just as observed by all the researcher, the vital initial step is wound care is surgical debridement and ought to be instigated before using NPWT. However, NPWT can be utilized for either promotion of wound healing or wound preparation to undergo surgical closure.
Therefore, more research is required for addressing constraints provided by the studies which lack diabetic foot wound control on the basis of race, sex, and age. Redefining the demographic variable and lessening the kind of wound may result in improved strategies for VAC usage. More studies are required for addressing resource usage as well as cost which may result in sound and knowledgeable decisions on the place and time for usage of VAC. Lastly, parts of concern need to solve the NPWT systems’ efficiency instead of VAC and also ought to explore instance whereby NPWT does not look likely to be operational as such.
1. Negative Pressure Wound Therapy needs to be taken into consideration as one of the multiple alternatives in an ample patient medication strategy for the elderly diabetic persons in stage III foot wound.
2. Comprehensive assessment and monitoring of the condition of wounds that need medical management needs to be observed while taking into consideration the systemic factors, wound condition and the underlying causes so as to establish a care plan that requires to be gradually reassessed to find out if improvement towards healing is attained.
Essentially, with the outcomes from the studies, they give backing evidence proving NPWT to be safe and efficient in management of old diabetes patients within stage III wounds. Nonetheless, NPWT need be instigated just like one component of all-inclusive wound management strategies that involves taut glucose control additional in traditional wound management. It is vivid from the findings of the studies that NPWT use in correspondence to debridement of the impacted foot accelerates the quantity of diabetic foot ulcers were cured, however, led to reduced duration needed for healing ulcers than for SMWT. Therefore, it is justified that NPWT together with the set standards of care guidelines facilitates effective healing and diabetic foot wounds closure for the elderly diabetic patients.