Topical oxygen therapy in - Wound Care Today · wound swab indicated she required a further course...

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:

GranuloxUK@molnlycke.com

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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