Chapter 30: Compression Therapy

Introduction

Fluid accumulates in extravascular tissues in response to changes in various forces normally controlling vessel permeability. Local factors include hydrostatic pressure changes and blockage of lymphatic channels, whereas on a systemic level, protein imbalance can result in generalized swelling. While most swelling is referred to as "edema," the general use of this term can lead to misunderstanding of the underlying pathology and, subsequently, inappropriate treatment. Critical distinctions exist between normal tissue edema and lymphedema, which is due to a dysfunctional lymphatic system. The reader is referred to Chapter 18 for a detailed discussion of this condition.

As is known from the Starling equation (Box 30.1), under normal conditions a state of near equilibrium exists at the capillary membranes. The amount of fluid filtering out from the capillaries almost equals absorption. The disequilibrium that exists favors accumulation in the interstitial tissues, and this is effectively handled by the lymphatic system under normal conditions.^1,2 The Starling equation suggests that effectively applied local pressure can facilitate reabsorption of fluid by veins and lymphatics.

Accumulation of fluid in the interstitium can greatly impede wound healing, yet it is seldom addressed as treatment plans are developed for management of wounds. While surgeons are quick to recognize and correct limb-threatening ischemia associated with a compartment syndrome, little attention is directed to handling low-level continuous swelling that occurs in chronic states of inflammation and gravity-dependent conditions. This is despite the fact that swelling has been demonstrated to be a significant deterrent in wound healing.^3,4,5

Fortunately for patients, a significant number of options exist to treat local swelling, improve tissue oxygenation, alleviate venous hypertension, and promote an environment conducive to wound healing. This chapter presents a variety of such options from short-stretch bandages to dynamic compression pumps that can be tailored to meet the needs of individual patients. When appropriately applied, compression can facilitate the healing of venous leg ulcers and other wounds. To the contrary, however, compression that is inappropriately applied can result in delayed healing and tissue necrosis.

Bandaging

Of the broad variety of compression bandages available for clinical use, each comes with its merits and concerns. Before selecting any bandage device, clinicians should be mindful of four principles addressed by Clark.⁶

1. What are the elastic properties of the bandage and how is it constructed?

2. What is the size and shape of the extremity?

3. How skilled is the clinician, patient, or caregiver at bandage application?

4. What will be the level of physical activity the patient will undertake?

Regardless of how superior a bandage is alleged to be, improper application or use ...