Asian Journal of Nursing Education and Research.

8(3): July- September, 2018

ISSN 2231-1149 (Print) Available online at

2349-2996 (Online) www.anvpublication.org
DOI: 10.5958/2349-2996.2018.00091.5
Asian Journal of
Vol. 08| Issue-03|
July- September 2018 Nursing Education and Research
Home page www.ajner.com

REVIEW ARTICLE

Advance in Wound Care: Negative Pressure Wound Therapy

Mrs. Nisha P Nair1, Mrs. Anitha Victoria Noronha2
1
Assistant Prof. JSS College of Nursing, Mysore
2
Assistant Prof. JSS College of Nursing, Mysore.
*Corresponding Author Email: avinanithatony@gmail.com, nisha.deepak7@gmail.com

ABSTRACT:
Quality of care is the slogan of all health care institutions. In order to meet the standards advanced techniques are
adopted. In wound dressing also there are various advanced wound care procedures, among them Negative
Pressure Wound Therapy is widely practised. Negative pressure wound therapy also called vacuum therapy,
Vacuum assisted closure, vacuum sealing or topical negative pressure therapy is a sophisticated development of
a standard surgical procedure, the use of vacuum assisted drainage to remove blood or serous fluid from a wound
or operation site.

KEYWORDS: Negative pressure, Therapy, Vacuum, Wound.

INTRODUCTION: What is Negative pressure wound therapy (NPWT)?

There are a wide variety of dressing techniques and
materials available for management of both acute
wounds and chronic non-healing wounds. The primary
objective in both the cases is to achieve a healed closed
wound. However, in a chronic wound the dressing may
be required for preparing the wound bed for further
operative procedures such as skin grafting. An ideal
dressing material should not only accelerate wound
healing but also reduce loss of protein, electrolytes and
fluid from the wound, and help to minimize pain and
infection.
Received on 19.12.2017 Modified on 11.01.2018
Accepted on 27.03.2018 ©A&V Publications All right reserved
Asian J. Nursing Education and Research. 2018; 8(3):447-450.
DOI: 10.5958/2349-2996.2018.00091.5
Negative pressure wound therapy also called vacuum
therapy, Vacuum assisted closure, vacuum sealing or
topical negative pressure therapy is a sophisticated
development of a standard surgical procedure, the use of
vacuum assisted drainage to remove blood or serous
fluid from a wound or operation site.
In essence the technique is very simple. A piece of foam
with an open-cell structure is introduced into the wound
and a wound drain with lateral perforations is laid on top
of it. The entire area is then covered with a transparent
adhesive membrane, which is firmly secured to the
healthy skin around the wound margin. When the
exposed end of the drain tube is connected to a vacuum
source, fluid is drawn from the wound through the foam
into a reservoir for subsequent disposal.1
The plastic membrane prevents the entry of air and
allows a partial vacuum to form within the wound,
reducing its volume and facilitating the removal of fluid.
The foam ensures that the entire surface area of the
wound is uniformly exposed to this negative pressure
effect, prevents occlusion of the perforations in the drain

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by contact with the base or edges of the wound, and 2. Enhanced blood perfusion:
eliminates the theoretical possibility of localised areas of Optimal blood perfusion is necessary to deliver oxygen,
high pressure and resultant tissue necrosis.2
Indications and contraindications
The principal indications for the use of NPWT: 3
• Acute and traumatic wounds
• Sub acute wounds (i.e. dehisced incisions)
• Pressure ulcers
• Chronic open wounds
(stasis ulcers and diabetic ulcers)
• Meshed grafts
• Flaps
• Venous stasis ulcers
• Lower extremity diabetic ulcers
• Pressure ulcers
• Lower extremity flaps
• Dehisced incisions
• Grafts
Contraindications include:
• Fistulas to organs or body cavities
• Necrotic tissue in eschar
• Osteomyelitis (untreated)
• Malignancy in the wound
Mechanism of action of negative pressure wound
therapy
1. Mechanical stress on the wound bed:
In NPWT mechanical stimulation of cells leads to cell
proliferation and levels of granulation tissue. Application
of mechanical force to wounds induces tissue
deformation at the level of individual cells, leading to
cell stretch, therefore providing a powerful mechanism
for inducing cell proliferation and angiogenesis.
nutrients, blood cells and growth factors to a wound and
in order to remove waste products such as carbon
dioxide. NPWT enhances blood perfusion to a wound.
3. Oedema and wound exudate is reduced
Wound oedema and exudate occur as a consequence of
the inflammatory response, and are enhanced in the
inflammation stage of healing of which chronic wounds
are stuck in this stage. NPWT helps to reduce oedema
and get the wound out of the inflammation stage of
wound healing.
4. Wound fluid composition is altered
In chronic wounds proteolytic activity is elevated and
this is central in the difference between acute and
chronic wounds. NPWT treated wounds indicating that
NPWT helps reduce proteolytic enzyme activity.
5. Reduced bacterial burden
Bacterial burden in chronic wounds has also been shown
to be reduced by the suction action of NPWT.
6. Cost effectiveness and quality of life
Two areas where NPWT has been evaluated and
explains why it is used in practice are its cost
effectiveness and its effect on quality of life. NPWT is
an expensive therapy, cost savings were made in terms
of the accelerated healing times in patients treated with
NPWT and in reduced frequency of dressing changes
needed. Wounds treated with NPWT healed 2.5 times
faster than conventional dressings.5

Patient assessment for NPWT5

Action
Carry out an holistic assessment of the
patient which will include:
a) Wound aetiology and position of the
wound
b) Nutritional assessment
c) Pain
d) Level of pressure ulcer risk
e) Peri-wound assessment
f) Assessment of Quality of life and
issues of diversity
g) Mobilisation
Rationale
a) NPWT is contraindicated in certain wound types. The underlying cause of the wound and any
complications must be established to enable assessment of the appropriate application. The
position of the wound may also prevent NPWT being applied effectively
b) Adequate nutrition plays a fundamental role in the process of wound repair and contributes
significantly to the formation of white blood cells, antibodies, fibroblasts and collagen.
Haemoglobin and serum albumin levels should also have been checked to ensure nutritional
support is adequate for wound healing.
c) NPWT can cause discomfort and pain. Analgesia may be required prior to dressing changes.
d) If NPWT is applied to a wound, the patient may be required to be nursed in bed. Appropriate
preventative measures will need to be taken such as a pressure ulcer risk assessment.
e) There needs to be at least a 2cm border of unbroken skin surrounding the wound. A complete
seal with the film drape is required for the vacuum to be created.
f) Patients may become anxious about starting the therapy. Agreement and concordance with the
therapy is essential for it to be therapeutically effective. The provision of information is known to
reduce anxiety and will help patients to understand the therapy prior to giving consent. If a patient
has a NPWT device attached to their wound and are having to carrying the pump around, this can
affect the patient’s quality of life. Patients may not comply with the treatment if it affects their
quality of life and this may have an impact on the effectiveness of the therapy. Such a situation
should not be a reason for denying this treatment unless the situation is contributing to possible
risks or harm.
g) The ability of a patient to mobilise with a NPWT device should be assessed. Mobilising with
such a device may increase the risk of a fall.

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Procedure of NPWT4
Step 1 The foam dressing is cut to the approximate size of the wound
with scissors (Figure1) and placed gently into position (Figure
2).

Figure 1 Figure 2
Step 2 The perforated drain tube is then located on top of the foam and
a second piece of foam placed over the top (Figure3). For
shallower wounds, a single piece of foam may be used and the
drainage tube is inserted inside it.

Figure 3
Step 3 The foam, together with the first few inches of the drainage tube
and the surrounding area of healthy skin, is then covered with
the adhesive transparent membrane supplied (Figure 4). At this
stage it is important to ensure that the membrane forms a good
seal both with the skin and the drainage tube.

Figure 4
The distal end of the drain is connected to the VAC unit, (Figure
Step 4 5) which is programmed to produce the required level of
pressure.

Figure 5
Step 5 Once the vacuum is switched on, the air is sucked out of the
foam causing it to collapse inwards drawing the edges of the
wound in with it (Figure 6).

Figure 6
Step 6 Fluid within the wound is taken up by the foam and transported
into the disposable container within the main vacuum unit.

The removal of NPWT5

Actions
1.The NPWT device should be switched off 15 – 30 minutes before
removal of the foam
2. Raise the tube connector above the level of the pump unit and drain
exudate into the canister.
3 Clamp off both sections of tubing
4 Wash hands and apply apron and non-sterile gloves in accordance with
Infection Control procedures.
5 Disconnect the dressing tubing from the suction tubing.
6 If the suction bottle is either two thirds full or has been in use for seven
days it will need to be changed. If the same suction is to continue being
used, ensure the connector end is covered with sterile gauze or a sterile
field whilst disconnected.
7 Gently stretch the occlusive film horizontally and slowly pull away from
the skin. Do not peel back.
8 Gently remove the foam or gauze from the wound using saline to assist
removal if necessary.
9 Check the number of gauze and foam pieces removed from the wound is
the same as the number that were originally placed in the wound.
10 All the NPWT consumables (tubing, suction and dressings) are all
disposable items that when removed should be discarded in an orange
infectious clinical waste bag
11 Remove apron and gloves. Discard them. A clean apron and gloves
should be applied and hands washed between removing the old dressing
and applying a new one to the patient.
Rationale
To reduce the risk of the dressing adhering to the wound bed
and to minimise patient discomfort
To ensure there is no fluid which could leak at the
disconnection site.
To prevent fluid from leaking out
To reduce the risk of cross infection
To separate the dressing from the NPWT device.
The suction is a sealed unit that contains a solidifying agent. It
should be changed regularly to prevent infection or overfilling
of the canister. Changes in the exudate colour and the amount
of exudate should be recorded.
To break the film adhesive whilst minimising trauma to the
patient
To minimise trauma to the wound tissue when removing the
dressing.
To ensure all the dressing is removed as if retained will cause
failure to heal and may require surgical removal.
To reduce the risk of infection
To reduce the risk of infection and to prevent contamination of
the wound.

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 Asian Journal of Nursing Education and Research. 8(3): July- September, 2018

NPWT settings5
Type of Initial Cycle Subsequent Cycle Target Pressure White Foam Dressing Change Interval
Wound Pressure (PVA)
Target Black
Foam
(PU)
Acute/ Continuous Intermittent 5 minutes on, 2 125 125 – 175 mmHg Titrate Every 48 hours Every 12-
Traumatic for first 48 minutes off for rest of mmHg pressure up 25 mmHg for 24 hours with infected
Wounds hours therapy wounds with high exudate wounds
Surgical Continuous - 125 125 – 175 mmHg Titrate Every 48 hours Every 12-
Wound for duration of mmHg pressure up 25 mmHg for 24 hours with infected
Dehiscence therapy wounds with high exudate wounds
Pressure Continuous Intermittent 5 minutes on, 2 125 125 – 175 mmHg Titrate Every 12-24 hours with
Ulcers Every for first 48 minutes off for rest of mmHg pressure up 25 mmHg for infection
48 hours hours therapy wounds with high exudate
Meshed Grafts Continuous Graft requires covering with 125mmHg Titrate pressure up 25 Remove dressing after 4-5
and for duration of wide meshed non-adherent mmHg for wounds with days when using either
Bioengineered therapy 75 – dressing if black foam high exudate foam
Tissues 125 mmHg issued
Chronic Continuous Intermittent 5 minutes on, 2 50 – 125 125 – 175 mmHg Titrate up Every 48 hours Every 12-
Ulcers, i.e. for first 48 minutes off for rest of mmHg 25 mmHg for wounds with 24 hours with infected
Leg Ulcers hours therapy high exudate wounds
Flaps Continuous - 125 – 150 125 – 175 mmHg Titrate up Fresh flaps = 72 hrs If
for duration of mmHg 25 mmHg for wounds with there are complications
therapy high exudate every 48 hours. Every 12-
24 hours with infection

Benefits of NPWT: • intolerance or non-adherence to the treatment

• earlier hospital discharge • lack of healing
• fewer wound dressing changes • frank pus in the dressing or canister
• less need for surgery • Uncontrolled bleeding or blood clot under the
• savings in nursing costs dressing.
• enable transfer from hospital to lower-cost health CONCLUSION:
care setting Dressings have advanced to such an extent that they now
• improved quality of life actively promote wound healing while maintaining a
moist wound environment . One of the advances in
Disadvantages of NPWT: wound care include negative pressure wound
• need to be hooked up to the unit for at least 22 hours therapy (NPWT), which is clinically proven to promote
a day active wound healing at the cellular level through
• initial pain, due to the application of negative negative pressure. Negative pressure wound care
pressure (NPWC) has been known to have the potential to
• Negative-pressure wound therapy is not always promote wound healing, alleviate concerns such as
effective and a non-healing wound may require increasing exudate and odor, and improve quality of life
other, potentially more invasive treatment. for patients.

Potential complications of NPWT: REFERENCES:

Rarely, complications may occur which may require 1. Argenta, L.C., Morykwas, M.J. Vacuum assisted closure: a new
discontinuation of negative-pressure wound method for wound control and treatment. Clinical experience.
Annals of Plastic Surgery. 1997,38(6): 563-7
therapy.3These may include: 2. Hunter, J.E., Teot, L., Horch, R. and Banwell, P.E. Evidence-
• pressure necrosis (tissue death) from the tubing based medicine: vacuum-assisted closure in wound care
• injury to skin around the wound management. International Wound Journal 2007,4(3): pp. 256-
• growth of granulation tissue into the foam dressing 269.
3. Hunter, J.E., Teot, L., Horch, R. and Banwell, P.E. Evidence-
• increased pain initially, due to reduced pressure as based medicine: vacuum-assisted closure in wound care
the foam collapses management. International Wound Journal 2007, 4(3): pp. 256-
• contact dermatitis due to the adhesive transparent 269.
4. Steve Thomas. An introduction to the use of vacuum assisted
tape closure, Worldwide wounds:May 2001: Available from,
• fistula (tunnel) formation http://www.worldwidewounds.com/2001/may/Thomas/Vacuum-
• Development of skin cancer as a result of increased Assisted-Closure.html
5. Guideline for Procedure for the use of Negative Pressure Wound
blood flow in the wound bed (very rare). Therapy (NPWT). Available
• Negative-pressure wound therapy may need to be from:file:///C:/Users/user/Downloads/Negative_Pressure_Wound
stopped if the patient experiences: _Therapy_(NPWT)%20(1).pdf
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