NPWT

in everyday
practice

made

easy

Volume 1 | Issue 5 | November 2010 www.woundsinternational.com

Introduction

Negative pressure wound therapy (NPWT) offers

clinicians an important option for the advanced
management of many wound types1,2. Key factors
for successful use are the appropriate preparation
of the wound bed and the application technique
used. In addition, a decision must be made about
the type of dressing selected within the NPWT
system: currently the choice is between gauze and
foam3. This document builds on the article NPWT
settings and dressing choices made easy3, and
focuses on the practical, everyday aspects of how
to deliver NPWT safely and effectively to make
best use of this technology and maximise patient
benefits.

Authors: Henderson V, Timmons J, Hurd, T, Deroo K,

Maloney S, Sabo S.
Full author details can be found on page 6.

When is NPWT indicated?

NPWT is indicated for use in many acute and chronic

wounds3, and has the potential to benefit a large number
of patients from both a symptom management and wound
healing perspective. Box 1 opposite summarises the key
advantages of the therapy. NPWT can be considered when
the wound4,5:
n
is not progressing towards healing in the expected
time frame, eg edges are slow to contract using
standard care
n
produces excessive exudate that is difficult to manage
n
is in an awkward location or is a difficult size so that
achieving an effective seal with traditional dressings is
problematic
n
requires reduction in size to achieve surgical closure.
NPWT is also indicated for use when the patient requires a
dressing/treatment regimen that stays in place securely and
does not need frequent changes. A good example of this is
in the case of children with wounds, where frequent dressing
changes may be traumatic or where dressings may fail to
stay in position6,7. In addition, in certain wound types and
with skin grafts, NPWT provides a splinting effect (rigid
support)8,9.

Box 1 Benefits of NPWT

Control of exudate: prevents exudate from soiling clothes and
bedclothes, and protects surrounding skin, thus enhancing patient
comfort10
Reduction in the number of dressing changes required: this allows
the patient to rest and reduces disturbance to the wound11
Reduced infection risk: the sealed system and fewer dressing changes
mean there is less chance of wound contamination and infection12
Rapid wound granulation, epithelialisation and contraction:
NPWT stimulates new tissue growth. It may also promote wellbeing as the patient can see positive results quickly13
Reduced pain at dressing changes: one study using NPWT with
gauze found wound pain during dressing changes was absent in
80% of dressing removals14
Reduces wound odour: improved management of exudate means
that odour from the wound often reduces over the course of therapy14
Concurrent rehabilitation: NPWT does not prevent/inhibit
physiotherapy or mobilisation so patients can undergo
rehabilitation simultaneously with treatment15
Treatment costs: reduced frequency of dressing change and faster
wound closure may help to reduce overall treatment costs16

What needs to be considered before

applying NPWT?

Before the application of NPWT, it is important that a full

assessment of the wound and the patient is undertaken by a
knowledgeable and competent practitioner to confirm whether
NPWT is appropriate. Points to consider include:
n
Will the patients symptoms be managed more effectively
using NPWT?
n
What are the dimensions of the wound and can NPWT be
easily applied?
n
Are there any contraindications (see page 4)?
n
Will the placement of tubing be a problem?
n
If the patient is discharged home on NPWT, will he/she be
able to manage the NPWT system alone at home?
n
Can the wound bed be effectively debrided and prepared
prior to application?
n
Is the patient willing/able to give consent (see page 4)?

What are the goals of treatment?

There should be a documented treatment plan for individual

patients, including short- and long-term goals and outcomes.
Short-term goals may include:
n
management of wound exudate
n
management of wound odour
n
reduction in pain
n
removal of sloughy tissue
n
prevention of infection.

NPWT

in everyday
practice

made

easy

Long-term goals may include:

n
reduction in wound area
n
reduction in wound exudate
volume
n
production of healthy granulation
tissue
n
wound closure through surgical
means or secondary intention
healing
n
restoration of physical function in
the wound site.

removal3. Transparent film is used over

the filler to create a seal around the
drain, which is imbedded in the gauze
or foam filler. Alternatively, a port can
be used in place of a drain. The drain
or port is then connected to a canister,
which is attached to the pump. Larger
units are often used in hospitals and
smaller portable units are suitable for
use in both community and hospital
settings.

When should NPWT not

be used?

Gauze or foam?

The NPWT device works through the

application of an open cell foam or
gauze dressing, which allows equal
distribution of negative pressure
across the entire wound bed3. Recent
published research18 has shown that
both types of dressing interface
are equally effective at delivering
negative pressure, wound contraction
and stimulation of blood flow at the
wound edge. However, studies have
documented in-growth of granulation
tissue into the cells of the open cell
polyurethane foam. This can cause
patients to experience pain at dressing
changes and a disturbance of the reepithelialisation process19-22.

As with any wound therapy, clinicians

must be fully aware of precautions and
contraindications17 (Box 2, page 4).
The use of NPWT should be carefully
considered and the risks weighed
against possible benefits.

What components are

there in a NPWT system?

There are a number of systems available.

Most comprise a base unit with pump
and a gauze or foam wound dressing
(filler). If foam is used, a non-adherent
wound contact layer can be beneficial
to reduce tissue ingrowth and pain on

Figure 1 NPWT foam (A) and gauze (B) dressings in situ (with permission of Smith & Nephew)

The rapid granulation associated with

foam dressings can sometimes be an
advantage in wounds that require
quick healing, such as in patients with
significant vascular problems or those
at risk of infection13.
It is important not to compress the
foam or overpack the wound so that
local vasoconstriction in the wound
can be prevented and allow fluid to
flow freely through the interface.
Contact between the foam and the
surrounding skin should be avoided
to prevent damage to the periwound
skin.
A list of benefits and disadvantages
of foam and gauze can be found in
Box 3.

Continuous or
intermittent suction
settings?

NPWT units usually have two suction

settings: continuous and intermittent.
Continuous suction is the most
commonly used setting and is the
recommended setting at the start of
therapy3. This is also the best setting
for wounds producing high levels of
exudate and to help maintain a good
seal. The continuous setting means the
unit will apply continuous suction to
the wound bed, providing stable and
consistent negative pressure.
The intermittent suction setting
usually provides a cycle of five
minutes on and two minutes off and
may be used once the amount of
exudate drainage has been reduced
or stabilised26. There are cases where
intermittent suction can be used
throughout treatment27.

Pressure settings
Most units provide a range of
negative pressure, between -40mmHg
and -200mmHg. Negative pressure

levels will be dependent on the patients tolerance and

wound aetiology. For example, the therapy is often
delivered at lower pressures for painful wounds or wounds
that have compromised perfusion 3. Clinicians may initiate
NPWT at -80 to -125mmHg for an adult patient, which may
be reduced if the patient is experiencing pain or slight
bleeding.

the wound because of the seal and the exudate

management system
n
can help to reduce the swelling in and around the
wound area, which can help healing and reduce pain.

Other essential patient information

Initially the negative pressure dressing may take

longer to apply than other products. However, this
therapy will be in place for up to three days
n
The device should make a noise only when it is
establishing a seal; once this has been achieved the
machine will operate more quietly
n
Portable devices are available that enable patients to
undergo therapy regardless of the setting.
n

When should NPWT be discontinued?

NPWT should be discontinued when the goal of treatment

has been achieved. Other reasons to discontinue NPWT
include:
n
when uniform granulation tissue and little depth to the
wound is present
n
the patient is not tolerating the NPWT, or withdraws
consent to treatment
n
when wound volume reduction is less than 15% over a
two week period8
n
the patient complains of extreme pain
n
there is excessive bleeding
n
an alternative treatment option is more suitable
n
there are signs of local or spreading infection.

Patient-specific factors
Informed consent

NPWT at home

As with any treatment option, the patient may not remain

in hospital for the duration of treatment. Before discharge,
it is important to assess whether the patient can continue
to receive NPWT in the home environment using portable
equipment. More and more patients are using NPWT in the
home environment and nurses are now very familiar with the
therapy.

The patient should understand the treatment options

and why NPWT is being proposed. This includes how the
treatment works, the rationale and treatment goals, the
possible side effects and how these will be managed, any
impact the treatment may have on quality of life, how long
the treatment is likely to take and possible outcomes.

Home use may raise certain safety issues. In particular, NPWT

involves a therapy unit pump which the patient must carry
with them (most models come with a carry bag). Where
patients have a foot or lower leg wound, this may present a
risk of tripping and falling. It is also important to check with
patients that their home electricity supply is safe and that
there are no problems such as loose wiring.

How should NPWT be explained to a patient?

Safety checklist

The basic elements of the NPWT system should be explained

and demonstrated. Key benefits of NPWT that can be easily
explained include that it:
n
manages fluid leaking from the wound by collecting in
an enclosed canister
n
protects the skin around the wound from exposure to
damaging enzymes present in wound fluid
n
speeds up the healing process by encouraging blood
flow in the wound
n
reduces the risk of infection as micro-organisms
cannot penetrate the sealed wound environment
n
can help to reduce the wound pain experienced
n
can reduce the number of dressing changes needed,
resulting in less inconvenience to the patient and his/
her family
n
helps to reduce the level of odour emanating from

Patient mobility does the patient use a walking aid?

Is the patient able to carry the device and manage the
weight and tubing?
n
Is the patient at risk of falling because of the device?
n
Is the patient/carer cognitively able to manage the
therapy? For example, paediatrics and patients with
learning difficulties may have problems
n
Does the patient have sensory deficits, such as
hearing loss or vision problems. Does the patient have
sufficient hearing/vision to manage the system (eg
hear alarms/see dial)?
n
Is the patient in a psychological and social situation
appropriate for NPWT?
n
Is the patients home electricity supply safe?
n
Are there stairs or other obstacles that the patient will
need to manoeuvre with the device?
n
n

Box 2 Patient risk factors17

Contraindications

Precautions

Osteomyelitis: NPWT is contraindicated in the presence of

untreated osteomyelitis

Weakened blood vessels: patients who have weakened blood

vessels, friable vessels and infected vessels (direct negative
pressure may cause trauma and bleeding)

Malignancy: NPWT is not recommended in malignant wounds

because it may stimulate proliferation of malignant cells

Exposed delicate structures: patients with exposed blood

vessels, delicate fascia, exposed tendons or ligaments (direct
negative pressure may cause trauma and bleeding)

Non-enteric and unexplored fistulae: there may be

communication with underlying vulnerable organs

Bleeding: wounds that are actively bleeding or where the

patient is at a high risk of bleeding or haemorrhage, receiving
anticoagulant therapy and/or platelet aggregation inhibitors
(negative pressure could encourage bleeding as local perfusion
will be increased and therefore blood loss will be greater)

Exposed vasculature, nerves, anastomotic sites or organs: if

directly applied to exposed structures, NPWT can cause damage
or rupture vessels due to the force of negative pressure

Fistulae: wounds with enteric fistulae (these require special

precautions to optimise therapy). The clinician needs to refer to or
take advice from a specialist in NPWT for these patients

Necrotic tissue with eschar present or thick slough in the

wound bed: appropriate debridement should be performed
before the application of NPWT. This therapy is not designed
to debride and quicker results will be obtained if the wound is
debrided prior to application of NPWT

Patients requiring certain treatments: special consideration

and caution should be taken where patients require magnetic
resonance imaging (MRI), hyperbaric oxygen treatment,
defibrillation, etc

Additional precautions: these include patients with spinal cord injury, infected wounds, wounds with sharp edges (eg bone
fragments) and vascular anastomoses

See http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications/ucm190658.htm for the FDA list of contraindications and risk factors

Box 3 Benefits and disadvantages of foam (open cell) and gauze application
Gauze

Foam

Many companies supply a gauze impregnated with the

antiomicrobial polyhexamethylene biguanide (PHMB) as
standard19. Antimicrobial wound contact layers are also available
for use with NPWT

Routine open cell foam does not contain an antimicrobial, but

silver impregnated foam is available23. Antimicrobial wound
contact layers are also available for use with NPWT

Some gauze-based systems offer three choices of drain which

are inserted into the filler beneath the adhesive film. Flat drains
are useful for shallow wounds; round drains are useful for deep
wounds and those with areas of undermining and wounds
producing copious exudate. Channel drains are useful in narrow
wounds or tunnelling19. Drains may require a greater degree of
user skill and could be a source of vacuum leaks

Usually there is no choice of drains to use with foam beneath the

adhesive film. Suction is more typically applied via a port which
is fixed to the upper surface of the adhesive film. This is an easier
technique and eliminates one source of vacuum leaks, although it
may be less efficient at fluid removal24

Quick to apply, conformable to complex wound surfaces and

versatile for all sizes and types of wounds. Can be used in
tunnelling and areas of undermining. Suitable for very large
irregular wounds and has been used for wounds caused by
explosive devices25. Gauze should not be overpacked

Foam requires cutting to the size and shape of the wound. Can
be quite challenging with a complex wound which has several
layers and uneven wound bed. Caution is needed in wounds with
tunnelling and undermining as in-growth of granulation tissue can
cause problems3. Foam is easy to apply to deep, regular shaped
wounds that will benefit from a high level of tissue contraction25

Gauze is easy to remove and does not disrupt the wound bed. It is
therefore less likely to cause pain at dressing changes14

Possible problems with in-growth of tissue into foam dressing;

may require more mechanical force to remove foam. This can
disrupt the wound bed and may increase pain on dressing
removal. Use of wound contact layers helps eliminate in-growth
and pain3

Gauze should be moistened before application, eg with saline

unless exudate levels are very high

Does not need to be moistened before application

No difference detected in overall wound volume reduction

compared to foam dressings. Granulation tissue may be slower to
develop and more robust compared to foam3

No difference detected in overall wound volume reduction

compared to gauze dressings. Granulation tissue may be faster to
develop and less robust than with gauze3

How to answer patients frequently asked questions

What support will I receive throughout the course of my NPWT treatment?
You will initially receive information from your nurse about the NPWT unit. Nursing
support will continue throughout treatment and nurses will change dressings when
necessary in your home.
How long am I likely to need this therapy?
The average duration of therapy is about two weeks although this will be entirely
dependent on the size and complexity of the wound and your needs.
How often does the dressing need changing?
Dressings should be changed according to the manufacturers recommendations;
however, the condition of your wound will ultimately influence the clinicians decision.
A good guide is every two days for foam and every three days for gauze. The need for
dressing changes will be dependent on the integrity of the seal.
How long does the battery last?
The battery life of NPWT devices can vary significantly. In many portable devices the
battery life can last up to 20 hours. For some of the larger NPWT systems (usually used
for inpatient stay) the battery life can last up to 40 hours. Most devices will alert you
when the battery is low. The battery can be recharged when plugged into the mains
with the power lead supplied. It is advisable to recharge the battery overnight.
What do I do when the canister is full?
When the canister is full, an alarm will sound. A nurse will show you how to change
canisters or may undertake the change for you. Canisters should be changed once
a week or when full. The full canister should be removed and a new one attached. A
dressing change is not necessary. Canisters are sealed and can usually be disposed of
in the normal rubbish bin. However, patients should check with their nurse to explore
disposal options.
How do I know if there is a leak and what do I do?
In most NPWT systems, if there is a leak, the alarm will sound. In this situation, silence
the alarm by pressing the mute button and listen for an air leak (indicated by a hissing
sound) around the dressing. Sometimes all that is needed is to simply press down on
the clear film drape and the dressing will re-seal. If the alarm continues and you are
unable to find the source of the leak, call the nurse/physician or helpline number if you
have one. A troubleshooting booklet is usually provided with NPWT units, which may
provide helpful advice.
What should I do if the tubing becomes disconnected?
In most NPWT systems, if the tube becomes disconnected, the alarm will sound. You
will usually have been taught how to reconnect the tubing. Once the seal has been
achieved, the alarm and the hissing sound should stop.
Can I bath/shower while using NPWT?
Showering is possible after clamping the tubing and disconnecting the machine.
However, it is generally recommended that you only shower immediately before
dressing changes just in case the dressing does not stay intact. Bathing is not
recommended as this may affect the seal of the film dressing.
Can I drive a car with the NPWT unit in place?
This should be possible but you should check with your physician that it is safe to do so.
Ensure that the tubing is secure and not in the way of the vehicles controls. Whether
driving is possible may depend on the site of the wound rather than the therapy.

Summary

Negative pressure wound

therapy has the potential
to benefit a large number
of patients in terms of both
symptom management
and wound healing. The
combination of managing
exudate, reducing odour
and promoting granulation
tissue formation are major
benefits of the therapy. It is
also essential that clinicians
use the therapy when it
will be most helpful. Best
results are found when
used on wounds that
have been debrided and
where rapid granulation
is sought. The decision
to use foam and gauze
interfaces should be based
on the individual patient
and wound assessment,
and on the goals that need
to be achieved, whether
they be wound healing or
symptom management or
both. Finally, all clinicians,
patients and carers should
be fully informed about
NPWT as a therapy, how
the system works, what
the benefits are and, most
importantly, what to do
when there is a problem.

References

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This article was supported by Smith &

Nephew.

Author details
Henderson V1, Timmons J2, Hurd T3,
Deroo K4, Maloney S5, Sabo S6
1. Clinical Lead Tissue Viability,
Northumberland Care Trust, UK
2. Medical Education Manager, Smith &
Nephew, Hull, UK
3. Clinical Nurse Specialist;
4. Clinical Nurse Specialist;
5. Senior Project Manager & Development;
6. Clinical Nurse Specialist;
Nursing Practice Solutions, Toronto, Canada

Further reading
Malmsj M, Borgquist O. NPWT settings and dressing choices made easy. Wounds International 2010; 1(3):
Available from http://www.woundsinternational.com
Ousey K, Milne J. Negative pressure wound therapy in the community: the debate. Br J Community Nurs 2009;
14(12): S4, S6, S8-10.

To cite this publication

Henderson V, Timmons J, Hurd, T, Deroo K, Maloney S, Sabo S. NPWT in everyday practice Made Easy.
Wounds International 2010; 1(5): Available from http://www.woundsinternational.com

Wounds International 2010