Matthew Garoufalis, DPM discusses the role of oxygen in wound healing, describing in detail the necessity of oxygen within a wound. Dr Garoufalis outlines the advantages and disadvantages of various oxygen delivery systems, emphasizing the significant advantages of cyclical pressurized oxygen treatment.
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Release Date: 03/16/2018 Expiration Date: 12/31/2020
Matthew Garoufalis, DPM, CWS
Professional Foot Care Specialists, PC
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TAPE STARTS – [00:00]
Male Speaker 1: One of our co-chairs, Matt Garoufalis is going to present a talk on something that we've been -- what we're studying right now. We're still engaged in study in cyclical pressurized oxygen as an adjunct to effective wound healing. Topical oxygen, hyperbaric oxygen had been battling back and forth for years. And I think there needs to be better science in this regard especially on topical oxygen. I'm really gratified to see that there is more and more evidence accumulating on the role of topical oxygen and it's efficacy in wound care. And so we've asked Matt Garoufalis to come to speak. Matt is no stranger to our meetings. Matt practices at Jesse Brown and Hines VA in Chicago. He is a past president of APMA. He is a fellow-fellow of the Royal College of Physicians and Surgeons of Glasgow Podiatric Physicians and Surgeons in Glasgow. And he has spoken -- he is also what the -- are you the Vice President of the International Federation or Federation of International Podologist or something. I forget -- I was at that meetings number of years ago. Anyway, Matt will come and talk to us now as one of his several lectures in our meeting on Cyclical Pressurized Oxygen. So let's welcome Matt Garoufalis.
Male Speaker 2: Well, good morning everyone. Thank you for showing up this morning bright and early. Breakfast was good, so that’s good. Yeah, Bob mentioned about this adjunct therapy that is unique to the VA. How about that? Out in private practice, you can't get your hands on this without paying for it out of your pocket. But in the VA, we have access to it. And it's something that if we don’t have access to hyperbaric oxygen which we most of us don't, this is a nice adjunct to treat some of the wounds we’re going to treat. So let me go through this. It's a little science heavy in the beginning, but of course we end up with some great case studies afterwards which is always good to see some -- really see how it works. So we got some learning objectives of course just learning about this pressurized oxygen therapy that is available to you. We've got the disclosure statement that the VA always likes to see when it's physicians do presentations. And I do speak for few other entities as it is and now here we go. Okay. All that crazy stuff that we have to get through. Oxygen. We know that oxygen plays a huge role in wound healing. But sometimes when we look at algorithms on wound healing, we don't always see where oxygen is needed. We know that moisture balance is good. We know that you have to control the inflammation and of course we know that every wound needs to be debrided at every visit. Those are givens, but what about oxygen. How we would deliver oxygen to the wound? We can’t expect oxygen to be delivered appropriately in many of our patients because they haven't adequate blood flow. They're getting just enough blood to try to heal that wound let alone perfuse oxygen appropriately. So that’s why HBO is so popular in wound healing, but we don't always have access to that. So we also have bio burdens that we have to deal with and this is why debridement is so important. Bio burdens and a variety of different ulcers that we treat are aerobes or anaerobes, all sorts of different bugs and bacteria on there that we have to deal with. Well, we also know that if these anaerobes were exposed to oxygen, they would disappear. They would help us in controlling what’s going on with the wound, so something to keep in mind. So this is just the diagram and it's kind of a busy diagram, but it shows the difference in oxygen levels at different sites within the wound itself and so even though that we have a wound that may look granular, it may not be getting the exact right amount of oxygen perfusion. Even though we’re creating angiogenesis, we're healing that wound, we still might need an extra boost of oxygen from somewhere to help it close and help it close a little bit quicker.
So these are some facts concerning oxygen and the wound. We know that the more oxygen we have at the wound, we know that heals better which is why we have some positive results when we use hyperbaric oxygen. We know that it helps with control of bio burden and bacteria. So these are just the few of things that we know that oxygen is helpful for. So how do we bring this to the wound itself. Well, we also know that in order for all the pathways to work appropriately, we need the right amount of oxygen delivered to the wound. There also are some reasons why this particular wound is not going to get adequate oxygenation. We know that our patients especially in the VA setting have a plethora of comorbidities that get in the way of the good work that we do in trying to heal these wounds, but the fact that we can actually heal this wound in our population is to our credit. I tell my residents that if you can heal wounds in this population, when you get out in the private practice, you're not going to have any problems at all as we deal with the most difficult patient population there is to heal wounds because of the comorbidities going on and the road blocks that keep getting in our way. So we know that oxygen balance is extremely important. We also know that there is reason why it doesn't happen. We know we need oxygen for collagen formation. We need it to create new blood vessel formation. We need it to fight infection. Hyperbaric as I said has been out there for a while but very limited. This pressurized cyclical oxygen that is available to us gives us a pathway to allow these patients to heal their wounds a bit faster. It works by cyclical pressure. It's done at the patient's home which is very nice. So it doesn't take time in your clinic to do this. The patient doesn't have to travel to have it done. It's actually done in their home. It's very easier to use and there is very few if any contraindications and we'll go over that a little bit more. The other thing that’s interesting that it provides for that hyperbaric oxygen doesn't always provide for is humidification of the oxygen which allows it to penetrate into the tissues with much more efficacy. So this is a busy little slide, but it compares the delivery system between topical oxygen, this pressurized oxygen that we're talking about and hyperbaric oxygen. And just some of the high points, it's very portable, it's relatively inexpensive compared to the hyperbaric oxygen. It does not -- it causes rejuvenation of the vasculature supply and there is no risk to any other organs when used unlike hyperbaric oxygen. So a few high points there. Here is the contraindication and in where there are contraindications in using hyperbaric oxygen, there is only one contraindication in using this type of product and that’s if they have an acute or untreated DVT. Of course, if they have an acute or untreated DVT, they have other issues that you have to deal with. So this is the least of their concerns. So there've been some studies and we always have to rely on data. So let's talk about some data that makes this very important to us. Here is a study that they cover a wound with impermeable dressing; in other words, oxygen couldn’t penetrate through the dressing and they put a permeable dressing on other wound. And they apply the oxygen for seven days and they discovered that there was a difference in the rate of wound healing in the wound that was dressed with permeable dressing, permeable to oxygen as opposed the wound that was protected and did not allow oxygen to the wound. While the wound was still granular and appeared to be healing, there was a much faster rate of healing in the wound that allowed oxygenation to occur. So that's one study. Here is a different study looking at full thickness wounds on a rat model and we're seeing increased perfusion of oxygen into the tissues with time and with increased pressure. Now, this is the kind of graphs that will make your head spin especially at this hour in the morning and because it talks about one of your favorite topics the growth cycle and ATP which will give most of us nightmares back to biochemistry and all that fun stuff. But if you look at and let's see if I can make this happen. This pointer isn’t very great, but look at the bar that goes up and down all the way over by zero.
Okay? That’s the oxygenation that most wounds have which tells us that you don't have adequate oxygenation for ATP metabolism. You don't have adequate oxygenation for collagen and you don't have adequate oxygenation for fighting infections. So a normal healthy person has adequate oxygenation to take care of all those functions. That’s that bar right there. This bar right here in the middle about to 100th that bar going up and down tells us that a normal healthy individual, they have adequate oxygenation to produce ATP, to produce collagen and also to fight infection. However when we apply the cyclical pressurized oxygen, that bar moves all the over to 800. That’s that bar at 800. And so we actually supercharge the oxygenation of the tissues at a very local level and we meet 100% of the ATP metabolism function, 100% of collagen production function and 100% of infection fighting ability of the tissues. So by applying this, we go above and beyond what a normal healthy person would be able to achieve and in our population with their comorbidities and their other deficiencies, we're actually stepping up the level of wound healing by applying this type of product, this type of delivery system to that chronic wound. What we see even at a cellular level or within tissues is a difference between a controlled and oxygenated tissue. We have new capillaries formed all the time all over the place. It stimulates angiogenesis. We see a difference in the granular bed. It becomes red. It becomes vibrant with healing because you have now oxygen diffusing into the wounds. This is just a wound every 60 minutes of cyclical pressurized oxygen. So we can tell a big difference occurring there. We can tell there is something going on. Again cellular level, we can see that the epidermis and dermis stimulated to produce normal dermis and normal epidermis as opposed to what it can produce in an oxygen-depleted state. So we're doing something very positive here. So how does this really work? Well, because we're varying the pressure cyclical and I urge you to look at the product close-up and up at the booth. So it acts as a pump also. So it has a pumping action, cyclical pressurized oxygen. It goes up to half of an atmosphere of pressure and this helps to drive the oxygen that is humidified into the tissues at a very local level. At the same time, it works a pump and helps recirculation and circulation of the blood into the extremity. So we have some effectiveness study, compared effectiveness studies here between healed and unhealed wounds and the bar in the middle is the oxygen bar and it competes pretty well with the other modalities that we use in terms of negative pressure and HBO in terms of what we can do and heal these wounds. Now, there are studies. Again, we go back to studies. There is a huge international study going on right now with several of VA's around the country and with several institutions in Europe. The study has reached a point now where we're getting ready for mid-term assessment of the study to see how we are doing and it looks very promising, looks very promising. There is also a poster-up from our institution looking at over 100 patients to see how this worked on well over 100 patients in our institutions. And with surprisingly positive outcomes -- not surprisingly because I know this works, but you'll be surprised when you read the study that this is something that you might want to bring it and use because it's that effective. It's different than the topical oxygen we're used to. This is much different and unfortunately when you say topical oxygen, you get that misnomer of, oh, it's a bag [Indecipherable] [0:15:04], something that’s just going to blow oxygen across the wound and it's not.
It's not that at all. These products don't have the data. They don't have the studies. They don't have the effectiveness. They're definitely hit or miss ideas. They don't provide the compression. They don't provide the perfusion into the tissue. They're pretty much hit or miss. Sometimes they work, sometimes they don't. And again, it's the data. The data is what sells this. And data is what sold me on this. Seeing at work as adjunct to the other products that we use is important. Now, that the study that’s going on and so far is looking very, very positive is without using any of the adjuncts that we would like to use in wound healing. The study -- the retrospective study that we did at Jesse Brown, we used these types of products along with the oxygen and got very outstanding results. So you can use it with these types of products which is very nice as long as the dressing is permeable which is very easy to do. There is also a comparison here with negative pressure and cost. So cost is always an issue. It didn't use to be a big issue in the VA, right? But now boy it seems like everybody is breathing down our neck of our cost. So here is something that even the folks in prosthetics can smile very happily and say, hey, this is pretty good. I'm glad you're getting good results with this. It's not killing us. So the cyclical pressure is what makes the difference compared to other products. That’s key. The pressurized cyclical oxygen is what does the trick here. It's been cleared for all kinds of chronic wounds. Post surgical wounds and traumatic wounds. So it's already worked on thousands of veterans already. Now, in Europe, believe it or not, they're little bit more advanced than we are in this format of wound healing. There are already many articles in Europe and guidelines in Europe on how to use this modality. So they're way further ahead of us there. So our toe hole here in the US is in the VA system. We have to show the rest of the country how effective this product is. And believe me with CMS breathing down the neck of HBO folks, they're looking for an alternative to HBO. This is the alternative to HBO. So as the studies finish up, this is something that CMS is already looking at. They're already looking at the data that’s been produced using this modality. So I don't think you're going to be an outlier when you begin using it, you're actually going to become very mainstream, especially if CMS approves this for use in public domain. So this is what the product looks like for home use. Again, it is home use. It's not done in the clinic. It's delivered to the patient's home. They're given instructions on how to use this product and they use it every day for 90 minutes. They can use it for more than 90 minutes. And I can tell you as a personal antidote those patients that have used it more than 90 minutes a day maybe 2 times or 3 sessions a day have even a better outcomes and even better results. Some case studies, what we see when we apply it to wound that we're having is progressing, but it's progressing slowly. This patient with a plantar wound, we see a 40% decrease in one week since applying this type of oxygen to the wound which is pretty dramatic. Here is a patient, that is necrotic Achilles tendon that you see there on the left. We see all kinds of progress. This patient moves on to this at six and nine weeks after the application of this modality which is dramatic. So patient that went from necrotic Achilles that if you go textbook, maybe we should have debrided that out, but we said, no, let's see if we can leave his Achilles there and granulate over it so we don't have to do the procedure and sure enough this patient went on to close very nice because the only thing we added to his therapy was the pressurized oxygen therapy. That’s the only thing that was added that made a difference. Here is a patient with venous stasis ulcers bilaterally and the only thing that we added was pressurized oxygen and in six weeks, we got that kind of closure. He was closing slowly, gradually and it would take a long, long time, but this is a bit of booster that we're able to close these wounds much faster with this type of an application. And this type of wound that was absolutely stalled no matter what product we would put on this wound because of the decrease in circulation and other comorbidities this patient had. We were able to jump start this wound again simply by adding this modality. So it's an interesting modality, give it a look, see if it fits into your patient treatment algorithm. We're very happy that we've been using it. We've been using it now for about two or three years and it is just something to take a look at. So, we have a few minutes for questions if that’s okay. Thank you very much for being here.
Male Speaker 2: Yeah.
Male Speaker 3: Well, for chronic wounds, are you still doing multilayer compression, and how do you logistically supplement that with a topical oxygen?
Male Speaker 2: I missed the first part.
Male Speaker 3: So for the chronic wounds, are you still doing multi-compression therapy?
Male Speaker 2: Yes, yes. We still use multi-compression therapy or multi-layer compression therapy and you can use this along with it because it's permeable.
Male Speaker 3: So you apply it over the dressings and --
Male Speaker 2: Yes.
Male Speaker 3: Okay.
Male Speaker 2: And the other thing that I forgot to mention is when you apply a dressing to a wound, you do not have to remove the dressing to use this modality. The dressing remains intact as long as it's a permeable dressing and most of our dressings are indeed permeable. The dressing stays intact in between your visits. The patient uses this modality over the top of that dressing. It doesn’t have to be removed so that in the end, it better fit. Any other questions? Okay. Great. I'll be around in case you do come up with anything later on. Thank you so much.
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