Transcript: Frank Aviles Jr., PT, CWS, FACCWS, CLT-LANA, ALM, AWCC, DAPWCA

Hello, my name is Frank Aviles. I'm a physical therapist by trade. I'm in the wound care/lymphedema space, and I'm starting a new position at My Life Rehab and Wellness doing lymphedema and wound care.

That’s a great question. Exudate management is critical. As we know with the wound bed preparation ideology that you have to manage exudate. And in the type of wounds that we see, especially venous leg ulcers and patient's with lymphedema, excessive production of fluid can definitely significantly impact the healing outcomes but also the overall patient's quality of life. Now I do want to expand on that, because when you start looking at all this excessive drainage you're looking at damaging probably the periwound skin. Anytime we make that wound fragile, it may increase the chances of bacteria into the tissue. We also want to control bioburden and also infection risk. When we have this high level of exudate containing a high level of inflammatory mediators, bacteria, and proteases, it can definitely delay healing. And what happens is it allows for the healing process to decrease cellular activity, decrease angiogenesis, and so we're not progressing. 

The other thing is that we may have a lot of odor, so we have to control the drainage, because the odor could actually hurt the patient's psychosocial status. They don't want to go outside, you know, there's a smell associated with it, and I've seen patients suffer great depression just from their exudate. And also, when you have a lot of exudate that you're not able to control, it decreases the ability to use the dressing appropriately. So if the dressing is indicated for 7 days, you're going to change it a little more often, which is going to increase health care dollars. And so effectively managing your exudate is key with patients so we can prevent complication and also improve healing and patient outcomes.

Alright, so some of the complications, we did talk about a few already, but besides the maceration of the periwound skin, we know that the wound may get bigger if we're not able to control that excessive moisture level in intact skin. Now, when we look at our patients, most of them are chronic, and these patients have decreased oxygen tension in the wound bed, but also it allows for bacteria to grow. So if we have exudate, which has high level of inflammatory, these mediators decreases also the growth factors to allow healing, but in addition to that, it starts eating the structure that we're trying to build. We talk about MMPs, matrix metalloproteinases; a high level of that is not going to be conducive to healing. And so the other thing that we can talk about with these patients, with the drainage, is, I alluded to that in the first question, but sometimes we chase the drainage in all essence. We're adding all these products to try to make sure that the patient can extend his wear time. Back in the days when I first started doing wound care, I was told if you can maintain a dressing over for 7 days, it allows the right environment for that wound to heal faster. When you're having to chase the drainage, you're changing that dressing so often that it doesn't allow for the optimal environment to occur. 

We also talk about compression therapy, some of the challenges. Compression therapy is the cornerstone for these patients with venous leg ulcers and lymphedema. So if we're not able to maintain consistent compressor because we're having to remove the, cut the drain, cut the actual compression dressing, then we're not allowing for that compression device to do its work over time. And so now we talk about the wound bed itself, some of the other complications that you may see. And I see this quite often. Usually when you have too much drainage exuding from the wound bed, the first thing we talk about is is it infected? Is there biofilm? Is it a venous leg ulcer that's not being compressed? And so sometimes you degrade that granulation tissue if you have too much drainage. We get what we call hypergranulation tissue. And that's not a good sign, because that means that we have too much drainage and not doing an effective job. But lastly, what matters is that we're not able to decrease that wound size because we're not promoting the right amount of moisture level. So we talk about the wound being dry, but having too much drainage also is not conducive for the patients, because we're trying to get that right environment.

So optimal management with these wounds, especially venous leg ulcers, is very critical to promote healing. So compression therapy, you know, the rationale behind that is that we want to decrease the problem. And a lot of times we talk about this, name the baby, or find out what's the etiology. So if it's a true venous leg ulcer, then what test did we do to verify that? Because the problem with venous ulcers is that you have a venous hypertension. So when you apply external compression to a lower extremity, then you're applying appropriate compression. And so there's different techniques that we can use, but we have to make sure that the patient can tolerate it. Because in the old days, we used to say, multilayer, 4-layer is the way to go. And then sadly enough, over time, we heard some compressions better than none. But what I find is that the appropriate compression is what we need. 

And so another strategy is the dressings. There's so many dressings out there indicated for various levels. And so understanding the dressings and having some in your toolbox is key. And you may also want to think about, some people use antimicrobial dressings as well because sometimes they think that there's a local infection. We do also want to protect the area, the periwound skin. Earlier I said if we keep all this drainage on intact skin, we make it, we make the skin pruney, more likely to break down, the wound may get bigger, so there's barriers, ointments and films, that we can apply to protect the skin around it. Then when we talk about biofilm, the way to address that is we know that we need to wound debride. Wounds that are debrided, appropriate wounds that are debrided heal faster, and so that will decrease the bioburden as well. 

Now, getting to the etiology, I want to say that getting to the underlying cost is huge because, it may be, if it's a venous, you know, condition, maybe they need an ablation as well, but also if it's lymphedema, it may be that you need to see somebody with complete decongestive therapy to be a whole package. You need to manage that edema, but the fact that a lot of times patients are given diuretics just to control the swelling may not be appropriate. And I have to tell people that if they're taking diuretics for a systemic condition or cardiac condition, that's fine. But if you're using it just to remove swelling, then it may not be the most appropriate way to treat. And maintaining the optimal environment means that you want to have the right amount of moisture level. So you got to have the right dressing, but also I call it dating, because you have to know when to change that dressing, because it may be that the dressing is made for 7 days, but it may be that initially you have to change it a little more frequently. But when you add compression, you manage your exudate, because in the lymphedema world, as we teach it, what we're doing is, when we apply that external compression, then we're decreasing the amount of filtration that's happening in that capillary, meaning that we're shutting down that hose that's running wild.

And one more thing I want to say is that to manage conditions, sometimes we have to look at alternatives or other modalities. And so, we have negative pressure that people use to remove that drainage from the wound bed. But also I like to use topical oxygen therapy, because there's one company out there that provides noncontact cyclical compression, and that's been tested. And so we have to make sure that we think outside the box but never forget the other, the holistic approach. Nutrition is very important. A lot of patients are malnourished ,and so we don't have the right energy and the right amino acids to help our body heal, then it's going to be harder for us to manage even the dressing and the drainage and patient education. And so it's very comprehensive when we talk about managing patients, especially the exudate, but you have to look at the whole picture and assess on a regular basis.

Yes, and actually, that's a great question, because when you manage, when you're writing a treatment plan, it's going to be a multidisciplinary approach, because most patients have a lot of comorbidities, so you need a team of people. And some of the comorbidities that I can tell you is like peripheral arterial disease. We talked about it, there's no blood flow there to compress. Now, that's 1. Now, number 2, diabetes. This is a population that has a hard time healing because either they have a high likelihood of getting soft or hard tissue infections, but also they experience lack of blood flow, microvascular, and so these patients, you’ve got to be very careful. Heart failure, we have to make sure that the patients are being treated by a cardiovascular surgeon or their provider, because it may be that they do need certain medications before we can compress. Renal disease is another one, because these patients may retain a lot of fluids, so we have to work collaboratively with or providers that are addressing the renal section of it. Obesity. Obesity is another thing that we have to consider because a lot of our patients are obese, but a lot of them sleep in their recliner chair, which is not conducive to managing the dressing or actually the exudate. And so we have to make sure that we address those, because a lot of the patients that have a hard time healing are usually the ones that have these comorbidities. 

So, as far as other things to look for, would be medications. There's certain medications that promote swelling, and if you have swelling, like a hose that has a little hole and you have a spigot open and you have a nozzle on the other side, it's going to keep leaking. And so we have to make sure that we look at medications together. And of course, there's a lot more, but the one thing I will say, and I was touched by one of the patients we treated, is to also consider their psychosocial consideration, because a lot of times these people don't want to leave the house. They have drainage, they smell, they have to stop working. And there's one patient in particular, she wanted to take her life because she was so embarrassed. And she was my age. And so, and of course, you know, I'm pretty young. So, the other consideration is the mobility factor and functional level, lifestyle. This is where the therapy component can come in, because all these things matter, especially to control drainage. 

So, as we're talking about managing exudate, the one key I will say is let's just get to the bottom of the bottom problem. What's the etiology of what's causing this? And make sure that we learn how to apply dressings and compressions properly. Because compression is key in managing exudate, especially with our venous leg ulcers and patients with lymphedema.