Towards a consensus on wound therapy

Professor Norbert Runkel, chairman of the International Negative Pressure Wound Therapy Expert Panel, speaks to MATTHEW BAILEY on why the time is right to seek a consensus on negative pressure wound therapy.

Currently, there is a lack of consensus on negative pressure wound therapy (NPWT) – a report compiled by the International Negative Pressure Wound Therapy Expert Panel recently pointed out that much remains unknown about its mode of action and how to integrate it with other techniques in order to obtain the best results. The evidence is patchy and does not extend to all wound types, while published studies on the subject have proven inconclusive. The one fact that clinicians seem to agree on is that more research is needed. However, practitioners on the frontline of wound care have been using NPWT techniques for over a decade now, for certain chronic, acute and surgical wounds, and many report significant improvements in wound healing. In view of this, an international NPWT expert panel recently met in Hamburg with the aim of closing the gap between reported experiences in the field and the published perception of NPWT, by achieving a global consensus on the technique. The meeting in Hamburg brought together surgeons and wound specialists from across the globe – including an expert panel of 22 clinicians from 17 countries, headed by Professor Norbert Runkel, professor of surgery and chairman of the department of general surgery at the Black Forrest Hospital in Villingen Schwenningen, Germany. All the members are recognised leaders in their fields who use negative pressure wound therapy extensively in their clinical practice. In addition to this not inconsiderable expertise and experience, the expert panel was joined by another 500 clinical delegates from 22 countries. “We convened such a large meeting so that we could draw from the global clinical experience with NPWT and form comprehensive consensus recommendations on the use of NPWT across a range of clinical applications,” said Prof. Runkel. “In Europe there is a prevalence of wounds caused by the ulcers common with chronic conditions like diabetes, while experts with experience in regions like South Africa and Afghanistan see a different range of traumas caused perhaps by disease, low living standards and knife and gun injuries. We felt that it was very important to get a truly global perspective.” The clinical panel drafted recommendations by examining all available evidence. If published evidence was insufficient, the group drew on the extensive experience of the panellists’ identified best practices. These recommendations and best practices were then presented to the delegates and, after detailed discussion, the audience was asked to align themselves on one side or the other of the panel’s recommendations by voting.

Why we need consensus for NPWT

Negative pressure wound therapy has radically changed the way clinicians manage a wide range of wounds. Hundreds of papers have been published and there are a number of systematic reviews available. For most of the last ten years, NPWT was available in only one format and this made it difficult to undertake the rigorous scientific work that can lead to understanding of basic questions such as: Which wound filler is best for different wound types? What level of pressure is optimal for the desired outcome? In addition, when it is best to start and to stop the NPWT process? “The conclusions as to the overall effectiveness of NPWT are clearly conflicting, yet they come from the same evidence,” said Professor Runkel. “One study concluded that there is little evidence to support its use, while another concluded that there are some worthwhile indications; a third said that the literature to support NPWT is overwhelmingly positive.” “We surveyed the delegates before they arrived in Hamburg,” continued Prof. Runkel. “They were mainly surgeons and nurses with six or more years’ experience with NPWT. More than 50% believe there is much more to learn about the practice. Regarding the wound interface, we can see that utilisation varies widely across the several different interfaces that are now commonly used. More than 60% said that ideal pressure varied depending on the type of wound.” Adoption of negative pressure wound therapy has been driven largely by favourable individual clinical experience rather than by scientific understanding. The anecdotal evidence coming back from practice was overwhelmingly favourable, Prof. Runkel explained, but there was little or no scientific data to back up the positive feedback. “We lack data, but thousands of doctors say that the technique has benefited millions of patients,” Prof. Runkel commented. “There is now a diverse range of products available to us. While the greater choice of NPWT products allows us to more freely exercise our clinical judgement, we must also recognise that more choice may also create greater uncertainty in the clinical community. “This also gives us an opportunity to undertake the kind of rigorous scientific examination of NPWT that has been lacking for many years. This is a good time to begin a process of examining the body of available research on NPWT and move forward towards comprehensive, evidence-based recommendations for its use; and where the evidence may be insufficient, to seek firm recommendations to identify best practices from the collective experience of the global clinical community.”

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