Examining The Impact of NPWT and Biofilm in Wound Care

My name is Dr. Chris Barrett, I am a podiatrist for the past 30 years. And a little over 20 years ago I had an opportunity to kind of subspecialize, and we know podiatrists usually get involved with wound care, but I had an opportunity to not only get involved, but to manage others who have the same passion and get involved at wound care center administration, outpatient hospital based wound center administration, and treat patients with wounds. And I took that leap of faith, and that's the path I've been following for the last 20 years. It's been a wonderful ride, and right now I'm working in the Crozer Chester or Crozer Health System located in Chester, Pennsylvania. And I work in one of their satellite hospitals in Springfield, Pennsylvania, but I've been at that location for about 12 years.

Started my wound care career at the University Hospital in Philadelphia, Pennsylvania. And my passion now is, my focus is on especially diabetic foot care and limb preservation, but I really got involved with all specialists. So, I really got involved with treating wounds from head to toe, collaborating with other specialists, and that's really been exciting. So, I really focus on just the overall patient and healing wounds, and that's kind of what I hope to do for the remainder of my career.

When I started practice, like I said, I got involved in wound care in the last 20 years, and that's really when negative pressure, when you think about it, the idea of negative pressure came to the market in the late nineties and that's really when I started my private practice. So, really didn't know much about the technology because I'd already been out of training, and it wasn't until I started my wound care career a little over 20 years ago, that negative pressure at that point was established and I started to slowly become educated on the benefits of negative pressure wound therapy, and I've kind of taken those steps and now it's become an integral part of how I treat patients.

Obviously, negative pressure has grown. We have many more companies involved, the advancements that have been made in negative pressure, specialized dressings, disposable mechanical negative pressure, making it easier for ambulatory patients, and that's really what's opened it up for me, because I spend all of my time in an ambulatory capacity. So, I have to take care of patients that have lives, that have quality of life that they'd like to maintain. And thankfully there's been a really a manufacturer of negative pressure that really started the concept, and they've always expanded on their offerings to patients. So, focused on research, focused on bettering the modality, I've really worked with that company and I love their products and I've found that they've been such an incredible benefit to my patients. And so, negative pressure is kind of my go-to, and when I go out and talk to other folks and educate, it's usually the primary message, is how you can use that technology to save limbs and also to heal wounds and improve lives.

If we're going to focus just on DPMs, that means we're going to kind of look at diabetic foot. That's really where negative pressure started. Certainly, when you look at advancements in negative pressure, most of it, and honestly, most of it has been really focused on those patients in the hospital. So, we have things like, installation, we have specialized dressings, open abdomen, these are all things that are not really going to affect those with diabetic foot ulcers. I think, when it comes to expanding what's offered for the diabetic foot with negative pressure, I would say, offering the types of dressings that are really more for ambulatory patients, I'd mentioned disposable types of negative pressure that are portable and allow patients to maintain their quality of life, to go to church, to go out to dinner, that's really, to me, I can probably say when it comes to negative pressure, that was the point that really opened my eyes, that's when I really, I said that was the first true change that I saw in negative pressure.

Yes, there had been advancements in dressings for patients that I don't take care of in the hospital, but when it came to the ambulatory patient, that point when I was introduced to a disposable ambulatory type of negative pressure for someone who works in an outpatient ambulatory capacity, that really changed it for me. And that's really when I was able to incorporate negative pressure into my practice more aggressively as a podiatrist.

I would say, for really focusing on diabetic foot, they're really, I would say, most of the technology, look at the latest consensus, it's really focusing on installation and infected patients in the hospital. And we can use those technologies for the diabetic footprint when, my world is the outpatient ambulatory world, and when you get there, the offerings are pretty standardized.

Biofilm. Now we all know what biofilm is. When I started my wound care career 20 years ago, there was no mention of biofilm. So, what's happened now is, as the researchers have recognized how biofilm, which has been around for a very long time, when you have communities of microbes attaching to surfaces, that's certainly not unique to wound care. But wound care researchers started to realize that biofilm existed, not just superficially, but if you look at the evidence, 80% to a 100% of wounds that are stalled, certainly, in an ambulatory capacity are likely stalled because of biofilm. All of a sudden it comes to the forefront. And now you have manufacturers who are designing dressings, designing technologies to address biofilm. So, for me, once I knew that biofilm is really kind of the root cause of lot of the chronicity in our diabetic foot population, I started to pay attention to the research, pay attention to the guidelines, and really the guidelines, it's pretty simplistic.

We know that these communities of microbes are protected and the way that you affect biofilm is by disrupting it. And we know that debridement, which is something all podiatrists do, it's what we do in wound care. It's the basic, it's really the foundation. So, we just know that we have to do it better, more aggressively, and we have to do it, of all things, more frequently, because we know biofilm reforms very quickly within two to three days. So, if you recognize that concept of biofilm and how it works, that if you debrided more frequently, use the evidence, showing you that more frequent debridement equals better outcomes, faster healing. So, that's how I incorporate it into my practice is as a podiatrist and as a wound care healer, no matter where the wound is, we need to address it more frequently, debride more frequently, debride effectively. And then again, appropriate dressing choice. And that's, again, leads kind of to another conversation is, we know that if we disrupt, we will open up that window of opportunity to treat the wound. Now, how do you treat the wound?

I think that biofilm became such an important topic that manufacturers bring out a lot of product. Okay, now you have to weed through the product and find out which ones have real evidence and look at their research, look at how it fits in an ambulatory population. Because again, there's a lot of great products that I would love to have. But when you're working in a hospital outpatient department, we also have to get paid. We have to be get reimbursed. So, a lot of that kind of takes some of them away from us, but we want to make sure the products we're using are designed to be effective against the biofilm phenotype bacteria. So, we want to know, a lot of these products will tell you that they destroy biofilm, but we know that no product can completely deconstruct and destroy a biofilm. They're very effective at taking your debridement and you work towards disrupting some of that biofilm and exposing some of that bacteria, and then your quality intervention that's designed to affect biofilm bacteria, can then take the work you've done and be effective at preventing those bacteria from reforming biofilm.

So, there are some really interesting topical, I'm not going to get into product specific, but there are some good topical preparations out of microbials that are designed to be effective against the bacterial biofilm phenotypes. So they prevent these bacteria from reforming, if again, your interventions are done more frequently. And one of the most interesting technologies that's really come to market is fluorescence. Okay, so I think that technology was just so needed and it's available to us in the ambulatory world, and this allows us to evaluate the effectiveness of our debridement. So, we debride the wound and now we can fluoresce it with a handheld device. So, point of care, I think that type of device is really what's going to kind of flourish in the years coming because being able to get inflammation at the bedside, especially for bacteria, which is really bacteria and inflammation is a real driver of wound chronicity.

So, when we can do a debridement and fluoresce that wound that we just debrided and recognize when we've done a great job, or actually when we need to do a little bit better job, and we can use that point of care technology to guide our debridement and really to guide our care and to monitor our progress and the effectiveness of our progress, that kind of technology I think is the future. Bedside, getting instant inflammation, whether that's fluorescing or whether actually we have, Europe's had for many, many years kind of a dipstick test for proteases. It exists, it's there. It's not, I guess, dealing with some of the hurdles that we have to bring it here to this country. But in the same way we can measure proteases inflammation, which is again, a driver of really bacterial biofilm, but being able to measure bacterial levels, if we can do that more easily, I think again, that's kind of the future of where, at least, ambulatory wound care is going.