Compression bandages

When should I choose a compression bandage instead of a compression stocking?

  • As a rule of thumb: when treating a patient with a leg ulcer, it will often be impractical to use compression stockings since the stocking has to be pulled over a wound dressing. Due to exudate, the stocking may also get soiled. In most cases with leg ulcers, compression bandages are used because of this.

  • A compression stocking can be a good alternative in cases with minor leg ulcers.

  • If you have a patient you plan on starting with compression stockings; it is usually a good idea to start with a compression bandage first. In this way, you can easier adjust the compression level, beginning the first days slowly and gradually increasing the intensity. After a week or so, the patient hopefully has become accustomed to the idea of compression and will more likely find it acceptable to go with a compression stocking. Also - if you use this approach, the level of edema should already have decreased by the time the patient purchases the stockings, and they will fit better. If you send a patient off to buy stockings without prior bandaging, the stockings will no longer fit correctly once the edema has subsided.

  • Compression stockings are costly and have to be renewed after some months. Compression bandages may be a cheaper alternative for the patient, especially if they are of the type that can be washed.

  • Sometimes it comes down to patient preference. We have patients that do not like using compression stockings for various reasons and prefer using a bandage over years instead.

 

Which type of compression bandage should I use? Short elastic or long elastic? Should it be a 2-,4-or even six-layer bandage? Should I apply it circular around the leg or in a fishbone pattern?

We purposely made the title above long and confusing- because, in reality, these are the choices you are facing if you have all resources available. Suppose you are working in a health care setting where you are lucky if you have some bandage at all; you will not have to make most of these decisions.

 

For the sake of argument, let us assume that you are working somewhere where you have all sorts of bandages available - what will you choose?  Compression treatment has been a messy subject for many years because the information we, as wound care practitioners, received was often downright confusing and sometimes contradictory.  This confusion has led to insecurity and resignation among healthcare workers. One of the biggest challenges in wound care is teaching colleagues how to apply a safe and effective compression bandage.

What does it mean when we say, for example, a 2- or 4- layer bandage? What are the different layers? In modern compression treatment, we should always use a comfort layer directly in contact with the skin. This is the first layer. It can be a cotton stockinette, cotton wool on a roll, or a particular type of thin foam on a roll.  The idea of the first layer is simply to protect the skin better and make it more comfortable for the patient to use compression. Layers 2,3,4.....8 are the elastic compression bandage. It is not more complicated than that. For most situations in wound care, a 2-layered compression bandage is sufficient. Putting on more layers with a compression bandage is usually something you do when treating lymphedema or other forms of severe edema.

If every wound care worker in the world could apply a 2- layered compression bandage safely, we would have come a long way in wound care globally. Sadly this is not the case, and in our practice, we see many hopeless examples of how a compression bandage should not be applied. 

 

It is now an international consensus that two-layer, short elastic bandages are the treatment of choice for most patients.  Yes, there will be exceptions to this recommendation - for example, lymphoedema or severe edema of the lower extremities where four layers are better. Again, if you become an expert at mastering the simple two-layered compression bandage, you will be able to handle also quite complicated cases.

Remember: the first layer ( inner layer of the compression bandage) is something that has a slight cushioning effect (comfort layer). This may be a roll of very thin foam or cotton wool roll. This comfort layer should NOT be applied tightly. If you do not have a comfort layer available, you could use a long woolen sock. The second layer is the elastic bandage, which gives compression.

 

If you have a standard cheap compression bandage, it is advisable to apply this in a fishbone pattern as this gives a more even distribution of the compression and holds better.  The modern self-adhesive compression bandages are more " idiot-safe" ( we apologize if anyone is insulted by this term, but we really want to get this point across) and can be applied in a simple circular pattern.  

Can patients with poor arterial circulation be treated with compression bandages?

 

The answer is: only if you know what you are doing. In theory, all patients with venous ulcers with an arterial component (so-called mixed ulcer or venous-arterial ulcer) need compression therapy. The edema that comes with venous insufficiency compromises the small blood vessels in the subcutaneous layers. Also, tissue with edema may have increased oxygen requirements. Today, the theory is that compression treatment can also improve arterial circulation.  Think of it this way - when you help the oxygen-poor venous blood flow back to the heart with compression treatment, oxygen-rich arterial blood can more easily find its way to the leg/foot. 

However, you can end up with a catastrophe (read amputation) if you simply apply a compression bandage to a patient with poor arterial circulation in the foot. In any case, you have to have some formal training on using a safe compression bandage, and this should always be done with great care in patients with poor arterial circulation. If you have little experience, it is safer for the patient to go without compression treatment.

Ideally, you should have access to a doppler device to measure the ankle-brachial index (ABI) before using compression treatment in a patient with poor arterial circulation.  If the patient has an ABI <8, you should apply the compression with great care and choose a less intense compression, closely monitoring the patient. If available, you should use the compression bandages marked as "LITE" - these have a lower compression intensity and are generally accepted down to an ABI of >0,5.  Compression should not be used in patients with an ABI <, 0,5. 

Should the compression bandage go up to the knee or the thigh?

In general, the compression effect will be best if the compression bandage is applied up to the upper parts of the thigh.  However, you will have trouble keeping the bandage up there - it will often start to roll downwards after the first day. In most circumstances, it is sufficient to apply the bandage from the roots of the toes to just below the knee.  We would come quite far in global wound care if everybody mastered this simple technique. Sadly this is not the case. 

In cases with pronounced edema like lymphedema, it is advisable to take the compression bandage as high as possible and instruct the patient to adjust the bandage many times daily when it starts to roll down in the upper parts of the thigh. 

How tight should I apply the compression bandage?

Ideally, a compression bandage should have 30-40 mmHg at the lower end of the foot, gradually decreasing this proximally ( approx. 20 mmHg at the top).  How can you know if you have the correct pressure? This is a thing of experience.  If you are inexperienced, start with weaker compression to ensure that you are not overtightening. Some bandages have indicators printed on them that change shape as you stretch the bandage, helping you to find the correct tension.  If you have all the resources available, you could invest in a gadget that can measure how tight you are applying the bandage.  The pressure is read off a digital gauge. Once you are happy with the bandage, you simply pull out the pressure gauge.  Kikuhime is probably the most known producer of such an aid.  If you work in a bigger institution or are involved in teaching compression bandaging, this may be a sound investment. If you are engaged in research on compression treatment, such a device may be decisive for achieving consistent results. 

The modern self-adhesive 2-layer compression bandages are more " forgiving" than simpler bandages, and a compression gradient from toes upwards is not as crucial. If you follow the instructions from the producer closely, you will generally achieve consistent results with these modern bandages.  They are, however, much more expensive than regular compression bandages.  

However, the most crucial factor is that the compression should be comfortable for the patient!  Never start a new patient with full compression! You could harm the patient and most likely cause the patient to hate compression treatment. Adapt the level of compression to their pain levels. We usually start a new patient with about half of the ideal compression level. After a few days, we can gradually increase the compression intensity if the patient gets used to it. Maybe your patient will never tolerate a full compression with 30-40mmHg, and you may have to accept that they use only half this intensity.  Remember the rule: some compression is better than none!  We recently came across a comment in a discussion on Facebook where someone wrote that compression below 30-40mmHg was no point - that you might as well use nothing. This is utter nonsense - some compression is better than none- remember that for always!

Which brand of compression bandage should I use?

As we mentioned above - the ideal compression bandage for most situations is a modern 2-layer self-adhesive compression bandage.  These are pretty expensive, and for most patients in Africa, they will simply not be an option. These patients will be lucky if they have any compression bandages available at all.

 

For the sake of argument, let us assume that you have all resources available - what is the best compression bandage? There are many producers of these types of bandages available, and each one of these producers has reasonable arguments for why their specific product is best. Often they will claim that the competitor's bandage will not hold as well and have a tendency to roll downwards after a few days. In the images below, we show the most common compression bandages used in Europe - the leading producers here are 3M (Coban), Smith& Nephew (Profore), and Jobst (Comprifore).  We have tested all these bandages with excellent results. It all comes down to price and how willing the distributors are to hold courses on how to apply these bandages.

Again, if you have a really tight budget, these types of bandages will not be available to you, and you must manage with cheaper options. Remember that we were able to administer effective compression treatment also before the modern self-adhesive bandages appeared on the market.  Regular compression bandages just require some more skill to apply and may have a higher tendency to roll down. 

Figure 1 Some of the leading brands of modern self-adhesive, short-elastic compression bandages in Europe.