Patent Application
20080208147
The present invention relates generally to an apparatus and method for treating tissue using time-varying sub-atmospheric pressure, and more particularly, but not exclusively, to an apparatus and method for treating wounds using sinusoidally varying sub-atmospheric pressure.
The field of medicine has long been concerned with healing tissue damage such as that which may be brought on by disease or trauma. Numerous treatment modalities have been introduced over the years, including more recently the development of wound treatment through the use of negative (or sub-atmospheric) pressure, pioneered by Drs. Argenta and Morykwas and set forth in U.S. Pat. Nos. 5,645,081 and 5,636,643, as well as US Published Application Nos. 2003/0225347, 2004/0039391, and 2004/0122434, the contents of which are incorporated herein by reference. Although the application of either continuous or intermittent negative pressure wound therapy as specified in the aforementioned patents demonstrates an increased rate of healing as compared to traditional methods, an enduring goal of medical treatment remains healing of wounded or damaged tissue as quickly as possible. Consequently, there remains a need in the field of medicine for devices and techniques that expedite the healing of injured or wounded tissue.
In accordance with the present invention, a tissue treatment apparatus is provided for treating tissue by application of time-varying sub-atmospheric pressure. Tissues that may be treated by the apparatus of the present invention include wounded tissues, such as those present in chronic wounds, acute wounds, open wounds, closed wounds, and so forth, for example. Such wounds may be created by a variety of causes, such as trauma, disease, thermal injury (e.g., bums or hypothermia), surgical complications, and other factors.
In order to administer sub-atmospheric pressure treatment to damaged or wounded tissue, the apparatus of the present invention includes a cover adapted to cover a wound and adapted to maintain sub-atmospheric pressure at the site of the wound. The cover may be conveniently provided in the form of a flexible sheet or drape capable of conforming to tissue surrounding the wound. Alternatively, the cover may be provided in the form of a rigid or semi-rigid structure capable of supporting itself out of contact with the tissue to be treated. The apparatus also includes a seal configured to seal the cover to tissue surrounding the wound, so that the sealed cover provides an enclosure above the wound in which sub-atmospheric pressure may be maintained. Optionally, the apparatus may include a screen disposed between the cover and the wound for promoting the distribution of sub-atmospheric pressure under the cover and/or stimulating growth of tissue at the wound site. The apparatus further includes a source of suction configured to generate a time-varying sub-atmospheric pressure having a periodic or other variable increasing and/or decreasing waveform comprising a gradual change in pressure. The suction source cooperates with the cover to supply the time-varying sub-atmospheric pressure under the cover to the wound. The cooperation between the cover and the suction source may be provided in the form of a tube that communicates via a port in the cover to deliver the periodic time-varying sub-atmospheric pressure under the cover.
In an additional aspect of the present invention, the time-varying sub-atmospheric pressure may desirably vary between a first pressure value below the inherent tissue tension of the wound tissue and a second pressure value above the inherent tissue tension of the wound tissue. Such a variation can provide gross deformation of the wound margin, which may accelerate tissue growth. For example, the time-varying sub-atmospheric pressure may have a minimum value of 25 mm Hg below atmospheric pressure and a maximum value of 100 mm Hg below atmospheric pressure.
In addition, the present invention provides a method for administering sub-atmospheric pressure to a wound. The method includes covering a wound with a wound cover configured to maintain sub-atmospheric pressure at the site of the wound. The cover is then sealed to tissue surrounding the wound to provide an enclosure for maintaining sub-atmospheric pressure under the cover about the wound. A time-varying sub-atmospheric pressure is then applied under the cover to the wound, where the sub-atmospheric pressure has a periodic or other variable increasing and/or decreasing waveform comprising a gradual change in pressure.
The foregoing summary and the following detailed description of the preferred embodiments of the present invention will be further understood when read in conjunction with the appended drawings, in which:
Referring now to the figures, wherein like elements are numbered alike throughout, a sub-atmospheric treatment apparatus, generally designated 100, is provided for applying a sub-atmospheric pressure comprising a gradual change in pressure to a tissue to be treated,
To administer a gradually changing sub-atmospheric pressure 310, 320, 330, 340 to tissue to be treated, such as a wound 40, the apparatus of the present invention includes a cover 10 for placement over the wound 40 to provide an environment about the wound 40 in which sub-atmospheric pressure may be maintained. An optional screen 20 may be provided under the cover 10 over the wound 40 to assist in the healing of the wound tissue. Sub-atmospheric pressure may be delivered under the cover 10 via a tube 30, which communicates at one end with the space under the cover 10 and at the other end with a suction source 50. The suction source 50 generates a sub-atmospheric pressure having a gradual change in pressure, which desirably has a periodic waveform. In this regard, the suction source 50 may comprise a waveform controller 60 for generating a sub-atmospheric pressure waveform.
Turning now to the figures in more detail,
To provide an enclosure under the cover 10 in which sub-atmospheric pressure may be maintained, the cover 10 may be sealed to tissue surrounding the wound using an adhesive. For example, if a self-adhesive flexible sheet or surgical drape is used as the cover 10, the adhesive backing may be secured to the tissue surrounding the wound 40 to provide a seal about the wound 40. Instead, if a non-adhesive cover 10 is used, a separately applied adhesive or other suitable material may be used to secure the cover 10 to the treatment site 90 to provide an enclosure about the wound 40 in which sub-atmospheric pressure may be maintained. Still further, for a rigid or semi rigid cover 10, the seal may be provided by cooperation between an edge of the cover contacting the treatment site 90 and the action of sub-atmospheric pressure under the cover 10 to create sealing contact between the cover edge and the treatment site 90.
An optional screen 20 may be provided between the cover 10 and the wound surface 46 to provide various functions, such as preventing the cover 10 from contact in the wound surface 46, promoting even distribution of sub-atmospheric pressure under the cover 10, assisting in drawing of liquid away from the wound surface 46, stimulating growth of tissue (e.g., granulation tissue) at the wound surface 46, and preventing loculation of the wound 40, for example. In this regard, the screen may comprise a variety of materials such as a synthetic polymer material, open-cell polymer foam, a non-adherent material, a polymer mesh, and combinations thereof, for example. The composition and structural properties, such as reticulation, for example, are selected with regard to the function(s) to be provided by the screen 20. For instance, the degree of reticulation (or porosity) of the screen 20 may be selected to deter growth of tissue within the screen 20. Conversely, the degree of reticulation of the screen 20 may be selected to promote tissue growth therein, which may be particularly desirable if the screen 20 comprises a bio-absorbable material.
The screen 20 may be provided as a unitary structure or as a composite of separate components assembled upon application to the tissue to be treated. Exemplary materials that may be used for the screen 20, alone or in combination with other materials, include V.A.C.® GranuFoam® and V.A.C.® WhiteFoam™ dressings (Kinetic Concepts Inc, San Antonio, Tex.), Prolene® Mesh (New Brunswick, N.J.), and the like. Exemplary non-adherent materials that may be used for the screen 20, alone or in combination with other materials, include Aquaphor® Gauze (Smith & Nephew, Largo, Fla.), Adaptic® Non-Adherent Dressing (New Brunswick, N.J.), and so forth. In addition, the non-adherent material may be provided as a coating disposed on or throughout the volume of the screen 20, such as an ointment, gel, natural or synthetic polymer, or other suitable materials. For example, the non-adherent material may be provided as part of the foam screen 20, either as a one-piece screen 20, with a non-adherent material integral to the screen 20, or as a two-piece screen 20, with the screen and a non-adherent material as separate pieces. Further, for the rigid or semi rigid cover 10 it may be desirable to draw the screen 20 taut across the opening of the cover 10 above the wound 40 and to optionally attach the screen 20 to the cover 10 to provide a barrier that impedes the growth of tissue into the cavity of the cover 10.
The screen 20 is desirably cut and shaped to fit into and fill the wound 40. As the wound 40 heals and becomes smaller in size, the size of the screen 20 may be decreased accordingly. The screen 20 may be held in place by contacting an adhesive coated under surface 12 of the cover 10 to assist in securing the screen 20 in a fixed position and to assist in the removal of the screen 20 when the cover 10 is removed. One particularly convenient configuration of cover 10 and screen 20 is the combination of a flexible self-adhesive polymer sheet or drape used in conjunction with an open-cell polymer foam.
Delivery of sub-atmospheric pressure to wound 40 may be provided via a tube 30, or other suitable structure, that gaseously communicates with the enclosure under the cover 10 via a port 36. The port 36 may comprise an edge of the cover 10 under which the tube 30 passes, such as a mesentery, for example, to communicate with the space under the cover 10. Alternatively, the port 36 may be provided as an opening, or a nipple, disposed at the surface of the cover 10, or other suitable structure. The distal end of the tube 32 disposed under the cover 10 may be located above or below the optional screen 20 or may be embedded within the screen 20. In addition to having an opening at the distal end 32, the tube 30 may be fenestrated along the portion of the tube 30 in communication with the enclosure under the cover 10 to deliver sub-atmospheric pressure along the fenestrated portion of the tube 30. For example, the tube 30 may comprise a Jackson-Pratt drain.
Sub-atmospheric pressure is provided to the wound 40 by a suction source 50 via the tube 30, which is in gaseous communication with the suction source 50 at the tube's proximal end 34. The suction source 50, which may comprise a vacuum pump, includes a waveform controller 60 for controlling the time-varying properties of the pressure waveform created by the suction source 50, so that the suction source 50 produces a time-varying sub-atmospheric pressure having a gradual change in pressure (a gradually changing sub-atmospheric pressure). Sub-atmospheric pressure having a gradual change in pressure is desirably provided in the form of a periodic, or cyclically-varying, waveform that is continuous over at least a portion of the period, T, of the waveform. For example, the gradually varying sub-atmospheric pressure may take the form of a sinusoidal waveform 310, a triangular waveform 320, a sawtooth waveform 330, or a digitized waveform, such as a digitized sinusoid 340, as illustrated in
In particular applications, it may be desirable that the maximum sub-atmospheric pressure, P2, and minimum sub-atmospheric pressure, P1, be selected to induce gross tissue deformation (e.g., radial inward and outward movement 44, 45 of the wound margin 42 as illustrated in
One such choice of minimum and maximum sub-atmospheric pressures P1, P2 for inducing gross tissue deformation are pressures that span the inherent tissue tension of the tissue or wound 40 to be treated. (Tissues have an inherent tension—if an incision is made the wound gapes open. Inherent tissue tension may be observed by the deformation of a circular defect into an elliptical shape after the tissue is removed. A mapping of these lines in humans is often referred to as ‘Langer Lines’.) If the maximum sub-atmospheric pressure P2 is sufficiently large, the maximum sub-atmospheric pressure P2 can provide a radial inwardly directed force that creates radially inward movement 44 of the wound margin 42. When such radially inward movement 44 is achieved, the value of the sub-atmospheric pressure is above the inherent tissue of the wound tissue. After the wound margin 42 has contracted inwardly due to the application of sub-atmospheric pressure, the wound margin 42 can relax and approach its original rest position if the minimum sub-atmospheric pressure P1 is sufficiently small (close to atmospheric pressure). In such a case, the time-varying sub-atmospheric pressure is said to vary between a first (minimum) pressure value P1 below the inherent tissue tension of the wound tissue and a second (maximum) pressure value P2 above the inherent tissue tension of the wound tissue. Thus, the cyclic variation in the sub-atmospheric pressure can create an accompanying cyclic radial inward and outward movement 44, 45 of the wound margin 42.
In addition to an apparatus as described above, the present invention provides a method for administering sub-atmospheric pressure to a wound 40. The method includes covering a wound 40 with a wound cover 10 configured to maintain sub-atmospheric pressure at the site of the wound 40, and sealing the cover 10 to tissue surrounding the wound 40 to provide an enclosure for maintaining sub-atmospheric pressure under the cover 10 about the wound 40. The method continues with the application of time-varying sub-atmospheric pressure under the cover 10 to the wound 40, where the sub-atmospheric pressure has a periodic waveform comprising a gradual change in pressure. The gradual change in pressure may extend over a portion of the period of the periodic waveform, or may extend over the full period of the periodic waveform. In addition, the time-varying sub-atmospheric pressure may vary between a first pressure value below the inherent tissue tension of the wound tissue and a second pressure value above the inherent tissue tension of the wound tissue.
A pilot study was performed on two pigs to compare the effects of sine wave application of sub-atmospheric pressure to continuous sub-atmospheric pressure, intermittent sub-atmospheric pressure, and wet-to-moist gauze dressings. The pigs were procured and allowed to acclimate to the new housing conditions for one week. The animals were transported to the operating room and the backs of the animals shaved and prepped for surgery. On the first animal four full thickness wounds, 5 cm in diameter and extending to the fascia covering the spine and deep back muscles, were created over the spine (midline). On the second animal, two pairs of wounds were created lateral to the spine, two on each side of the spine. One treatment was applied to each wound: 1) sine wave sub-atmospheric pressure varying from 50 mm Hg below atmospheric pressure to 150 mm Hg below atmospheric pressure; 2) continuous sub-atmospheric pressure at 125 mm Hg below atmospheric pressure; 3) intermittent sub-atmospheric pressure on for 5 minutes at 125 mm Hg below atmospheric pressure and off for 2 minutes(i.e., no sub-atmospheric pressure applied); and 4) wet-to-moist gauze dressings. The volume of the wounds was measured by taking alginate impressions, then submersing the cast impression into a water filled graduated cylinder. The volume of fluid displacement equaled the volume of the defect.
The first animal was euthanized after seven days as all wounds became infected. The second animal was treated for 10 days. It was noted for the first animal, prior to becoming infected, that the sine wave sub-atmospheric pressure treated wound appeared ‘grayish’ in color, perhaps due to the sub-atmospheric pressure level being too high (i. e., too far below atmospheric pressure). The sine wave sub-atmospheric pressure treated wounds produced new granulation tissue faster than the continuously treated wounds, but less rapidly than the intermittent sub-atmospheric pressure treated wounds. All three sub-atmospheric pressure applications caused formation of granulation tissue faster than wet-to-moist gauze dressing changes. It was also noted during the study that the wound edges of the intermittent sub-atmospheric pressure treated wounds grossly moved with each cycle of sub-atmospheric pressure application and cessation. The edges of the sine wave and continuous sub-atmospheric pressure treated wounds grossly moved only on initial application of the sub-atmospheric pressure. It was determined that the amplitude of the sine wave, even at the low end (i.e., end closest to atmospheric pressure, was too great (greater than the inherent tissue tension). It was concluded from this pilot study that a further study needed to be undertaken in which the level of sub-atmospheric pressure of the sine wave application should oscillate above and below the inherent tissue tension of full thickness pig skin.
In preparation for the second study, a test was conducted to determine the correlation between vacuum level and force. A 10 ml syringe was fixed vertically with the tip up and the plunger down. A tube was connected to the tip of the syringe, with the other end of the tube connected to a vacuum pump. The plunger was withdrawn. A predetermined sub-atmospheric pressure level was applied, which resulted in the
plunger being drawn into the barrel of the syringe. Weights were applied to the plunger until the plunger stopped moving. (Increased weight would have drawn the plunger back out of the barrel of the syringe.) A linear response was determined for sub-atmospheric pressure versus applied force (F=ma). The static friction of the system was measured by having the plunger fully inserted into the barrel of the syringe, then applying weights until the plunger started to move down. The static friction was subtracted from the measurements to determine the relationship between sub-atmospheric pressure and force. The resulting relationship between force in Newtons, F, and sub-atmospheric pressure in mm Hg, P, was found to be F=0.0214 P−0.1372. According to an article by Ksander, et al. (Plastic and Reconstructive Surgery, 59(3): 398-406, 1977), wounds created on the back (dorsal surface) of young swine require approximately 50 grams of force to grossly displace the edges of the wound (Ksander,
Six 25 kg white feeder swine were used as the animal models in this study. Each pig was acclimated to the environment for a full week before the study began. At the outset, each animal was sedated via intramuscular injection of a 10 ml ketamine, 2 ml acepromazine and 1 ml xylazine cocktail. Once sedated, the pig was transferred to the animal surgery suite, shaved, prepped for surgery and anesthetized with halothane and oxygen. Under sterile conditions two 5 cm diameter, circular, full-thickness wounds were created, 5 cm apart, on the animal's dorsal midline, extending down to the deep postural back muscles. A GranuFoam® sponge (Kinetic Concepts Inc, San Antonio, Tex.) was then cut into two circles of 5 cm diameter to fit the two wounds. Evacuation tubes were connected to each sponge and the whole area was draped with an Ioban® drape (3M Corporation, St. Paul, Minn.). A heavy plastic harness was then placed over the dressing, and two stockinette t-shirts were positioned over the harness, to stabilize dressings and tubing. The pig was then returned to its housing and one evacuation tube was connected to a V.A.C.® pump delivering 5 minute on/2 minute off intermittent square wave application of 100 mm Hg below atmospheric pressure and the other evacuation tube was connected to a vacuum pump delivering a sine wave application varying between 25 and 100 mm Hg below atmospheric pressure with a 60 second periodicity. The subjects were staggered such that if the square wave was applied to the front wound and sine wave applied to the back wound, then the next subject would have opposite application, to control for the influence of the wound's anatomic position on wound healing.
Daily dressing changes and volume measurements were made by making impressions of the wounds using Jeltrate® Alginate (DENTSPLY International, York, Pa.) impression material. The volume was measured by water displacement in a 100 ml graduated cylinder.
Data from six 25 kg white feeder swine demonstrate a 19% increase in the rate of granulation tissue formation in the sine wave sub-atmospheric pressure (mean rate 1.354 cc/day) when compared with square wave intermittent sub-atmospheric pressure (mean rate 1.141 cc/day) (p=0.12). If this data were extrapolated and compared with prior studies, then sine wave sub-atmospheric pressure demonstrates roughly 122% acceleration in granulation tissue formation when compared with standard moist gauze application to the wound bed. In addition to providing for an increased rate of healing as compared to intermittent sub-atmospheric pressure, sine wave sub-atmospheric pressure appears to reduce problems associated with air leaks. Sine wave sub-atmospheric pressure is thought to prevent air leaks, because the sub-atmospheric pressure is applied and removed more gradually. Further, unlike intermittent sub-atmospheric pressure, leaks may be deterred by providing a gradually varying pressure that does not return to atmospheric pressure during the pressure variation cycle.
These and other advantages of the present invention will be apparent to those skilled in the art from the foregoing specification. Accordingly, it will be recognized by those skilled in the art that changes or modifications may be made to the above-described embodiments without departing from the broad inventive concepts of the invention. It should therefore be understood that this invention is not limited to the particular embodiments described herein, but is intended to include all changes and modifications that are within the scope and spirit of the invention as set forth in the claims.
