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Pages S41-S46 of Methods of Treatment
Indications: Patients with threatened skin breakdown (mottling, absent capillary refill etc.) may temporarily benefit from topical oxygen. The superficial skin does breathe and the therapy may prolong the life of the skin envelope. Additional time is, thus, gained to allow for revascularization with boot therapy or other methods.
Application technique: We wash the foot gently first with mild soap and water to remove skin debris, dirt, caked blood or drainage. We then soak the foot in multielectrolyte solution (Sea Soaks) containing 40 mg gentamicin per liter to reduce skin bacteria flora and to hydrate the skin. Then the foot is loosely wrapped with a single layer of sterile gauze to prevent the plastic air bag from sticking anywhere to the skin. A nasal oxygen catheter is placed around the foot with the nasal prongs under the arch of the foot and directed towards the toes. A thin clean plastic bag is then placed over the foot and ankle; this bag will contain the oxygen around the foot. The plastic bag is contoured against the foot by wrapping gauze around it loosely from the toes to the ankle. The portions of the plastic bag reaching the calf are rolled down and bunched up behind the Achilles tendon where the “contour gauze wrap” is also used to hold it in place thus providing a soft pad over the tendon to keep the heel off of the bed. The gauze is gently taped as necessary to prevent its coming apart. A flow of oxygen at one liter a minute is then started through the nasal catheter. It there appears to be drying of the skin, the oxygen source is bubbled through sterile water to fully saturate the oxygen stream with water.
Results and warnings: Previously mottled and deep blue skin may appear relatively normal for several minutes after the oxygen bag is removed. A visiting consultant unfamiliar with the technique may mistakenly underestimate the severity of the ischemic process if he/she does not wait those several minutes. The foot can be smothered and damaged if the oxygen stream is interrupted while the plastic bag is in place. The patient and attending nurses need to be made aware of this possibility.
| Patient Position | Gravity | Boot | Indications |
| Supine | 0 | Long | ASHD, lymphedema, stasis, diffuse ASO |
| Reverse Trendelenburg | 17% | Long | CHF, severe diffuse ASO |
| Sitting, legs horizontal | 33% | Long | All of above |
| Sitting on edge of chair, legs slanted | 67% | Long | Severe ASO, unable to tolerate above |
| Sitting, vertical tibia | 67% | Miniboot | ASO below the knee |
| Standing | 100% | Miniboot | Rare, severe ASO and able to stand |
| Choice of Compression Bags | Area Covered | Indications |
| Miniboot bag | Toe-to-ankle | Small arterial disease limited to foot |
| Miniboot bag | Toe-to-knee | ASO below the knee, antibiotic injections into foot, antibiotic solutions within the Miniboot |
| Sleeve | Groin-to-ankle | Diffuse ASO throughout leg with painful foot |
| Sleeve | Groin-to-midfoot | Diffuse ASO throughout leg with painful distal foot and toes |
| Full Bag | Groin-to-toes | ASHD, CHF, lymphedema, diffuse ASO, stasis disease that includes both calf and thigh |
| Full bag | Knee-to-toes | Stasis disease of calf and ankle |
| Monitor Settings | Indications |
| Internal clock (adjustable rate independent of EKG) | Ischemic pain associated with severe iliac disease or associated with a rapid irregular pulse. Those with iliac disease might be given 10 to 20 full leg compressions per minute, each compression 0.40 to 0.45 second. |
| Patient EKG - Computer Pacer | Preferred mode. Monitor computer continually averages the last ten RR intervals, uses a formula to predict the duration of the next RR interval, deducts 0.04 seconds from the predicted RR interval to maximize the ventricular cardiac-assist action of the booting, and sets a delay time with each beat accordingly. |
| Patient EKG - manual adjustment of delay time | Both the "delay time" and the "compression time" are set by the technician. The sum of the two equals the RR interval, which, divided by 60, gives the pulse rate per minute. |
| Compression time - duration of boot | Long enough to overcome the inertia of the fluids in the vascular channels: 0.34 second in the Miniboot and 0.40 to 0.45 second in the Long Boots. |
| Delay time | Automatically set in preferred mode (above) or manually set to equal the RR interval minus the compression time, thus placing the compression time in the end-diastolic period. |
| Divide QRS by | 1:1 setting (compressing the leg after each QRS complex) used in those with moderate arterial insufficiency of the leg or those with lymphedema, ASHD or stasis disease. Used in Miniboot patients with slow pulse rates (eg, <60). 1:2 setting (compressing the leg after every other QRS complex) used in long-boot patients who have more advanced arteriosclerosis and who develop pain on the 1:1 mode. Also used in most Miniboot patients. 1:3 setting (compressing the leg after every 3rd heartbeat) used in patients with rapid heart rates and ischemic disease who develop ischemic pain on the 1:2 setting. |
Lymphedema: Case 1: Patient RP was a 74 year old white male with a 40 year history of lymphedema in both legs. He had consulted many doctors to arrive at his therapy on presentation: thyroid replacement, furosemide 40 mg daily, Hygroton 50gm daily and support stockings. During the intervening years, he had prostate and thyroid surgery along with a vasectomy, none of the procedures having an effect on his lymphedema. Normal studies before his boot therapy included a CAT scan of the abdomen and arterial and venous flow studies. His leg circumferences before and after eight outpatient treatments delivered to his right leg only are given in Table VIII. As both legs were swollen up to the groin and the right leg was slightly larger than the left, it was hypothesized that he had lymphatic obstruction above the groin that was more prominent on the right and that the swelling of the distal leg was secondary to the proximal obstruction. A full bag extending from the toes to the groin was used to pump his leg with 30 inches of water pressure after each heartbeat. This approach was chosen to send a fluid pulse, much like a water-hammer, into his pelvic lymphatics from his leg. Over the course of his eight treatments, perhaps 25,600 such compressions were delivered. Both legs decreased in size. The benefit lasted for two years when he again returned for a few treatments.
| Leg circumference | Six inches above patella | Midcalf | Ankle |
| Right | 22.5 to 22.1 | 18.0 to 16.2 | 13.1 to 11.3 | Left | 22.3 to 21.1 | 17.2 to 16.0 | 12.5 to 11.5 |
Case 2: Patient SG had been an iceman for many years. He presented at age 68 with a history of leg swelling since his teens. He was rejected by the armed forces because of the swelling and a leg ulcer. He had seen many physicians over the years for his swelling and had settled on the simple use of support stockings. A venogram and a CAT scan of his abdomen were found to be normal by his last consultant. At the time of referral for boot therapy, his legs were leaking fluid and he had a chronic cellulitis of his left lateral calf; he was taking tetracycline, coumadin and furosemide. It was hypothesized that his major lymphatic obstruction was in his left leg as the circumference of his left upper thigh was one inch greater than the right. To avoid pumping an excessive amount of fluid too quickly from his legs, only his left leg was treated. He received full leg compressions after each heartbeat diuresing with each treatment. The circumference of his left calf decreased from 16 to 14.75 inches and his right calf from 13.75 to 13.25 inches. His legs were softened by the treatments and his previously absent venous respiratory variation by Doppler was restored. His cellulitis disappeared. He was advised to get a Jobst compression boot for home use for maintenance therapy. His leg did well over the next year when he was discovered to have a histolytic lymphoma. It was hard to relate the latter to his 50 year history of lymphedema.
Comments: (1) We make an effort to guess the pathophysiology of the lymphedema and force fluid through the obstructed area, occasionally effecting a “cure”. Swelling below the obstructed area is viewed as a secondary event not to be primarily addressed. Pumping on the foot, for example, has but a remote effect on obstructions in the pelvis.
To help understand the multiple effects of boot therapy on peripheral arterial blood flow, the reader is invited to follow the evolution of a formula for blood flow following each commentary section.
I. Effective Blood Flow = f (variables) / interstitial fluid pressure or EBF = f (V) / IFP
Venous Stasis Disease: Patient RD had diverticulitis and an intestinal perforation in 1968, subsequent pulmonary emboli and a caval ligation. Venous stasis disease developed and, in 1980, he developed his first indolent ulcer having hit his right foot with a stick. The ulcer healed. Then the left supramalleolar area was traumatized in an automobile accident and also ulcerated; this too healed. In early 1983 the supra-malleolar ulcer in his right leg spontaneously recurred and persisted in spite of various outpatient treatments (rest, whirlpool, vitamin E, betadine, peroxide and diuretics) and a 24-day hospitalization that included whirlpool, intravenous antibiotics and hyperbaric oxygen treatments. He was referred by his vascular surgeon for boot therapy (Figure 1).
(2) The leg is frequently softened by the rapid compressions and massaging effect of our therapy when it is not so softened by slower acting boots.
(3) These patients are most successfully treated early in their course when swelling follows events like broken hips.
(4) Long-standing lymphedema associated with fibrotic changes in the tissues responds less well; the fluid may be partially reduced but the fibrotic tissue does not disappear at least over a few months therapy.
(5) Therapy reduces interstitial fluid pressure and softens the leg; after therapy pulse volume measurements at the calf are increased even in normal subjects.
(6) Our lymphedema population was been relatively small and spread out over time making formal studies of the problem difficult. Such studies might best be made as part of a multi-institutional group.
 Figure 1. Patient RD: Medial and Lateral Aspect of Right Leg on Presentation. |
Pseudomonas aeruginosa, Enterococci and Beta streptococci (group B) were cultured from his ulcers. Wet-to-dry dressings with 1/2% neomycin in multi-electrolyte solution (Sea Soaks) were applied over his lesions and his legs were pumped in the Long-Boots from toes to groin after each heartbeat. He received 26 treatments over the next three months and healed.
He returned a year later for four treatments because of a small ulcer on the right calf. His right leg did well but the left leg broke down four years later bringing him in again for treatment (Figure 2).
 Figure 2. Patient RD was seen on follow-up a year later and was found to have a new ulcer on the opposite leg which had not been treated. |
The left leg responded to wet-to-dry dressings with Tobramycin in Sea Soaks and Long-Boot treatments. Over the next few years his legs did well in spite of various illnesses including prostate cancer, bladder biopsy, transurethral prostatic resection and removal of a parathyroid adenoma.
Comment: Patients with stasis disease are advised that they have a chronic problem and must pursue a common sense approach to their disease: avoid quiet standing, elevate the legs when possible and wear appropriate support leggings or stockings. We prefer CircAide leggings because they have Velcro tongues allowing daily individual adjustments and ease of application and because they are inelastic and do not stretch during the day. (CircAid Medical Products, Inc. 9323 Chesapeake Drive, Suite B1, San Diego, CA 92123). In general, we are able to heal cooperative and mentally-oriented patients as outpatients. Oral antibiotics and antibiotic solutions in wet-to-dry dressings are used regularly in patients with painful draining ulcers. Transcutaneous PO2 measurements are commonly low in the indurated areas next to such ulcers and rise with boot therapy as the tissue is softened and swelling reduced. Local pain and induration along with a return to a low transcutaneous PO2 reading suggest imminent formation of a new ulcer; such findings are considered an indication to restart boot therapy as it is easier to maintain the skin than it is to heal it. If prolonged pneumatic boot therapy is indicated, we recommend they consider home use of other simpler pneumatic boots. Some of our patients have had no success in healing their ulcers with other boots and purchased a long Circulator Boot for home use.
II. Effective blood flow = f (variables) / venous pressure or EFB = f (V) / VP
or together with “I”: EFB=f(V) / (VP)(IFP)
Pages S46-S48 of Methods of Treatment.
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