Negative Pressure Wound Therapy Use: Recommendations and Insights From a Middle Eastern Panel of Experts

ABSTRACT

The number of patients requiring wound care is increasing, placing a burden on healthcare institutions and clinicians. While negative pressure wound therapy (NPWT) use has become increasingly common, Middle East‐specific wound care guidelines are limited. An in‐person meeting was held in Dubai with 15 wound care experts to develop guidelines for NPWT and NPWT with instillation and dwell (NPWTi‐d) use for the Middle East. A literature search was performed using PubMed, Science Direct and Cochrane Reviews. Prior to the meeting, panel members reviewed literature and existing guidelines on NPWT and/or NPWTi‐d use. A wound management treatment algorithm was created. Patient and wound assessment at presentation and throughout the treatment plan was recommended. Primary closure was recommended for simple wounds, and NPWT use was suggested for complex wounds requiring wound bed preparation. NPWTi‐d use was advised when wound cleansing is required, if the patient is unsuitable for surgical debridement, or if surgical debridement is delayed. When NPWTi‐d is unavailable, panel members recommended NPWT. Panel members recommended NPWT for wound bed preparation and NPWTi‐d when wound cleansing is needed. These recommendations provide general guidance for NPWT and NPWTi‐d use and should be updated as more clinical evidence becomes available.

Summary.

• The number of patients requiring wound care is increasing, but region‐specific guidelines for negative pressure wound therapy (NPWT) use in the Middle East are limited.

• Fifteen wound care experts from across the Middle East convened to create a treatment algorithm for NPWT and NPWT with instillation and dwell (NPWTi‐d).

• For simple wounds, primary closure is preferred, with NPWT as a bolster for grafts or closed incision negative pressure therapy (ciNPT) for high‐risk surgical sites.

• For complex wounds, NPWT or NPWTi‐d is recommended for wound bed preparation, especially when surgical debridement is not possible or delayed.

• These recommendations serve as the initial framework for use across the Middle East and should be updated as more regional clinical evidence emerges.

1. Introduction

In the Middle East region, chronic wounds such as pressure injuries and diabetic foot wounds have an estimated prevalence of 12.8% and between 2.7% and 8.5%, respectively [1, 2]. Similarly, road traffic injuries, one of the most prevalent acute injuries in the Middle East and North Africa, have been estimated to affect 3.6 million people in 2017 [3]. With the number of patients requiring wound care growing, increasing numbers of health care providers (HCPs) are being tasked with providing wound care [4, 5, 6].

Available wound care products include simple dressings or more advanced therapies such as negative pressure wound therapy (NPWT) for use in both acute and chronic wounds. NPWT utilises subatmospheric pressure to draw wound edges together, remove exudate and infectious material, reduce edema, and promote perfusion and granulation tissue development (Table 1) [7, 8, 9]. In addition, compared to standard wound care dressings, the use of NPWT has been reported to reduce time to secondary wound closure and shorten hospital length of stay [10, 11, 12]. When used as a bolster for grafts, NPWT use was associated with increased graft take, reduced length of hospital stay, and decreased patient‐reported pain [13, 14, 15].

TABLE 1.

Mechanisms of action of negative pressure wound therapy with and without instillation.

Mechanisms of action	NPWT	NPWTi‐d
Draws wound edges together	X	X
Provides a moist wound healing environment	X	X
Promotes granulation tissue formation	X	X
Promotes perfusion	X	X
Removes fluid and infectious material	X	X
Reduces edema	X	X
Cleanses wounds		X
Dilutes and solubilizes infectious material and debris		X

Abbreviations: NPWT, negative pressure wound therapy; NPWTi‐d, negative pressure wound therapy with instillation and dwell.

NPWT with instillation and dwell (NPWTi‐d) is an evolution of traditional NPWT that uses the delivery of topical wound solutions and programmable dwell time to dilute and solubilise infectious materials and wound debris. The subsequent negative pressure cycle removes the instilled solution along with the solubilised wound debris and infectious materials providing wound cleansing in addition to the benefits of traditional NPWT [16]. NPWTi‐d use has been reported to increase granulation tissue development, provide wound cleansing, reduce the number of debridements and increase wound closure rates [17, 18, 19, 20].

As the demand for wound management is growing globally [21], many HCPs without wound care specialisation are increasingly asked to provide wound care services [4, 5, 6]. However, limited published evidence exists providing guidance for the use of NPWT and/or NPWTi‐d in the Middle East. An in‐person meeting with wound care experts was convened to develop guidelines for NPWT use with and without instillation.

2. Methods

2.1. Panel Selection and Meeting

Publication panel members were recruited for participation according to the following: (1) health care practitioners from across the Middle East region, (2) documented experience managing diverse wounds using NPWT systems, (3) prior history of peer‐reviewed publications and/or delivering oral presentations on the use of NPWT modalities and (4) an ability to participate in treatment algorithm development. Panellist inclusion criteria were generated by a steering committee comprised of industry personnel (Solventum Corporation, Maplewood, MN). Fifteen panellists were identified based on wound care experience and ability to participate in the meeting. Panel members included vascular surgeons (n = 2), a trauma surgeon (n = 1), general surgeons (n = 3) and plastic surgeons (n = 9). The in‐person meeting, hosted by industry (Solventum), was held on 24–25 May 2024 in Dubai, UAE. The meeting schedule included presentations on the use of NPWT (3M V.A.C. Therapy, Solventum Corporation, Maplewood, MN, USA) and NPWTi‐d (3M Veraflo Therapy, Solventum Corporation) along with discussion and development of a NPWT/NPWTi‐d use algorithm.

No formal consensus method was used to develop the panel member recommendations. Open discussion was held between the panel members for each recommendation statement. Any disagreements over treatment recommendations were mediated by the corresponding author until all panel members reached a consensus.

2.2. Negative Pressure Wound Therapy With and Without Instillation

NPWT and NPWTi‐d are advanced wound therapies that utilise negative pressure to help manage both acute and chronic wounds. NPWT uses subatmospheric pressure to draw the wound edges together, remove fluid and infectious material, and promote perfusion and granulation tissue development. NPWTi‐d utilises features of traditional NPWT with an added wound cleansing cycle where topical wound solutions are instilled into the wound bed and allowed to dwell for a user‐selected time before removal through the negative pressure cycle. The mechanisms of action for NPWT and NPWTi‐d are listed in Table 1.

2.3. Literature Search

A brief literature search was performed using PubMed, Science Direct, and Cochrane Reviews for peer‐reviewed articles published between January 2000 and April 2024. Keywords included ‘NPWT’, ‘negative pressure wound therapy’, ‘NPWTi’, ‘NPWTi‐d’, ‘negative pressure wound therapy with instillation’, ‘negative pressure wound therapy with instillation and dwell’, ‘topical negative pressure’, and ‘negative pressure therapy’. Abstracts, posters, and off‐topic articles were excluded. Existing published NPWT guidelines from around the world were also considered. Prior to the meeting, panel members received the meeting agenda and literature featuring the use of NPWT and/or NPWTi‐d along with previously published treatment recommendations for review.

For literature supporting the panel member recommendations, the use of region‐specific literature was prioritised; however, in the event that other clinical evidence sources were needed, peer‐reviewed literature, published within the last 10 years, in English, with a patient population of 10 or more was utilised. Where possible meta‐analyses, randomised controlled trials, or case/control studies were used.

2.4. Therapy Use Algorithm

The panel members split into two groups. Each group developed their own draft algorithm providing guidance on NPWT and NPWTi‐d use. The groups presented each algorithm to the rest of the panel members. Elements from each draft algorithm were combined to create the final algorithm. All panel members reviewed and approved the final algorithm.

3. Results and Discussion

3.1. Patient and Wound Assessment

Patient factors (i.e., age, tobacco use, diabetes, social and economic status and cultural influences) and wound characteristics (i.e., aetiology, duration, size, presence of infection) can affect wound complexity and healing (Table 2) [22, 23, 24, 25]. Panel members recommended that a thorough patient and wound assessment should be performed at presentation and throughout the treatment plan regardless of the complexity of wound type (Figure 1). This is supported by recent publications [26, 27]. Atkin et al. recommended that repeated patient and wound assessments be conducted throughout the wound care journey and should include laboratory parameters, appropriate imaging, patient medical and wound care history, along with an assessment of the patient and caregiver's ability to adhere to the care plan [26]. Additionally, Sibbald and colleagues recommended taking patient and family concerns into account when assessing the patient and the wound, and to monitor the rate of healing at regular intervals throughout treatment [27].

TABLE 2.

Patient factors and wound characteristics affecting wound healing.

Patient factors	Wound characteristics
Age	Aetiology
Nutrition	Location
Diabetes	Wound duration (i.e., acute/chronic)
Medication usage	Number of wounds
Tobacco use	Wound classification (i.e., diabetic foot/ulceration/grade)
Comorbidities	Wound size and depth
Social status	Amount of exudate
Economic status	Involvement of important structures
Religious/cultural influences	Presence of implants (i.e., prosthetics or mesh)
Education	Presence of contamination or infection
Treatment compliance	Devitalized tissue
Previous medical/surgical care	Necrosis
Undergoing palliative care	Oedema
Anaesthetic and surgical fitness	Neurologic and vascular status
	Injury severity

FIGURE 1.

Negative pressure wound therapy use algorithm. AWD, advanced wound dressing; ciNPT, closed incision negative pressure therapy; NPWT, negative pressure wound therapy; NPWTi‐d, negative pressure wound therapy with instillation and dwell.

Panel members noted that adequate nutrition, continuous management of underlying disease, and psychological support are also important when managing patient wound care regardless of wound complexity. Nutritional deficiency can affect wound healing by limiting the resources available for tissue and bone repair [23]. Nutritional supplementation tailored to the patient may provide the necessary building blocks needed for tissue and/or bone repair. Similarly, patient comorbidities can create barriers to wound healing. This can be due to defects in wound healing pathways caused by the disease itself or by the medications used to manage the underlying condition [22]. Continued management of contributing patient factors throughout the wound care treatment plan can help reduce potential barriers to healing in complex patients. Psychological stress can also complicate wound healing through biological pathways and the patient's social responses (i.e., anxiety, depression, isolation) [28]. By providing psychological support to the patient and caregivers, health care providers can offer an outlet for stress and increase patient/caregiver education, which may further reduce barriers to healing.

3.2. Simple Wounds and Panel Recommendations for Treatment

Wounds that are acute, non‐ischemic, clean, of small size, do not affect delicate structures (such as nerves, veins, tendons or bone), have minimal to no devitalized tissue, are granulating, or are deemed ready for closure by the clinician were considered a simple wound [29].

3.2.1. Panel Recommended Treatment

The panel members recommended primary closure for simple wounds, as immediate primary closure is the ideal management for a majority of simple, acute wounds (Figure 1) [30]. Once surgical closure has been performed, clinicians have a number of options for post‐surgical care. These options should be selected based on the needs of the patient and product availability. In patients that are at high risk for surgical site complication development, closed incision negative pressure therapy (ciNPT) is recommended [31]. If a graft has been utilised to close the wound, the use of NPWT as a bolster can help increase graft take by removing exudate, keeping the graft in contact with the wound bed, and helping to minimise tissue shear [32].

In the case of limited availability of NPWT and/or ciNPT, or when the use of NPWT is not feasible, panel members recommended the use of advanced wound dressings to provide protection against external contamination and to help remove excess exudate. Dressing selection should take into account product availability, patient needs, and surgical incision requirements with absorptive dressings used for postoperative incisions with moderate to high levels of exudate [33].

For a subset of simple wounds, such as acute wounds with edges that cannot be approximated, primary closure may not be feasible. In these patients, wound healing may be supported using traditional or disposable NPWT or advanced wound dressings and allowing the wound to heal by secondary intention. Product availability, patient needs, and the wound environment should be taken into consideration when selecting the wound management pathway. Higher exudating wounds and/or wounds with dead space would require more absorptive wound fillers and secondary dressings while superficial wounds with little to no exudate can be covered with lower absorbing dressings such as foam dressings, film dressings or hydrocolloid dressings [33].

3.3. Complex Wounds and Panel Recommendations for Treatment

Wounds that have extensive loss of the skin, affect underlying structures (such as tendon, bone, nerves, vessels) and periwound skin, are ischemic, show signs of infection or contamination, have areas of devitalized tissue or necrosis, or have been non‐healing for 3 months are deemed complex wounds [34].

3.3.1. Panel Recommended Treatment

Panel members recommended patient referrals to a specialist or higher‐level health care facility when necessary. Referrals should be performed when the patient requires specialised care or when the required advanced care equipment is unavailable at the current facility. In line with the panel member recommendations, a study of the e‐referral system in Saudi Arabia showed that common reasons for referral to specialists of a higher‐level health care facility included unavailability of a specialist or subspecialist for wound management, patient beds, advanced care equipment, or in cases of a patient health crisis [35]. It is intended that these guidelines serve to educate and aid in the decision making of less experienced wound care providers and thus increase the availability of NPWT outside of the current specialist centres. Further opportunities exist to expand accessibility in the Middle East through training and education.

When the wound has injury to the underlying structures, significant contamination, a significant tissue defect, or when the patient is unsuitable to undergo anaesthesia, wound bed preparation is recommended (Figure 1) [30]. Panel members recommended using NPWT or NPWTi‐d to promote granulation tissue development, remove infectious materials, and prepare the wound for potential surgical closure procedures. In a randomised controlled trial from Turkey, patients with stage 3 and 4 pressure injuries were managed either with NPWT or wet‐to‐dry dressings [11]. The average granulation tissue formation rate was higher and the wound area smaller at the end of treatment in the NPWT group [11]. A cost‐utility analysis for the management of diabetic foot ulcers in Iran reported that NPWT use was less costly and more effective than standard dressings with a reduced number of amputations and an increased number of healed wounds reported in the NPWT group [36].

Additionally, NPWT use has been associated with reduced time to skin grafting or surgical closure, shorter hospital length of stay, and increased wound healing rates compared to standard wound care methods across a variety of wound types and geographical regions [37, 38, 39]. A randomised controlled trial from India reported improved development of granulation tissue, wound size reduction, and wound healing rates in patients with grade 1 and 2 diabetic foot ulcers [37]. In another meta‐analysis with global patients, NPWT use was associated with increased percentage of wound healing, reduced time to healing, and lower cost of hospitalisation in patients with grade 3 and 4 pressure injuries compared to standard wound care [39].

For wounds with slough, poor granulation tissue, or signs of infection, NPWTi‐d use was recommended along with institutional infection treatment protocols. NPWTi‐d was also advised when wound cleansing is required, when the patient is unsuitable for surgical intervention or debridement, or if surgical debridement is delayed due to logistical reasons. NPWT use was recommended either following NPWTi‐d, after debridement, or when NPWTi‐d is not available. If the patient is unable to remain in the hospital but still requires NPWT, panel members recommended portable or disposable NPWT use with follow‐up in the outpatient clinic.

Currently, only one study has been published that examines the use of NPWTi‐d in the Middle East region [40]. A small case series of three Kuwaiti patients with complex wounds reported reduced slough following the use of a reticulated open cell foam dressing with through‐holes and NPWTi‐d when complete surgical debridement was not possible [40]. However, NPWTi‐d use has been supported across other wound types and regions [17, 19, 41, 42, 43, 44]. Achiti et al. reported a reduced amount of fibrinous wound surface area and increased granulation tissue in French patients with fibrinous lower limb ulcers that had previous unsuccessful debridement [17]. In the United States, NPWTi‐d was associated with higher closure rates in patients with soft tissue necrotizing infection compared to traditional NPWT after controlling for differences in smoking status, intravenous drug use, number of surgical procedures, and wound location [41]. Similarly, a global patient population meta‐analysis from Gabriel et al. reported reduced number of surgical debridements, time to closure, and length of therapy in the NPWTi‐d group compared to either standard wound dressings or traditional NPWT [19]. Additionally, wounds receiving NPWTi‐d were found to be 2.39 times more likely to close than the control group [19].

4. Limitations

Differences in the provision of healthcare exist across the Middle East. Panel members were selected from across the region to reduce potential location bias and provide a representative experience. As a result, the wound care recommendations created provide general guidance for NPWT and NPWTi‐d use and are a starting point for region‐specific recommendations. The panel meeting discussions focused on one manufacturer's NPWT products and may have introduced bias towards certain products due to their availability for use within the Middle East region. Limited published evidence for the use of NPWT and NPWTi‐d in the Middle East exists, though currently available global evidence has been published supporting NPWT and NPWTi‐d use.

5. Conclusion

Global prevalence of wounds is increasing, leading to increased demand for wound care services across the health care system. However, there is a lack of wound care guidelines specific to the Middle East region. Panel members recommended the use of NPWT for both simple and complex wounds. However, clinical evidence supporting NPWT use in the Middle East has been limited. As more regionally published clinical evidence becomes available, these initial NPWT and NPWTi‐d use recommendations should be updated.

Conflicts of Interest

Muneera Ben‐Nakhi, Heitham Albeshri, Fahad Aljindan, Maram Alkhatieb, Ali Al‐Malaq, Fatema Al Subhi, Mohamed Baguneid, Mario Cherubino, Samiah Faraj Mushara, Yasser Khattab, Saadia Laher, Marcelo A.F. Ribeiro Jr, Suléman Vadia and Mark J. Portou are consultants for Solventum. Sadhana Trivedi is an employee of Solventum. The panel meeting was sponsored by Solventum. Panel member selection criteria were developed by Solventum. Solventum provided medical writing support and paid publication fees for this article. The authors received honoraria for their participation in the advisory board that led to this publication and for their time in the development of this article. The resulting manuscript represents the authors' original work and has not been altered by any industry, organisation or third party.

Ben‐Nakhi M., Albeshri H., Aljindan F., et al., “Negative Pressure Wound Therapy Use: Recommendations and Insights From a Middle Eastern Panel of Experts,” International Wound Journal 22, no. 12 (2025): e70791, 10.1111/iwj.70791.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.