Military Use of Negative Pressure Wound Therapy Increasingly Essential Since Iraq, Afghanistan Wars

BETHESDA, MD — Since 2004, beginning in the battlefield medicine setting, negative-pressure therapy has been regularly used in the treatment of acute injuries and nonhealing wounds.

“It represents a new standard of practice in combat wound care; it promotes granulation tissue formation and creates mechanical forces supporting wound contraction, facilitating definitive wound closure,” researchers from what was known at the time as the Walter Reed Army Medical Center wrote in 2011, as the war in Iraq, which began in March 2003, officially concluded with the withdrawal of all U.S. forces in December. The war in Afghanistan, while winding down, didn’t official end until 2021, although the major combat mission ended in 2014.¹

Lower limb injuries were the most common extremity wounds in both of those wars, with a significant percentage of combat injuries involving the lower extremities. More than 1,500 U.S. servicemembers suffered amputations, with more of half of those involving lower limbs.

In an acute setting, negative pressure wound therapy (NPWT) involves a sealed wound system with a foam dressing and vacuum pump to manage complex wounds, such as traumatic injuries, open fractures and post-surgical wounds. In addition to protecting the wound from contamination, the process is used to drain fluid, reduce swelling, promote blood flow and create a stable, moist environment for healing.

Earlier this year, an updated critical care air transport clinical practice guideline was released; it provided in-depth advice on the use of NPWT. “The goal of this CPG is to optimize wound management for the traumatically injured with a focus on the aeromedical evacuation (AE) environment,” wrote the military authors working with the Center for Sustainment of Trauma and Readiness Skills at the University of Cincinnati Medical Center. “This CPG provides an overview of negative pressure wound therapy and its uses in the treatment of soft tissue battle wounds. It describes the technical aspects of troubleshooting negative pressure wound therapy, addresses equipment and dressing failures; and provides an algorithm for how to treat bleeding that may occur during patient evacuation. Throughout the guideline, a focus has been placed on the special conditions associated with en route care. “

“Negative pressure dressings can be left in place for 24 to 72 hours, depending on wound characteristics,” the guideline authors explained. “This makes the NPWT dressings generally less labor-intensive to manage and more ideal for AE. NPWT allows for the accurate measurement of fluid and blood loss from wounds, to include losses associated with temporary abdominal and chest closures after damage control surgery. Understanding wound-related fluid losses is an important part of optimizing post-surgical resuscitation.”

Aeromedical evacuation (AE) was first used on a limited basis during the Korean War, but accelerated advancements after the terrorist attacks Sept. 11, 2001, are credited with created historically low U.S. mortality rates from operations in Iraq and Afghanistan. For example, wounded warrior movements from the theater to advanced levels of care during the Vietnam War took approximately 45 days; now, the time has been reduced to as little as 36 hours. And NWPT provided during flight has played a critical role in that.²

Traumatic Soft-Tissue Injuries

A recent study published in the Journal of Trauma and Acute Care Surgery in June also strongly endorsed the use of the technology, noting, “Negative pressure wound therapy (NPWT) has emerged as a valuable tool in the management of traumatic soft tissue injuries. Negative pressure wound therapy alters the local wound environment through a variety of mechanisms at both the macroscopic and microscopic level to reduce edema, stimulate angiogenesis, decrease bacterial burden and promote healing. In battlefield or disaster response settings, NPWT offers additional advantages including reductions in dressing changes and the skilled personnel required to complete them, as well as less exposure to the surrounding environment and associated infection risk.”³

Researchers from Vanderbilt University Medical Center in Nashville and Blanchfield Army Community Hospital in Fort Campbell, TN, advised, “Since it first became popularized for use in difficult-to-manage wounds, its indications have expanded to include bolstering partial thickness skin grafts and augmenting the healing of high-risk surgical incisions. Negative pressure wound therapy enhances wound healing through multiple, well-described mechanisms. At the macroscopic level, it stabilizes the wound environment and causes wound contraction. The semiocclusive drape prevents desiccation of the wound and provides thermal insulation, which can be especially relevant for physiologically unstable patients with large traumatic wounds. Negative pressure wound therapy also minimizes skin and soft tissue retraction that can occur after traumatic or surgical disruption of soft tissue, resulting in improved approximation of wound edges and increased likelihood of primary wound closure.”

In the review, the study team added that, on the microscopic level, “continuous evacuation of extra-cellular fluid leads to microdeformation of cells in the wound environment, which catalyzes increased cell proliferation, production of growth factors, and angiogenesis.”

In May, Smith+Nephew, the global medical technology company, was selected to provide its Renasys Touch Negative Pressure Wound Therapy (NPWT) Systems under a single award, 10-year contract for up to $75 million by the DoD through the Defense Logistics Agency (DLA). A Smith+Nephew press released noted that the system “demonstrated clinical efficacy, and operational fitness including portability, an intuitive interface, and the ability to provide a range of therapy modes, set points and cycle times that allow individualized patient care.”

The system will allow military medical providers to administer therapy through prolonged casualty care, first surgical intervention, aeromedical transport and definitive care in military treatment facilities. “Future conflicts will be more difficult and complex. This implies medical devices and treatments will need to be simplified and more intuitive to be used farther forward by a wide range of providers,” Dennis Lyons, MSG (ret), SO-ATP and Sr. Director Military & Federal Health for Smith+Nephew, pointed out in a press release.

In 2024, Smith+Nephew announced it would be part of a Master Cooperative Research and Development Agreement (CRADA) initiative with the U.S. Army Institute of Surgical Research (USAISR) to transform wound and burn care across the military care continuum.

At the same time as NPWT has become more essential to the military, a new ability to quantify its effects might be opening “a new frontier in precision wound medicine,” according to a recent study.

“Negative pressure wound therapy (NPWT) has revolutionized the management of complex wounds via mechanisms such as microdeformation, angiogenesis and exudate control. However, its clinical effect has historically only been evaluated by qualitative and visual parameters. This study integrates near-infrared spectroscopy (NIRS) as a biofeedback tool to quantify physiological response to NPWT in real time,” wrote Leticia Vallejo-Carmona, PhD, MSN, the president of the Puerto Rico Wound Healing Society, Wound Care Plus Education and Research Center, the clinical director of the Wound and Ulcer Care Clinic of San Juan, Wound and Ulcer Center of Florida and a professor in the Department of Health Sciences at the Ana G Méndez University in San Juan, Puerto Rico.⁴

In the Journal of Wound Care, Vallejo-Carmona explained, “The integration of NIRS redefines the clinical role of NPWT, allowing therapy to be customized based on specific physiological data. This combination represents a new frontier in precision wound medicine. The results of this study provide a foundation for a new generation of clinical decisions in advanced wound management.”

Her study sought to quantitatively demonstrate the physiological and structural changes induced by an NPWT system in patients with complex wounds, measured using NIRS. The prospective real-world observational study was conducted with a cohort of 23 patients with 33 wounds.

“The data showed a progressive reduction in wound area and volume, accompanied by an increase in tissue oxygen saturation and a sustained decrease in deoxygenated haemoglobin,” Vallejo-Carmona pointed out. “These findings, objectively quantified through NIRS as a real-time biofeedback tool, highlight the improvement in oxygenation and wound-bed perfusion and support the hypothesis of tissue biomodulation induced by NPWT.”

Meanwhile, feedback from patients and healthcare providers is influencing the design of the devices.

A University of Iowa study published in Wound Repair and Regeneration advised that the most common wound care procedures (WPPs) performed on open wounds are dressing changes and wound cleansing. “Dressing changes cause moderate to severe pain in 74% of patients, nearly half (36%) of whom experience severe pain (rated as 8 to 10 on a 10-point numeric rating scale),” the authors wrote. “High intensity pain causes substantial stress for both patient and clinicians.”⁵

Complicating the issue, they wrote, is that when wound care professionals cause high intensity pain, “those changing the dressing may ‘hurry through the procedure’ in an effort to stop the pain. … This may lead to incomplete cleansing and packing, an increased risk of infection, delayed healing, and higher costs.”

Another unintended effect is changing nociceptive pain pathways, which elevates anticipatory pain and makes future procedures even more painful.

In response, some manufacturers have developed products that are easier to use than hard port alternatives. The RenasysSoft Port, for example, can be applied and removed with minimal pain in even the most difficult-to-treat contours of the body to improve patient experiences.

Those types of improved products have been well received, according to a study led by Norton Children’s Hospital in Louisville, KY. The authors explained that NPWT application sometimes requires a technique known as ‘bridging” to prevent ulcerations caused by delivery port and tubing when positioning the device. Requiring extra time and resources, bridging is used when it is considered essential to move the NPWT delivery port away from the wound bed or when treating wounds inclose proximity to each other.

A survey of 200 healthcare professionals (HCPs) in the United States who are experienced in traditional NPWT and bridging sought to explore HCP opinion on 2 types of tNPWT delivery ports (soft and hard) between 2 leading manufacturers. The questions focused on the need for bridging, alleviation of complexity in application and reducing concerns relating to medical device-related pressure injury when applied to awkward anatomical areas. Results were published in the journal Wounds earlier this year.

The researchers, including some from industry, found that 75% of HCPs (150) agreed that the bridging technique makes application of tNPWT slightly more challenging. Reasons included additional time taken to apply (74%; n=148), increased dressing resource (67%; n=134), and additional staff required (50%; n=100).

In addition, more than half, 53%, agreed that the soft port can eliminate the need for bridging. They also agreed that using a tNPWT soft port reduced the risk of pain/pressure versus applying a hard port over a smaller wound size (29%; n=58) and certain anatomical areas which pose a risk of pressure injury or kinked/twisted tubing (31%; n=62).

“tNPWT soft ports remain effective regardless of kinks or twists and can eliminate bridging in anatomical areas where patients may weight-bear on tubing or delivery ports, saving time and decreasing risks of periwound trauma,” the researchers concluded.

Widely accepted contraindications to NPWT usage include:

• Necrotic tissue: Presence of dead tissue or eschar in the wound bed.
• Malignancy: Cancerous tissue in the wound.
• Untreated osteomyelitis: Active bone infection that has not been properly treated.
• Exposed structures: Visible organs, blood vessels, nerves or an anastomotic site within the wound.
• Nonenteric or unexplored fistulas: Tunnels that lead to a body cavity or organ, especially if their course is unknown.

 

1. Couch KS, Stojadinovic A. Negative-pressure wound therapy in the military: lessons learned. Plast Reconstr Surg. 2011 Jan;127 Suppl 1:117S-130S. doi: 10.1097/PRS.0b013e3181fd344e. PMID: 21200282
2. Ingalls N, Zonies D, Bailey JA, et al. A Review of the First 10 Years of Critical Care Aeromedical Transport During Operation Iraqi Freedom and Operation Enduring Freedom: The Importance of Evacuation Timing. JAMA Surg. 2014;149(8):807–813. doi:10.1001/jamasurg.2014.621
3. Luther, Lauren MD; Maxson, Ridge MD; Stinner, Daniel J. MD, PhD. Negative pressure wound therapy in resource-limited environments: Review and field guide. Journal of Trauma and Acute Care Surgery 99(3S):p S143-S149, August 2025. | DOI: 10.1097/TA.0000000000004708
4. Vallejo-Carmona L. Structure-guided negative pressure wound therapy (NPWT): personalised tissue biomodulation with an NPWT system in adults and older adults. J Wound Care. 2025 Nov 1;34(S11e):S1-S23. doi: 10.12968/jowc.2025.34.S11e.S1. PMID: 41216833.
5. Gardner SE, Abbott LI, Fiala CA, Rakel BA. Factors associated with high pain intensity during wound care procedures: A model. Wound Repair Regen. 2017 Aug;25(4):558-563. doi: 10.1111/wrr.12553. Epub 2017 Aug 14. PMID: 28805960; PMCID: PMC5831166.
6. Chariker ME, Handsaker J, McCarthy C. Removing the complexities associated with traditional negative pressure wound therapy (tNPWT) bridging applications. Wounds. 2025 Mar;37(3):107-113. doi: 10.25270/wnds/24074. PMID: 40215360.