Lymphedema Flashcards
1
Q
Definition of lymphedema
A
- protein rich accumulation in interstitial space
- reduced lymph transport capacity
- caused by damage to lymph vessels or nodes or by absence or malformation of lymph vessels
- Lymphatic system is network of vessels that transports interstitial fluid from interstitial space back to venous circulation’
2
Q
Lymphedema : pathophysiology
A
- Lymphatic system is network of vessels that transports interstitial fluid from interstitial space back to venous circulation’
- Chronic lymphedema:
- increased protein
- increased colloid osmotic pressure of interstitial fluid lead to an influx of fluid from plasma
- viscous cycle high protein lymphedema
- General edema:
- excessive fluid in body space, vascular space, within cells
- varied etiology
- usually unilateral or uneven
- limbs > trunk, genitals, face
- High protein content –> fibrosis and abnormal fat deposition
- fibrosclerosis encases vessels –> pain
- Late skin changes:
- hyperkeratosis, papillomatosis, hyperpigmentation, inflammation
- interdigital and nail mycosis, lymph cysts, fistulas, maceration, lymphorrea
3
Q
Causes of lymphedema
A
- cancer treatment (most common cause)
- breast cancer treatment 20-30%
- melanoma
- gynecological cancers
- prostate cancer
- sarcoma
- chronic venous insufficiency
- obesity
- reduced mobility
- filiarias, leprosy in developing world
- primary lymphedema (genetic condition)
- Hypoalbuminemia (reduced plasma colloid pressure)
4
Q
Breast cancer and lymphedema
A
- latency 1-2 years or longer
- progressive fibrosis occludes lymphatic vessels
5
Q
Differential diagnosis
A
- recurrence of cancer
- dvt
- cellulitis
6
Q
Self care to prevent worsening of lymphedema
A
- risk of cellulitis
- skin hygiene
- low ph cream
- avoiding punctures to skin (IV, injections, acupuncture insect bites)
- avoid extreme heat (hyperemia)
- avoid extreme cold (rebound edema)
- avoid weight gain
- exercise
7
Q
Combined decongestant therapy
A
- Phase 1
- reduction of edema
- intensive treatment
- education and support
- MLD, compression and gentle exercise
- Manual Lymphatic Drainage
- light massage to increase intrinsic contractility of superficial lymph vessels.
- unskilled or vigorous massage may cause lymphangiospasm
- starts with head and neck, trunk
- 45 minutes daily for 2-4 weeks
- then apply bandages
- Simple lymphatic drainage can be taught to do at home
- Compression bandaging
- Inelastic bandages
- kept on for 24 hours initially, changed at each MLD
- works best is edema early and still pitting
8
Q
Stage 1 lymphedema management
A
- reverses spontaneously with elevation
- initial management directly with compression garments
- skin care
- exercises
9
Q
Stage 2 lymphedema management
A
- Moderate lymphedema
- does not reverse with elevation
- will progress to fibrosis if untreated
- Modified multilayer inelastic bandaging
- skin care
- simple lymphatic drainage
- exercises
- If successful
- compression garment
10
Q
Stage 2 and 3 moderate / severe lymphedema
A
- skin changes are present
- intensive treatment
- MLD 2-4 weeks + bandaging + exercises
- Maintenance treatment : compression garment, skin care, exercises, SLD
11
Q
Compression garments
A
- prescribed only after edema reduction with intensive therapy
- prevents further swelling
- 20-30 mm or 30-40 mmHg
- custom made flat knit garments best
- avoid tourniquet effects
12
Q
How do decongestive therapies work?
A
- lymphatic capillaries rely on external compression from striated muscle fibres to enable flow
- Extrenal compression increases interstital pressure and reduce pressure gradients that force fluids out of capillaries
- reduces fluid fluxes into interstital space
Inelastic bandages multiple layers
- high working pressures
- with movement creates massaging effect which stimulates lymph flow’
- at rest pressure constant and non stimulating
Exercise
- progressive weight training
- aerobic program
- flexibility exercises
- tai chi
- dancing
13
Q
Contraindications to Combined Decongestant Therapy
A
- Congestive heart failure
- DVT acute
- caution with
- arterial insufficiency
- severe pain
- peripheral neuropathy
- malnutrition
14
Q
Medications for lymphedema
A
- worsens:
- NSAIDS
- CCB
- alpha blockers
- steroids
- treat cellulitis/erysipelas
- meticulous skin care / nail care
- steroids for peritumour edema
15
Q
Diuretics for Lymphedema
A
- reduce volume of lymphedema tissue by hemoconcentration
- more water returns to blood
- plasma proteins remain in tissue
- triggers fibrosis and infection
- Avoid diuretics unless cardiac or venous component
- Can use for tense ascites at EOL
